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Melissa D. David BSN2Y1-2B ASSESSMENT Subjective: Masakit yung tahi ko lalo kapag gumagalaw ako as verbalized by the patient.

. Objective: Pain scale of 6/10 V/S: Temp: 37.4 RR: 24 cpm PR: 99 bpm BP: 130/90 Facial grimace Discomfort NURSING DIAGNOSIS Pain related to perineal suture as manifested by pain scale of 6/10, facial grimace and discomfort. PLANNING After 4 hours of nursing intervention the patient will experience a lesser pain above a tolerable level as manifested by : Pain scale of 4/10 Stable RR or at least below 20 bpm No facial grimace Stay calm most of the time INTERVENTION Independent: 1. Promote perineal exercise and comfortable sitting position such as: - Kegels exercise RATIONALE EVALUATION After 4 hours of nursing intervention the patient was able to experience lesser pain and above a tolerable as manifested by: Pain scale of 4/10 RR: 18cpm No facial grimace Calm and cooperative Therefore the goal was met.

1. Decrease discomfort - 3 or 4 times a day with 5 times succession reduces discomfort and improves circulation in the area and decrease edema. - Before sitting squeeze buttocks together and sit with that position reduces physical discomfort. 2. So that the patient may fix her mind frame about the pain, this in return will lessen the perception of pain and her anxiety. 3. Facilitates relaxation.

- Sitting position

2. Tell the patient that the pain and discomfort usually last more than 3 days.

3. Instruct the patient to do breathing exercises. Dependent: 1. Administer analgesic as ordered by the physician.

1. To relieve pain.

Kevin D. Evangelista BSN2Y1-2B ASSESSMENT Subjective: Hindi ko nararamdaman kapag naiihi ako as verbalized by the patient. Objective: Uncontrollable bed wetting, lost the sense when she has to void V/S: Temp: 36.7 RR: 20 cpm PR: 80 bpm BP: 110/80 Urine output : 4 NURSING DIAGNOSIS Altered urinary elimination related to perineal edema and decreased bladder tone from fetal head pressure during birth. SCIENTIFIC BASIS During vaginal birth the fetal head exerts a great deal of pressure on the bladder and urethra as it passes on the bladders underside. This pressure may leave the bladder with a transient loss of tone that, together with edema surrounding urethra, decreases a womans ability to sense when she has to void. PLANNING After 8 hours of nursing intervention the patient will be able to attempt common measures to initiate voiding. The patient will be able to : Verbalize understanding of the condition. Identify negative factors affecting urinary elimination. Participate in different nursing interventions. INTERVENTION Independent: 1. Assess amount of urine voided during labor and reassess fundal height and position. 2. Assess what measures patient thinks would help her to void. 3. Discuss importance of continuing to drink. 4. Discuss importance of emptying bladder 5. Stress importance of drinking extra water during post partum period RATIONALE EVALUATION

Dependent: 1. CBI as ordered

Goals met as 1. Assessing fundal height evidenced by: and position provides Patient was evidence about the degree able to void of bladder filling. more than 100 2. Respecting clients ml within 2 preferences helps her to hours time. maintain feeling of control. Fundal height 3. Helps initiate bladder returns to 1 reflex. fingerbreadth 4. Retention of urine below the predisposes to infection. umbilicus after 5. Women should drink voiding. ample fluid during the post Patient partum period to counteract ambulates to normal dieresis and ensure the bathroom to good urine output. void with assistance 1. To prevent urinary tract Patient obstruction by flushing out confirms she small blood clots that form has been after prostate or bladder drinking 1 glass surgery. of fluid an To dissolve certain bladder hour. calculi with chemolytic Knows to drink agents. 6-8 glasses of To treat an irritated, fluid daily. inflamed, or infected bladder lining.

Melissa D. David BSN2Y1-2B DRUG 1. Co-Amoxiclav INDICATION - Infections of URT, LRT, GUT, skin, soft tissue, bone and joint, post surgical infections. CONTRAINDICATION - Hypersensitivity to penicillin ADVERSE REACTION - Diarrhea, indigestion, nausea, vomiting, rash NURSING CONSIDERATION - Obtain patients history of allergy. - Assess for signs and symptoms of infection, wound characteristics, sputum, urine, stool, fever, WBC count. - Should be taken after meals - Do not use in larger or smaller amounts or for longer than recommended - Assess patient before pain before therapy.

2. MVI (Conzace)

3. Mefenamic Acid

4. Ferrous Sulfate

- Nutritional supplement - Promote cellular / tissue maintenance and repair. - Relief of pain including muscular, rheumatic, dental, postoperative, post partum pain, migraine - Prevention and treatment of iron deficiency anemia

- Treatment of pernicious anemia. - Wilsons Disease - Hemachromatosis - Pregnancy and lactation

- Upset stomach, headache, unusual taste in mouth - GI discomfort, diarrhea, constipation, gas pain, nausea, vomiting - GI irritation, anorexia, nausea, vomiting, diarrhea, constipation, dark stool

- Hypersensitivity to any ingredient, hemosiderosis, hemolytic anemia - Hypertension,Toxemia, Pregnancy (Cat.C)

5. Methergine

- Post-partum hemorrhage and uterine atony, sub-involution

- Evaluate hemoglobin, hct and reticulocyte during pregnancy - Increase fluid intake, take with orange juice. - Hyper- or hypotension, nausea, - Be alert for adverse reactions vomiting, chest pain, dyspnea, and drug interactions. headache, hematuria, thrombophlebitis, - This drug should be used water intoxication ,hallucinations, extremely carefully because of its leg cramps, dizziness, tinnitus, nasal potent vasoconstrictor action. IV congestion, diarrhea, use may induce sudden diaphoresis, palpitations, foul taste hypertension and cerebrovascular accidents. As a last resort, give IV slowly over several minutes and monitor blood pressure closely

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