INTRODUCTION:

PATIENTS PROFILE
Name: Maria Marla H. Gallegues
Address: #505 M.H Del Pilar St. Malanday, Valenzuela City
Age: 37 years old
Sex: Female
Civil Status: Single
Religion: Roman Catholic
Fathers Name: (Deceased)
Mothers Name: Milagros Hermanio
Date of Admission: June 28, 2014
Chief Complaints: Labor Pain
Impression/Diagnosis: Pregnancy Uterine 38wks, Cephalic in labor
Operation: Median episiotomy plus repair of perineal laceration

A case of Mrs. Gallegues is Gravida 4 Parity 3. The patient complains about Labor Pain. Patient
was admitted last June 28, 2014 at 3:50am. Based on internal examination the patient has cervix
of 4cm dilatation and 70% effacement cephalic. (+) Bow. June 28, 2014 at 9:58 AM she gave
birth through Normal Spontaneous Vaginal Delivery.



Name of
Drug
Therapeuti
c Action
Indication Adverse
Effect
Contraindicati
on
Nursing
Consideration
Generic
Name:
Mefenamic
Acid

Brand
Name:
Ponstan

Classificati
on: Anti-
inflammato
ry;
Analgesic.

Aspirin like
drug that
has
analgesic
antipyretic
and anti-
inflammat
ory
activities
Moderate to
moderately
severe pain.
Relief of
pain
including
muscular,
rheumatic,
traumatic,
dental, post-
operative
and
postpartum
pain,
headache,
migraine,
fever and
dysmenorrh
ea, pain
from
rheumatoid
arthritis
including
Stills
disease, soft
tissue
injuries.
Therapy
should not
exceed 7
days.
CNS:
Dizziness
CV:
Vasodilati
on
EENT:
Visual
disturbanc
es
GI: Nausea
and
Vomiting
GU:
Urinary
retention
SKIN:
Pruritus

Pregnancy
and Lactation.
Hypersensitivi
ty with drugs,
acute
intoxication
with alcohol,
physical
opioid
dependence
Kidney or liver
impairment.
Children less
than 14 years
old.
Tell patient
that drug
works best
when taken
before pain
becomes
severe
Recommend
abstinence
from alcohol
when taking
medication
Caution
patient that
drug can
cause
dependence
Tell patient
to report
occurrence
of drug
induced
adverse
reactions.
Advise
patient to
immediately
report
persistence
or failure to
relieve pain.





Assessment
Diagno
sis
Planning
Nursing
Intervention
Rationale Evaluation
Subjective:
Sumasakt
yung tahi
paminsan
minsan. As
verbalized
by the client.

Objective:
Facial
grima
ce
Pain
scale
of
6/10
Slow
ed
move
ment
V/S taken as
follows:
T:
37.3
RR: 21
PR:
96
BP:
100/8
0
Acute
vaginal
pain
related
to right
median
lateral
episioto
my as
evidenc
ed by
facial
grimaci
ng.
After 8 hours of
nursing care, the
client will be
able to:
Express
alleviatio
n of pain
from
scale of 6
to 2
To know
different
techniqu
es in
alleviatin
g pain
Comforta
bly fall
asleep
Provide
rapport
with the
patient
Monitor
vital
signs
Provide
a
therape
utic
environ
ment
Encoura
ge
verbaliz
ation of
feelings
Encoura
ge to do
diversio
nal
activitie
s
Encoura
ge rest
and
sleep
To
gain
trus
t
and
full
coo
per
atio
n
duri
ng
the
pain
alle
viati
on
peri
od
Vita
l
sing
s
alte
red
duri
ng
acu
te
pain
To
aid
alle
viati
on
of
pain
To
assi
st in
eval
After 8 hour of
nursing care, the
client:
Expresse
d
alleviatio
n of pain
from
scale of 6
to 3
Knew
different
techniqu
es in
alleviatin
g pain
Comforta
bly feel
asleep
uati
on
To
alle
viat
e
pain
To
assi
st in
alle
viati
on
of
pain