Alabang-Zapote Road, Pamplona 3, Las PiasCity, Metro Manila 1740, PHILIPPINES

www.perpetualdalta.edu.ph +63(02) 871-06-39

Nursing Care for Patient in Pre-Term Labor

In Partial Fulfillment
Of the requirement for the course
NCM 102

PRESENTED BY:
BSN 2A GROUP 1
BATCH 2018

Almario , Michelle I.
Aragon , John Cedric
Chang, Bryan Christian
Dalusag, Raven Samantha M.
Decena, Kimberly Jo-Ann
Dingding, Allyssa
Diocareza, Angelica Jane
Dottie, Sophia
Francia, Diana Marie
Galias, Edylaine

March 2016
 INTRODUCTION

Case

Patient JQJ, a 38 year old female was admitted in Jonelta Ward last January 15, 2016,
4:22 am at University of Perpetual Help System DALTA Medical Center with a diagnosis
of G3P2 (2002) Pregnancy Uterine 36 2/7 weeks Cephalic in Preterm Labor, Previous CS
II Primary for Arrest in descent.

DESCRIPTION OF DISEASE:

Premature labor is also called preterm labor. Its when your body starts getting

ready for birth too early in your pregnancy. Labor is premature if it starts more than three

weeks before your due date.

This happens because uterine contractions cause the cervix to open earlier than

normal. Consequently, the baby is born premature and can be at risk for health problems.

Lots of different things can increase your risk of premature labor. Some of them

are smoking, being very overweight or underweight before smoking, being very

overweight or underweight before pregnancy, not getting good prenatal care, drinking

alcohol or using street drugs during pregnancy, having health conditions, such as high

blood pressure, preeclampsia, diabetes, blood clotting disorders, or infections, being

pregnant with a baby that has certain birth defects, being pregnant with a baby from in

vitro fertilization, being pregnant with twins or other multiples, a family or personal

history of premature labor, getting pregnant too soon after having a baby.

Warning signs and symptoms of premature labor include five or more uterine

contractions in an hour, watery fluid leaking from your vagina (this could indicate that

your water has broken), menstrual-like cramps in the lower abdomen that can come and
go or be constant, low, dull backache felt below the waistline that may come and go or be

constant, pelvic pressure that feels like your baby is pushing down, abdominal cramps

that may occur with or without diarrhea, increase or change in vaginal discharge.

Premature labor occurs in about 12% of all pregnancies. However, by knowing

the symptoms and avoiding particular risk factors, a woman can reduce her chance of

going into labor prematurely.

In the United States 9.6% premature birth report were reported as of 2015. This
national data source is used so that data are comparable for each state- and jurisdiction-

specific premature birth report.

The Philippines is in the 8th place out of ten countries with the greatest number of

preterm labor with an average of 348,900 cases in the world according to WHO as of

2015, number one is India.

 ANATOMY AND PHYSIOLOGY

UTERUS

The uterus (womb) is the part of the female reproductive system in which a baby

grows.

The female reproductive system is made up of internal organs, including the

vagina, uterus, ovaries and Fallopian tubes, and the external genital organs (the parts that

make up the vulva). All the internal organs are in the pelvis, which is the lower part of the

abdomen between the hip bones.

Structure

The uterus is a hollow, muscular organ that is shaped like an inverted pear. It has 3

parts: fundus (top) , body (the main parts of the uterus, including the uterine cavity), and

cervix (lower, narrow part).

The uterus is located above the vagina, above and behind the bladder and in front of the

rectum. It is about 7 cm long and 5 cm wide (at the widest point). The wall of the uterus

is thick and has 3 layers: endometrium The inner layer that lines the uterus. It is made

up of glandular cells that produce secretions; myometrium The middle layer, which is

made up mostly of smooth muscle and perimetrium The outer serous layer that covers

the body of the uterus and part of the cervix.

Function

The uterus receives a fertilized egg (ovum) and protects the fetus (baby) while it

grows and develops. The uterus contracts to push the baby out of the body during birth.

Every month except when a woman is pregnant or has reached menopause the

lining of the uterus is shed through the cervix, into the vagina and out of the body. This is

called menstruation.
 OBJECTIVES OF THE STUDY

1. To be able to explain preterm labor in women.

2. To identify the causes of preterm labor in pregnancy.

3. To be able to identify the risk factors of preterm labor in pregnancy.

4. To be able to recognize when a woman will be experiencing preterm labor in

pregnancy.

5. To be able to give nursing interventions that is appropriate for the patient's

conditions.
 PATIENTS PROFILE

Clients name or Initials : Mrs. JQJ

Age : 38 years old

Civil Status : Married

Religion : Roman Catholic

Address : 804 San Jose Manuyo I, Las Pias City, Metro

Mnila 1740

Birth Date and Place : June 6, 1977 Las Pias City

Race/Nationality : Filipino

Usual Source of Medical Care : Hospital

Chief Complaint : Abdominal Pain

Admitting Physician : Dr. Julie Jane Dy

Attending Physician : DR. MARITESS BLAS

Admitting Diagnosis : G3P2 (2002) Pregnancy Uterine 36 2/7 weeks in

Cephalic Preterm Labor, Prev. CS II

Primary for Arrest in Descent

HISTORY OF PRESENT ILLNESS

The patient was amenorrheic for 4 weeks and did a pregnancy test 5 weeks that

revealed a possible result.

During the 1st trimester, she had her 1st prenatal check-up at Jonelta OPD at 6-7

weeks AOG. Transvaginal UTZ (ultrasound), CBC (Complete Blood Count), urinalysis,

FBS (Fasting Blood Sugar), VDRL test (venereal disease research laboratory, to assess

whether or not you have syphilis, a sexually transmitted infection (STI)), and Hepa B

were done. She took multivitamins, folic acid, and calcium. She was diagnosed with

Bacterial Vaginosis. She took metronidazole and it resolved.

During the 2nd trimester, she felt quickening at around 5-6 months. No bleeding or

spotting. No watery discharge. No infections noted. She continued to take multivitamins,

FeSo4 (ferrous sulfate) and Calcium once a day.

During the 3rd trimester, no spotting or bleeding noted. No watery discharge. No

uterine contractions noted. With good fetal movement. She continued to take

multivitamins, FeSo4 and Calcium once a day.

Two days prior to admission, the patient noted abdominal pain with every fetal

movement, with a PS (pain scale) of 4/10. Then is associated irregular contraction. No

spotting/bleeding or watery discharge noted. Pain and contractions eventually resolve.

One day prior to admission, abdominal pain now with a PS of 6/10. Contraction

becomes frequent. No spotting/bleeding or watery discharge noted. Before patient was

about to sleep, the pain and contractions resolved.

 11 hours PTA, abdominal pain and regular contractions noted. There is also lower

back pain, no spotting or bleeding. No watery discharge.

Persistence of symptoms prompted consult. Upon IE, cervix is 1cm and with

regular contraction of 6 minutes interval. Hence, this admission.

GORDONS FUNCTIONAL PATTERN OF ASSESSMENT
January 18, 2016, 9:00 AM
Functional Pattern
Chief Complaint or Reason for
Visit
Childhood Illness
Childhood Immunization
History of Allergies
Accidents and Injuries
History of Hospitalization
Medications
Family History of Illness
Health Perception and Health
Management Pattern
Nutritional Metabolic Pattern
Elimination Pattern
Before/During
Abdominal Pain
The patient had some instances of fever, cough and colds
during her childhood. She and her younger sister had
asthma.
Mrs. JQJ claimed that she was not immunized for it was
not yet available during her time.
The patient said that she doesnt have allergy to medication
but had allergy to fish.
The patient stated that she had no history of accident and
injury.
The patient said that she was not hospitalized for a major
or serious illness. She was hospitalized only during giving
birth to her 1st (female) and second child (male).
She stated that her medication is for her pregnancy such as
FeSO4, Calcium, Multi Vitamins and Folic Acid. She took
all this medicines OD (once a day).
According to the patient her father had HPN
(Hypertension). She and her sister had asthma during their
childhood but eventually resolved.
According to her during times of illness she goes to Jonelta
for check-up. Her mother took care of her children when
she and her husband goes to work and when her children
had minor illness her mother uses herbal medications to
treat them.
Before Hospitalization
Prior to admission, patient stated that her usual
meals during breakfast were milk with bread, lunch and
dinner is composed of various foods and vegetables. She
preferred vegetables especially chopseuy and pakbit.
The patient stated also that she has an allergy with
fish but no allergy in medications.
During Hospitalization
The patient said that she was in SD (soft diet) for
the 1st day after giving birth but for the succeeding day her
diet is DAT (diet as tolerated).
Before Hospitalization
The patient claimed that she void 7-8 times a day with
yellow color and her bowel elimination is usually every
morning before taking a bath with dark brown color. The
 patient stated that she is not using any kind of laxatives.
During Hospitalization
During confinement she urinates 7-8 times a day
with yellow colored urine. She defecates once a day with
dark brown stool.
Activity Exercise Pattern Before Hospitalization
The patient had no difficulties in performing the
basic activities such as grooming, locomotion and
performing household chores. She does household chores
when off duty.

During Hospitalization
The patient stated that she is in limited activity due
to her post operation, CS (Caesarian Section). She needs
assistance going to comfort room. She needs assistance
most of the time.

Sleep Rest Pattern Before Hospitalization

Mrs. JQJ stated that her sleeping pattern is normal.
She usually sleeps 8-9 hours a day. She said that she
normally goes to bed around 9pm and wakes up around
6am.

During Hospitalization
The patient stated that she had enough sleep; she
wakes up only just to breastfeed the baby. Her husband is
with her and helps her take care the baby.
Cognitive/Perceptual Pattern Before Hospitalization
The patient stated that she is able to read and write and
was able to finished college.
During Hospitalization
JQJ has a good perception, she responses very well and
very cooperative.

Self-Conception and Self- Before Hospitalization

Concept Pattern Mrs. JQJ is a loving and caring person and seldom
gets mad at her children; she talks to them calmly during
family problems.

During Hospitalization
Mrs. JQJ accepted all the changes and she didnt bother
anymore because it is not her first time to have this kind
of situation as she had already undergone two previous
caesarian section surgery.
 Role Relationship Pattern
Sexuality Reproductive Pattern
Coping and Stress Tolerance
Pattern
Value Belief Pattern
Before Hospitalization
Mrs. JQJ is the second born among four siblings in her
family. She has a good relationship with them. She has a
husband and two children, a son and a daughter. Her
mother also lives with them.
Theyre always after the sake of each members of their
family by helping one another and they value the gift of
family very well. Shes the decision-maker of the family.
During Hospitalization
JQJ receives care and support from her family
especially from her husband.
The patient stated that she and her husband seldom engage
in sexual activity after she got pregnant.
Before Hospitalization
Upon interview, the patient stated that whenever they
have a problem they talk about it and provide choices or
alternative to solve it.
During Hospitalization
The husband stated that he is very much stressed
because her wife was in pain during labor.
Before Hospitalization
The patient said that she seldom goes to church
because of her inconsistent time of working hours, but
despite of that she still believe and have faith in God.
During Hospitalization
The patient stated that because of her condition she
has to pray more often and it makes her faith to God much
stronger. She believed that God would not give her
problem if she cannot solve it.
 PHYSICAL ASSESSMENT

January 18, 2016, 10:00 AM

General Appearance

Area Assessed Technique Used Actual Normal Analysis

Findings Findings
Body built Inspection Proportionate Proportionate Normal
Posture Inspection Guarding Coordinated and Presence of
and gait behaviour and erect pain due to
Slouched post operation
(CS).
Body odor Inspection No body odor No body odor No body odor

Signs of Inspection Distress No distress Presence of

distress pain due to
post operation
(CS).
Effect of mood Inspection Cooperative Cooperative Normal

Speech Inspection Coherent Coherent Normal

Vital Signs during the assessment (Date: January 18, 2016 Time: 8:00 AM)

Area Assessed Technique Used Actual Normal Analysis

Findings Findings
Temperature Measured using a 36.1 degree 36-37.5 degree Normal
thermometer Celsius Celsius
Pulse rate Palpation 90 bpm 60-100 bpm Normal
Respiratory Inspection 20 cpm 12-20 cpm Normal
rate
Blood Measured using a 110/70 mmHg 90/60 120/80 Normal
Pressure sphygmomanomet mmHg
 er and stethoscope

Skin

Area Assessed Technique Used Actual Normal Analysis

Findings Findings
Color Inspection Brown Light brown to Normal
brown
Symmetry of Inspection Symmetrical Symmetrical Normal
color
Edema Inspection Absent Absent Normal

Skin lesions Inspection No lesions No lesion Normal

Moisture Inspection Moist Moist Normal

Temperature Palpation Warm to touch Warm to touch Normal

Skin Turgor Palpation Good skin Good skin turgor Normal

turgor

Nails

Area Assessed Technique Used Actual Normal Analysis

Findings Findings
Nail curvature Inspection Convex Convex Normal
Texture Inspection and Firm Firm Normal
palpation
Nail bed color Inspection Pinkish Pinkish Normal

Surrounding Inspection Intact Intact Normal

tissue
Capillary refill Palpation 2 seconds Less than 2-3 sec Normal

Head
Area Assessed Technique Used Actual Normal Findings Analysis
Findings
 Shape Inspection Normocephalic Normocephalic Normal
with smooth
contour
Nodule/Masses Palpation Absent Absence of Normal
nodule/masses

Eyes

Area Assessed Technique Used Actual Findings Normal Analysis

Findings
Pupils Inspection Black, pupils Black, pupils Normal
equal, round, equal, round,
reactive to light reactive to light
accommodation accommodation
(PERRLA)
Extra ocular Inspection Coordinated Coordinated Normal
movement
Eyebrows Inspection Evenly Evenly Normal
distributed distributed
Eyelids Inspection Intact skin, Intact skin, Normal
bilateral blinking bilateral blinking

Conjunctiva Inspection Pinkish Pinkish Normal

Cornea Inspection Clear Clear Normal
Lacrimal gland Palpation No tenderness No tenderness Normal
Eye lashes Inspection Evenly Evenly Normal
distributed distributed

Ears

Area Assessed Technique Used Actual Findings Normal Analysis

Findings
Pinna Inspection Uniform in Uniform in Normal
color, color,
symmetrical symmetrical
Ear canal Inspection Presence of Presence of Normal
cerumen/earwax cerumen/earwax
Hearing acuity Inspection Responds when Responds when Normal
called called
Nose

Area Assessed Technique Used Actual Findings Normal Analysis

Findings
External nose Inspection Symmetrical Symmetrical Normal
Nasal cavity Inspection Dark pink, dry, Dark pink, dry, Normal
free of exudates free of exudates.
Sinus Palpation No tenderness No tenderness Normal
tenderness
Nasal mucosa Inspection Intact and Intact and Normal
midline midline

Pharynx

Area Assessed Technique Used Actual Findings Normal Analysis

Findings
Uvula Inspection In midline In midline Normal
Oropharynx Inspection Pink Pinkish Normal
Gag reflex With the use of a Intact Intact Normal
tongue depressor

Mouth

Area Assessed Technique Used Actual Findings Normal Analysis

Findings
Lips Inspection Symmetrical Symmetrical Normal
Teeth Inspection Complete 32 pearly normal Normal
teeth
Gums Inspection Pinkish, moist, Pink, moist, Normal
firm, intact firm, intact
Tongue Inspection Midline and Midline, pinkish, Normal
movable movable
Palate Inspection Light pink, intact Light pink, intact Normal

Neck

Area Assessed Technique Used Actual Findings Normal Findings Analysis

Muscles Palpation Symmetrical Symmetrical Normal
Movement Inspection Coordinated Coordinated Normal
Range of motion Inspection Full Full Normal
Muscle strength Inspection Equal Equal Normal
Lymph nodes Palpation Not palpable Not palpable Normal
Trachea Inspection In midline In midline Normal

Chest and Lungs

Area Assessed Technique Used Actual Findings Normal Findings Analysis

Breathing Inspection Regular Regular Normal
pattern
Symmetry Inspection Symmetrical Symmetrical Normal
Spinal Inspection and Aligned Aligned, in Normal
alignment palpation midline
Skin Inspection Smooth, no Smooth, no Normal
tenderness and tenderness and
lesions lesions
Breath sounds Auscultation Clear Clear Normal

Heart

Area Assessed Technique Used Actual Findings Normal Findings Analysis

Rhythm Auscultation Regular Regular Normal
Heart sounds Auscultation S1 louder at S1 louder at apex, Normal
apex, S2 louder S2 louder at base
at base
Abdomen

Area Assessed Technique Used Actual Findings Normal Findings Analysis

Skin integrity Inspection Unblemished Unblemished Normal
Contour Inspection Rounded Flat/Rounded Normal
Symmetry Inspection Symmetrical Symmetrical Normal
Bowel sounds Auscultation High pitched, High pitched, Normal
irregular gurgles, irregular gurgles,
5-35 times/min 5-35 times/min in
in all quadrants all quadrants
Percussion Percussion N/A Generalized Has a
 tympanic sounds suture on
the
abdomen
due to CS
Palpation Palpation N/A No tenderness Has a
suture on
the
abdomen
due to CS

Back and Extremities

Area Assessed Technique Actual Normal Analysis

Used Findings Findings
Muscle size Inspection Equal Equal Normal
Muscle tone Palpation Firm Firm Normal
Muscle Inspection Unequal Equal Due to pain
strength associated with
a suture on the
abdomen
Bones Palpation No tenderness No tenderness Normal
Joints Palpation No tenderness No tenderness Normal
Range of Inspection Minimal Full Presence of
motion Movement pain due to post
operation (CS)
 LABORATORY STUDY

Complete Blood Count (CBC)

C.S #: C862030L Test Requested : January 16, 2016 (8:06:17 PM)

Physician: Blas, Maritess Conejares Result Encoded: January 17, 2016 (7:32:00 AM)
Specimen: Blood Result Printed : January 17, 2016 (7:32:53 AM)
Hospital #: 96944 Accession #: 1
Admission #: 261304

Procedure Indication/Purpose Normal Values Results Interpretation

It is the count of the Normal for post
actual number of red operation patient due
RBC blood cells per 4.50-5.50x10^12/L 2.90 to blood loss related to
volume of blood. surgery (Cesarean
Section)

(www.emedicinehealt
h.com)
It is a protein used by Normal for post
red blood cells to operation patient due
Hemoglobin distribute oxygen to 110.00-150.00g/L 83 to blood loss related to
other tissues and cells surgery.
in the body.
(Merck Manual,
Lifesstrong.com)
 It is traditionally Normal for post
defined as the operation patient due
Hematocrit percentage of RBCs 0.37-0.47L 0.25 to blood loss related to
per volume of whole surgery
blood.
(Merck Manual,
Lifesstrong.com)
These immune cells Normal for post
form in the bone operation patient for
WBC marrow to help fight 4.50-10.00x10^9/L 17.5 immunity purposes.
infection.
(ph.answers.yahoo.co
m)
Segmenters Used to determine if 0.50-0.70 0.75 Normal for post
there is infection. operation patient for
immunity purposes.
Eosinophils A type of phagocyte 0.00-0.05 0.02 Normal
that produces the
anti-inflammatory
protein histamine.
Used to diagnose
allergy, drug
reactions, and
Parasitic infections.
Lymphocytes Include T-cells, B- 0.20-0.40 0.16 Low lymphocytes may
cells, and NK cells. indicate infections or
Viral infections may inflammation
increase their
number. (www.wikipedia.com)

It is a type of white
blood cell that is
produced by the bone
Monocytes marrow and helps to 0.00-0.07 0.07 Normal
protect the body from
foreign invaders,
such as harmful
bacteria and viruses.
Platelets Helps to determine 150.00- 239 Normal
 the presence of 400.00x10^9/L
bleeding

Urinalysis

C.S #: C862030L Test Requested : January 15, 2016 (9:21:12 PM)

Physician: Blas, Maritess Conejares Result Encoded: January 15, 2016 (7:42:00 AM)
Specimen: Urine Result Printed : January 15, 2016 (7:43:30 AM)
Hospital #: 96944 Accession #: 8A
Admission #: 261304

Color Yellow
Transparency Hazy
Reaction (pH) 6.0
Protein Negative
Glucose Negative
Specific Gravity 1.030
RBC 0
Pus cells 0
Epithelial cells Few
Bacteria Few
 CLINICAL FINDINGS

The patient is lying on bed, awake, conscious, responsive, and coherent with the

following vital signs: Temperature rate is 36.1 Degree Celsius (NV: 36.5 37.5 Degree

Celsius), Blood Pressure is 110/700 mmHg (NV: 120/80 mmHg), Respiratory rate is 20

cpm (NV: 12 20 cpm) and Pulse rate is 90 bpm (NV: 60 100 bpm). Her CBC

(Complete Blood Count) on January 16, 2016 the result shows that there is decrease in

Red Blood Cells 2.90, for the hemoglobin the result is 83, and Hematocrit is 0.25. This

result shows that they are normal for post operation patient due to blood loss related to

surgery. On the other hand there is increase in WBC (White Blood Cell), the result shows

17.25 and segmenter is 0.75 which means that it is normal for post operation patient for

immunity purposes, because during surgery they act as compensatory mechanism for

foreign objects used during surgery. For lymphocytes, low results may indicate presence

of infections which is normal for post operation thats why WBC compensates the low

results of lymphocytes. For the patient's Urinalysis Test that was conducted on January

16, 2016, result shows no problem.

 PATHOPHYSIOLOGY

Pre -Term Labor

MODIFIABLE: NON-MODIFIABLE:

long travel to Congenital uterine

work (from Talon or cervical
3 Las Pias City lllll anomalies
to Pasig City)
Stress due to Age: 38 years old
work and travel
multiple gestation
Previous CS (2x) Lll
inadequate
prenatal care

Uterine contraction on 36
weeks and 2/7 days of 6
minutes interval with
dilatation of 1 cm

Lower back pain Abdominal cramping

or tightening
 Legends:
Risk
Factors Pathology
Actual Problem
Problem Rank
Acute Pain related to
surgical incision due to
caesarean birth as
evidenced by facial
grimace with a pain scale
of 7/10.
Activity intolerance
related to presence of
surgical incision as
manifested by limited
mobility on the lower
extremities.
Impaired skin integrity
related to mechanical
trauma of surgical
removal of skin and
Manifestation Problem
PROBLEM PRIORITIZATION
s
Justification
1 Caesarean delivery is the surgical removal of the infant from the
uterus through an incision made in the abdominal wall and the uterus.
Pain must be given the 1st priority because this is one of the basic
physiological demands that need proper management which
facilitates recover, prevents additional health complications, and
improves an individuals quality of life.
2 Activity intolerance is our second priority because
immobility, stress, and weakness are some factors which affect
clients tolerance to activity. Insufficient physiological
and psychological energy may hinder clients ability to
engage in necessary activities. The client has just undergone C-
section a few days ago which altered her physical state and
restricts the patient from achieving full level of activity.
3 Skin is the bodys first line of defense against foreign
materials that can be considered as injuring agents. Once
the skin is disrupted, this will put a person at risk since it
may become a good medium for bacterial growth. Cesarean
subcutaneous tissue
secondary to Cesarean
Section.
Potential Problem
Problem
Risk for infection related
to inadequate first line of
defenses (intact skin)
secondary to surgical
incision.
Risk for falls related to
postoperative conditions
as evidenced by body
weakness.
section, like any other surgical procedures, includes
invasion of the inside body, specifically the skin and
subcutaneous area, that makes it our third priority.
(NANDA 9th edition.pp461-465) (MedSurgicalNursing,
Black and Hawks 8th Edition pp856-859)
Rank Justification
1 The infection must be given the first priority because the
skin is a barrier to infectious agents; however, any break in
the skin can readily serve as a portal of entry putting the
individual at risk for potential infections.
(Fundamentals of Nursing by Kozier, et.al., 7th edition,page
633)
2 The risk for fall is our second priority. Prevention of falls is an
important dimension of the nursing care settings. Implementation of
policies and procedures designed to prevent falls is an essential part of
nursing care in any health care setting. Fall prevention strategies need
to promote patient dignity and functional independence by
significantly limiting the use of physical restraints to maintain safety.
Nurses also have a major role in educating patients, families, and
caregivers about prevention of falls in the home.
(Gulanick, 2007)
 NURSING DIAGNOSIS

Nursing diagnosis (3 Actual and 2 Potential)

3 Actual:

1. Acute Pain related to surgical incision due to caesarean birth as evidenced by

facial grimace with a pain scale of 7/10.

2. Activity intolerance related to presence of surgical incision as manifested by

limited mobility on the lower extremities.

3. Impaired skin integrity related to mechanical trauma of surgical removal of skin

and subcutaneous tissue secondary to Cesarean Section.

2 Potential:

1. Risk for infection related to inadequate first line of defenses (intact skin)
secondary to surgical incision.
2. Risk for falls related to postoperative conditions as evidenced by body weakness.
 DISCHARGE PLANNING

Medication

Should be taken regularly as prescribed, strictly follow exact dosage, time, &

frequency. The patient and relatives must make sure that they fully understand the

importance of taking the medications.

Instruct patient and relatives to immediately report any side effects/adverse

reactions.

Exercise

ROM exercises.

Gradual back to basic daily routines.

Should be promoted in a way by stretching all body parts every morning. Patient

should be encouraged to keep active through light exercises.

Maintain rest periods in between activities.

Treatment

Discuss the purpose of treatments to be done and continued at home:

Cleaning and properly dressing of the suture.

Discussed on the importance of strict adherence to medication regimen to ensure

complete healing.
Instructed patient to understand and follow discharge instruction religiously and
accurately.
Instructed patient to follow proper instruction on medication prescribed by the
physician.
Health Teaching

Discuss to the patient and family the importance of:

Bed rest

Proper Hygiene

Promote safety and comfort.

Instructed patient to avoid any strenuous or heavy activities.

Notify MD if s/sx noted (ex: fever, chills, redness around the incision, and any
discharges).

Outpatient

Patient is advised for follow up check-up to her physician one (1) week after
discharge.
Remind the patients family that frequent check-ups are important to improve

patients condition and improve optimum level of wellness

Inform significant members to report any abnormalities as soon as possible to

prevent further complications.

Instructed patient to notify physician of there is any undesired feeling about the
disease.

Diet

Advise patient to have complete nutritional intake to

Spiritual counseling

Advise patient to pray. A helpful way of promoting general well-being and sense

of connection with himself, or spiritual power. Never forget to thank god for all

the blessings she and her family has been receiving.

Encourage patient and family to continue participating in desired religious

activities such as contact with minister, rosary, singing in choir. Family that shows

support and understanding of the patients condition strengthens bonds, faith in

God, and decreases occurrence of stress.

 REFERENCE:

Books

Berman, A., Snyder, S. (2011). Kozier & Erbs fundamentals of nursing: concepts,

process, and practice (9th ed.). Philadelphia: Prentice Hall

Doenges, M., Moorhouse, M. F., Murr, A. (2010). Nurses pocket guide

diagnoses, prioritized interventions, and rationales (12th ed.). Philadelphia: F.A.

Davis Company.

Karch, A. (2012). Lippincotts nursing drug guide (17th ed.). Philadelphia:

Lippincott Williams & Wilkins.

Smeltzer, S., Bare, B., Hinkle, J., et al. (2010). Brunner & Suddarths textbook of

medical-surgical (12th ed.). Philadelphia: Lippincott Williams & Wilkins.

Electronic Sources:
HTTP://WWW.CANCER.CA/EN/CANCER-INFORMATION/CANCER

TYPE/UTERUS/ANATOMY-AND-PHYSIOLOGY/?REGION=ON

HTTP://EMEDICINE.MEDSCAPE.COM/ARTICLE/167981-OVERVIEW