College of Health Sciences

Bachelor of Science in Nursing

A.Y 2018-2019 2nd Semester

A CASE STUDY IN

INTRAUTERINE FETAL DEATH

PRESENTED BY:

Cortez, Ronyx Nicomedes M.

Salavaria, Shiela Mae S.
Tabiolo, Ace Gabriel M.

PRESENTED TO:
Prof. Levi Ubalde
TABLE OF CONTENTS

I. Introduction 1

II. Objectives 2

III. Client’s Profile 3

IV. Nursing History 4

V. Gordon’s 11 Functional Health Pattern (table 1.0) 5

VI. Theoretical Framework 8

VII. Anatomy and Physiology (figure 1.0, 2.0, 3.0) 10

VIII. Pathology and Physiology (figure 4.0) 13

IX. Physical Assessment (table 2.0) 15

X. Diagnostic Procedure (figure 5.0) 22

XI. Drug Study (table 5.1, 5.2) 24

XII. Nursing Care Plan (table 6.1, 6.2, 6.3) 32

XIII. Discharge Plan 39

0
I. Introduction

Intrauterine fetal death/demise or commonly known as stillbirth, is used to describe

a death of an infant in the uterus. Common causes are congenital birth defects, placental
abruptio, placental dysfunction, uterine rupture and cord compression.
Intrauterine fetal demise is the 5th leading cause of death worldwide but less than
5 percent of still births are recorded globally. Chronic hypertension increases stillbirth risk
up to three-times. While Diabetes increases stillbirth risk up to five times. A meta-analysis
showed that only improving glucose control prior to conception reduces the rate of
stillbirth. With optimal glycemic control, the risk of stillbirth may be reduced. In type 1
diabetics, the stillbirth rate is 16.1 per 1000 births. Poor diabetic control determined by
elevated glycosylated hemoglobins before pregnancy and later in pregnancy were
associated with stillbirth. In type 2 diabetics, the stillbirth rate is 22.9/1000 births. A higher
BMI and elevated glycosylated hemoglobin before pregnancy were associated with
stillbirth. The birth weight may be affected by diabetes and is also related to the risk of
stillbirth. If the birth weight is less than the 10th percentile, the risk for stillbirth is elevated
six times in mothers with type 1 diabetes and three times in those with type 2 diabetes
compared to fetuses weighing in the 10th to 90th percentile. With type 2 diabetes, the risk
for stillbirth was twofold higher if the birth weight was over the 95th percentile. A
significantly higher number of stillborns in women with type 2 diabetes are male gender.
A third of the stillbirths associated with diabetes occur at term. The highest rate for stillbirth
is in the 38th week for type 1 diabetes and in the 39th week for type 2 diabetes.

The student nurses were assigned to this case as one of their requirements; it is
interesting and it allows us to understand more about this case in an obstetric setting and
how they are affected with this illness and thus, giving the other student nurses more
knowledge on the said case and learn how to apply it in the near future. This will not be
possible if not with the cooperation of the client which were very cooperative in helping
us to achieve whatever our aims are in this study.

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II. General Objectives:

This study aims to understand the different problems that are related to Intrauterine
Fetal Death. Thus, giving the researchers the right idea on how to formulate nursing
interventions related to such case and to apply it in their time in the clinical area.

II.A Specific objectives:

1. Establish rapport to the client and to the relatives.

2. Assess and collect specific information about the client to serve as baseline data.
3. Formulate nursing diagnosis related to the problem.
4. Planning and implementing the different interventions to the client.
5. Evaluate if the nursing interventions were effectively.

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III. Client’s Profile

A.) Patient’s Biographical Data

Name: J.J
Age: 28 years old
Sex: Female
Civil Status: Single
Address: Eastwood Residences, Rizal
Religion: Born Again Christian
Birthplace: Quezon City
Health Care Financing: Phil Health
Admitting Diagnosis: G1 P0 36 5/7 weeks CIL: Chronic Hypertension t/c
Gestational Diabetes Mellitus Intrauterine Fetal Death
Admitting Date: May 26, 2020
Admitting Time: 7:00 pm
Room: Private
Final Diagnosis: G1 P1 (1000) pregnancy uterine and cephalic, stillbirth
in an emergency caesarean section secondary to
arrest in cervical dilatation with spinal anesthesia
delivered a stillbirth baby Girl BW: 2750g BL 47 cm

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IV. Nursing History

A.) Chief Complaints

Poor detection of fetal heart tone

B.) History of Present Medical Condition

10 minutes prior to admission patient was at a local lying-in clinic when there
was noted with difficulty getting fetal heart tone. Patient denies any vaginal
discharge. LMP 09/12/2019 AOG 36 5/7

C.) History of Past Medical condition

No past medical condition was noted.

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V. Gordon’s 11 Functional Health Pattern

Table 1.0– Gordon’s 11 Functional Health Pattern

FUNCTIONAL
BEFORE DURING
HEALTH ANALYSIS
HOSPITALIZATION HOSPITALIZATION
PATTERN
The patient defines The client stated that I The client realizes
health as the absence of thought I was healthy; I being hospitalized that
any disease or illness. eat right, and I did not being healthy is not just
According to the client, feel anything weird about eating right and
Health she takes ferrous sulfate while being pregnant. the absence of the
Perception / twice a day during her But I still loss my first signs and symptoms of
Management pregnancy. She uses child. disease.
OTC drug such as
neozep and paracetamol
whenever she DISTURBED ENERGY
experiences illness. FIELD
According to the patient According to her, she Due to her loss, she is
her favorite meals were tries to eat the meal experiencing low
mango, chips, fried given to her by the appetite.
fishes and cakes. She hospital and by his
Nutritional also eats 2-3 cups of visitors, but she has a
- rice per meal. And 7 poor appetite and easily
Metabolic glasses of water a day gets full.
she confessed that she IMBALANCED
frequently drinks soda NUTRITION: LESS
and juices during her THAN BODY
early pregnancy. REQUIREMENTS
The patient defecates 2x The client is currently Due to the spinal
a day with bulky and inserted with catheter. anesthesia natural
well-formed stool. She bladder emptying is
Elimination urinates 5-7x a day with impaired.
yellow amber color. She
also has no history of IMPAIRED URINARY
difficulty defecating ELIMINATION
According to the client, The client is put into As the client undergone
she walks every bedrest. The does only cesarean section, she
morning, do some light limited activities during wasn’t able to do much
Activity - chores like washing activities as it may
her hospital stay.
Exercise clothes and dishes. affect her post-surgical
incision.
IMPAIRED PHYSICAL
MOBILITY

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 No problem with senses She continually follows The client is able to
Oriented to people, time, the instructions given by understand her
and date. her doctor and nurses. situation. She shows
Cognitive- Responds to stimuli The client is seen signs of sadness and
Perceptual verbally and physically apathetic and irritable grief.
sometimes.
DEFICIENT
KNOWLEDGE
The client stated that The client stated The client experiencing
she usually sleeps at difficulty sleeping. She light sleep due to
6pm and wakes up at 4 is experiencing light sudden change of
am. She takes a nap for sleeps with frequent environment and
Sleep - Rest 2-3 hours at noon. wakes. She usually emotional stress.
sleeps around 9pm and
wakes around 1am or
3am tries to sleep again
and completely wakes DISTURBED SLEEP
up at 7am PATTERN
According to the client, She stated that she is Due to her loss, she is
at first her partner was in having doubts about having her doubts about
Self-Concept / shock in hearing the herself and health. her self-perception and
Self news but later on they self-concept.
Perception both became excited to
see her growing belly SITUATIONAL LOW
SELF-ESTEEM
The client feels the The client stated that She is experiencing
support of her partner she is having doubts if doubts about her
Role - and family. She had she can still conceive motherhood and self.
Relationship problem doing her usual and be an effective
tasks and roles as home mother in the future
maker. GRIEVING
The client had her The client stated that Due to the unexpected
menarche at the age of she is having doubts if loss, she is
12. She has she could still conceive experiencing doubts
regular/monthly and give birth and uncertainty about
Sexuality - menstruation that lasts her capability to
Reproductive for 3-4 days before reproduce and
getting pregnant. Uses conceive.
withdrawal method as
natural contraceptive
SITUATIONAL LOW
SELF-ESTEEM
The client stated that The client stated that She tries to cope by
she manages stress by when she feels sad and taking it in by herself.
Coping – watching TV programs uncertain, she cries or
Stress and going to neighbor to stares blankly at the
Tolerance have chitchats. corner thinking of IMPAIRED INDIVIDUAL
different things. RESILIENCE

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 The client is a born According to the client, She had a hard time
again Christian. She she prays for Guidance attending worship while
attends their worship and ask why this pregnant. While in
once a month. happened to her, to hospital she tried to
Value - Belief give her clarity and look for answers why
peace of mind in these this happened to her by
times. asking God.

RISK FOR SPIRITUAL

DISTRESS

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VI. Theoretical Framework

Jean Watson: Philosophy and Science of Caring

According to Jean Watson, Nursing is not just a mere profession, it is a Nurse’s

“Caring instinct”. A caring attitude promotes health better than just delivering medical
treatment. As a Nurse we take care of our patient with compassion, integrity, and
justice. We treat our patent with a highest value, to receive quality care, to be nurtured,
understood and assisted. Our role is to promote growth, while providing a caring
environment where the patient is accepted from what she is and she may become.

Caring consists of carative factors. Watson’s 10 carative factors are: forming

humanistic-altruistic value systems, instilling faith-hope, cultivating a sensitivity to self
and others, developing a helping-trust relationship, promoting an expression of feelings,
using problem-solving for decision-making, promoting teaching-learning, promoting a
supportive environment, assisting with gratification of human needs, and allowing for
existential-phenomenological forces.

Discussion

Our group associated this theory from Jean Watson to our assigned Case study;
we all know that a death of loved one, especially a mother who loss a baby would make
them vulnerable and may feel incomplete. As future Nurses, we should show our patient
kindness and caring. We should address their needs in a holistic approach.

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VII. Anatomy and Physiology

External Female Reproductive System

Figure 1.0 Anatomy and Physiology

The Hymen
It covers the opening of the vagina. It is a thin piece of tissue that has one or more
holes in it. Sometimes a hymen may be stretched or torn when you use a tampon or
during a first sexual experience. If it does tear, it may bleed a little bit.

The Vulva
It covers the entrance to the vagina. The vulva has five parts: mons pubis, labia,
clitoris, urinary opening, and vaginal opening.

The Mons Pubis

It is the mound of tissue and skin above your legs, in the middle. This area
becomes covered with hair when you go through puberty.

The Labia
Labia are the two sets of skin folds (often called lips) on either side of the opening
of the vagina. The Labia Majora are the outer lips, and the Labia Minora are the inner lips.
It is normal for the labia to look different from each other.

The Clitoris
It is a small, sensitive bump at the bottom of the mons pubis that is covered by the
labia minora.

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The Urethral Opening
It is where your urine (pee) excretes from the body.

Internal Female Reproductive System

Figure 2.0 Anatomy and Physiology

The Ovaries
Ovaries are two small sex organs. Before puberty, it’s as if the ovaries are asleep.
During puberty, they “wake up.” The ovaries start making more estrogen and other
hormones, which cause body changes. One important body change is that these
hormones cause you to start getting your period, which is called menstruating. Once a
month, the ovaries release one egg (ovum). This is called ovulation.

The Fallopian Tubes

It connects the ovaries to the uterus. The released egg moves along a fallopian
tube. That is composed of fimbriae, Infundibulum, ampulla and isthmus

The Uterus — or womb

is where a baby would grow. It takes several days for the egg to get to the uterus.
The uteral muscle is composed of endometrieum, myometrium and perimetrium. As the
egg travels, estrogen makes the lining of the uterus (called the endometrium) thick with
blood and fluid. This makes the uterus a good place for a baby to grow. You can get
pregnant if you have sex with a male without birth control and his sperm joins the egg
(called fertilization) on its way to your uterus.

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The Cervix
Is the narrow entryway in between the vagina and uterus. The cervix is flexible so
it can expand to let a baby pass through during childbirth.

The Vagina
is like a tube that can grow wider to deliver a baby that has finished growing inside
the uterus.

Fetal Circulation

As early as the third week

of intrauterine life, fetal blood
begins to exchange nutrients with
the maternal circulation across the
chorionic villi. Fetal circulation
differs from extrauterine
circulation because the fetus
derives oxygen and excretes
carbon dioxide not from gas
exchange in the lung but from gas
exchange in the placenta. Blood
arriving at the fetus from the
placenta is highly oxygenated.
This blood enters the fetus
through the umbilical vein (called a
vein even though it carries
oxygenated blood, because the
direction of the blood is toward the
fetal heart). Specialized structures
present in the fetus then shunt
blood flow to first supply the most important organs of the Figure 2.4 – Fetal Circulation
body: the brain, liver, heart, and kidneys. Blood flows
from the umbilical vein to the ductus venosus, an accessory vessel 0 that directs
oxygenated blood directly to the fetal liver. Blood then empties into the fetal inferior vena
cava so oxygenated blood is directed to the right side of the heart. Because there is no
need for the bulk of blood to pass through the lungs, it is shunted, as it enters the right
atrium, into the left atrium through an opening in the atrial septum, called the foramen
ovale.
From the left atrium, it follows the course of adult circulation into the left ventricle
and into the aorta. A small amount of blood that returns to the heart via the vena cava
does leave the right atrium via the adult circulatory route—that is, through the tricuspid
valve into the right ventricle, and then into the pulmonary artery and lungs to service the
lung tissue. However, the larger portion of even this blood is shunted away from the lungs
through an additional structure, the ductus arteriosus, directly into the descending aorta.

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Most of the blood flow from the descending aorta is transported by the umbilical arteries
(called arteries, even though they are now transporting deoxygenated blood, because
they are carrying blood away from the fetal heart) back through the umbilical cord to the
placental villi, where new oxygen exchange takes place.
The blood oxygen saturation level of the fetus is about 80% of a newborn’s
saturation level. The rapid fetal heart rate during pregnancy (120–160 beats per minute)
is necessary to supply oxygen to cells, because the red blood cells are never fully
saturated. Despite this low blood oxygen saturation level, carbon dioxide does not
accumulate in the fetal system because it rapidly diffuses into maternal blood across a
favorable placental pressure gradient.

The blood circulatory system (cardiovascular system) delivers nutrients and

oxygen to all cells in the body. It consists of the heart and the blood vessels running
through the entire body. The arteries carry blood away from the heart; the veins carry it
back to the heart. The system of blood vessels resembles a tree: The “trunk” – the main
artery (aorta) – branches into large arteries, which lead to smaller and smaller vessels.
The smallest arteries end in a network of tiny vessels known as the capillary network.

There is only one blood circulatory system in the human body, but two, which are
connected: The systemic circulation provides organs, tissues and cells with blood so that
they get oxygen and other vital substances. The pulmonary circulation is where the fresh
oxygen we breathe in enters the blood. At the same time, carbon dioxide is released from
the blood.
Figure 2.5 – Fetal Circulation
Blood circulation starts when the heart 0
relaxes between two heartbeats: The blood flows
from both atria (the upper two chambers of the
heart) into the ventricles (the lower two
chambers), which then expand. The following
phase is called the ejection period, which is when
both ventricles pump the blood into the large
arteries.

In the systemic circulation, the left

ventricle pumps oxygen-rich blood into the main
artery (aorta). The blood travels from the main
artery to larger and smaller arteries and into the
capillary network. There the blood drops off
oxygen, nutrients and other important
substances and picks up carbon dioxide and
waste products. The blood, which is now low in
oxygen, is collected in veins and travels to the right atrium and into the right ventricle.

This is where pulmonary circulation begins: The right ventricle pumps low-oxygen
blood into the pulmonary artery, which branches off into smaller and smaller arteries and
capillaries. The capillaries form a fine network around the pulmonary vesicles (grape-like
air sacs at the end of the airways). This is where carbon dioxide is released from the

12
blood into the air inside the pulmonary vesicles, and fresh oxygen enters the bloodstream.
When we breathe out, carbon dioxide leaves our body. Oxygen-rich blood travels through
the pulmonary veins and the left atrium into the left ventricle. The next heartbeat starts a
new cycle of systemic circulation.

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 VIII. Pathophysiology
Figure 4.0 Pathophysiology
Predisposing factors
Precipitating
-Primigravidarum factors

-Hypertension -diet

(>140/90mmHg) -lifestyle

-Diabetes Mellitus -lack of prenatal

checkup
-Obesity

-oligohydramnios

Pregnancy

Early pregnancy >20 weeks pregnancy

(<20weeks )

Invasion of trophoblast
Decreased peripheral in the spiral artery Increase
vascular resistance
diameter of
the spiral
Failure of Trophoblast
artery

Less blood supply in

the placenta Increase
Normal BP blood
circulation to
<140mmHg Placenta release Placenta will the fetus
SBP substance due to become ischemic
<90mmHg stress
DBP Fetal
Damaging the growth
Restriction of
endothelial cells
fetal growth

Issue with
EDEMA
permeability STILLBIRTH
Platelets in
action

HYPERTENSION Vasospasm
Decrease in
circulation
leads to DIC
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IX. Physical Assessment
Patient Name: W.G.
Weight: 95 kg
Height: 170 cm
Temperature: 36.8 °C RR: 24 bpm
Age: 36 years old CR: 110 bpm
BP: 160/80
General Appearance: Fair skin, lordotic, conscious and alert.

Table 2.0 - Physical Assessment

Methods of
Body Part Normal Findings Actual Findings Interpretation Analysis
Assessment

Skin Inspection Skin is intact, and With some discoloration Normal Normal
Palpation there are no due to pregnancy
reddened areas.
And normal skin
tones without
unusual or
prominent
discoloration
Hair Inspection Evenly distributed ▪ Evenly distributed Normal Normal
hair, thick hair, hair.
silky resilient hair, ▪ Long, black and
No infection or an shiny hair.
infestation.
Scalp Inspection Rounded, ▪ Rounded, Normal Normal
Palpation normocephalic normocephalic and
and symmetrical, symmetrical, smooth
smooth and has

15
 uniform and has uniform
consistency. consistency.
Absence of
nodules or
masses.
Face Inspection Symmetrical ▪ Symmetrical facial Normal Normal
facial movement, movement, palpebral
palpebral fissures fissures equal in
equal in size, size, symmetric
symmetric nasolabial folds.
nasolabial folds.
Eyelids Inspection Skin intact, no ▪ Skin intact with no Swollen eyelids Due to the patient
discharges, no discharges, reddish due to excessive sudden loss she
discoloration. to pinkish coloration lacrimal secretion experiences extreme
Lids closes and notably swollen. sadness or guilt.
symmetrically ▪ Lids close
symmetrically and
blinks involuntary
Sclera Inspection Pearly white in Appears white Normal Normal
color without any
discoloration
Iris and Inspection Color of iris will ▪ Iris: Dark brown in Normal Normal
depends on colour, equal in size
Pupils ethnicity with ▪ pupils constrict when
round smooth looking at near
border, iris flat object, and dilate,
and round, pupil when looking at far
constrict when objects.
looking at near ▪ Both pupils constrict
object pupils when light is near
converge when

16
 near object pupils and dilates when
converge when light is removed.
near object is
moved toward
nose.
Auricles Inspection Color of auricles Symmetrical and same Normal Normal
and Pinna Palpation is same facial overall color with the
skin tone body
symmetrically
auricle is same
as facial skin
symmetrically
auricle is aligned
w/ the outer
canthus of the
eye, mobile firm,
non-tender.
External Inspection Without impacted No masses or lumps Normal Normal
ear canal Palpation cerumen
Hearing Inspection Can hear sound Can hear sound clearly Normal Normal
acuity test clearly
Nasal Inspection Mucosa is pink, No lesions, no Normal Normal
cavity no lesions and discharge.
nasal septum
intact and in
middle with no
tenderness

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Lips and Inspection No ulcerations, Dry chapped lips, no Signs of Due to the patient’s
buccal Palpation no masses, color masses, and ulcerations inadequate fluid current condition, she
and leisure intake is experiencing
insufficient fluid intake
Teeth Inspection Deciduous Teeth Complete teeth and Normal Normal
and gums Formation pinkish gums

Upper
Central incisor
8-12 months
Lateral incisor
9-13 months
Cuspid
16-22 months
First molar
13-19 months
Second molar
25-33 months

Lower
Second molar
23-31 months
First molar
14-18 months
Cuspid
17-23 months
Lateral incisor
10-16 months
Central incisor
6-10 months
And formation of
permanent

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 central and lateral
incisor and
eruption of
permanent first
molar
Tongue/ Inspection Central position Central position Dry and Signs of Due to the patient’s
floor of the pinkish but w/ reddish color w/ veins inadequate fluid current condition, she
mouth whitish coating prominent in the floor of intake is experiencing
which normal w/ the mouth. insufficient fluid intake
veins prominent
in the floor of the
mouth.
Palates and Inspection Hard palate is ▪ The palate is Normal Normal
uvula concave in color concave.
lighter pinkish in ▪ light pinkish in color
color it has many
ridges it is moist
without any
lesions or
malformations.
Oropharynx Inspection No tenderness ▪ No tenderness Normal Normal
and tonsils Palpation and masses. No ▪ No masses
pain when ▪ No pain
palpated.

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Neck Inspection No tenderness, No tenderness, no Normal Normal
muscle Palpation no masses masses symmetrical.
symmetrical.
Trachea Palpation Spaces should be Central placement in Normal Normal
systematic on the midline of neck: spaces
central are equal on both sides.
replacement in
midlife of neck
spaces are equal.
Nails Inspection ▪ Smooth ▪ With short and clean Edematous lower Due to edema blood
Palpation texture fingernails and extremities circulation is not
▪ Convex and toenails. optimal resulting to a
with good ▪ Capillary refill of longer capillary refill
capillary Refill upper extremities 2-3
time of 2 seconds.
seconds. ▪ Capillary refill of
lower extremities 4-5
seconds.

Chest Area Inspection Symmetrical with Symmetrical with no Normal Normal

Palpation no lumps and lumps and masses
masses
Abdomen Inspection Unblemished skin ▪ Linea negra and Normal Normal
Auscultation uniform in color, striae gravidarum
Palpation fat, no evidence can be seen and
Percussion of enlargement of we could feel the
liver and spleen. that the abdomen
is firm and
contracted.
▪ With visible
wound on the

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 hypogastric
region
Lower Extremities
Hip and Inspection ▪ Bilaterally ▪ Good pelvic thigh Normal Normal
Thigh Palpation symmetrical fixation
and equal
▪ Pelvis by
manual
fixation
Foot and Inspection ▪ Bilaterally Has edema from shin Accumulation of Poor blood circulation
Ankle Palpation align, below fluid to lower
symmetrical, extremities
equal
▪ Right and left
has no
lesions.
▪ Skin color is
the same as
other part of
the body.
Muscles Inspection Equal in size both Muscle strength grading Weakened muscle Decrease muscle
Palpation sides of the body, of 4/5 strength strength due to
smooth, sedation
coordinated
movement, 100%
of normal full
movement
against gravity
and full
resistance.

21
Bones and Inspection Right alignment, No deformities or Normal Normal
joints Palpation normal length, swelling, joints move
move smoothly, smooth
no swelling, no
deformities

22
X. Diagnostic Procedure

RADIOLOGIC IMAGING (XRAY)

ID No: **** Hospital no.: ****** OR no.: ***

Name: W.G, Age: 28 yrs. Old Sex: Female Room: ***
Requesting Physician: Dra. Macapagal Date: 05/27/2020

RADIOLOGIC FINDINGS

Both lungs are clear.

Heart and great vessels are within normal size and configurations.
Other chest structures are unremarkable.

INTERPRETATION:

Normal Chest Impression

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 HEMATOLOGY REPORT (CBC)

ID No: **** Hospital no.: ****** OR no.: ***

Name: W.G, Age: 28 yrs. Old Sex: Female Room: ***
Requesting Physician: Dra. Macapagal Date: 05/27/2020

TEST RESULT UNITS REFERENCE VALUE

WBC COUNT 14.3 -10^3/uL 5-10

RBC COUNT 4.06 -10^6/uL M:4.6-6.2 F:4.2-5.2
HEMOGLOBIN 116 -g/dL 125-150 g/dl
HEMATOCRIT 0.36 0.38-0.54
PLATELET COUNT 223 -10^3/uL 150-450
SEGMENTERS(%) 0.76 0.46-0.56
LYMPHOCYTES(%) 0.19 0.20-0.40
MONOCYTES(%) 0.06 0.00-0.06
EOSINOPHILS(%)

BASOPHILS(%)

INTERPRETATION:

High white blood cell count and segmenters denotes that the body is fighting of
an infection (inflammation).

24
 XI. Drug Study
Table 5.1

INDICATION ADVERSE NURSING

DRUG NAME ACTION CONTRAINDICATION
AND DOSAGE EFFECTS RESPONSIBILITIES

Aspirin-like drug Relief of pain Pregnancy and lactation. Dependent on those Baseline Assessment:
GENERIC NAME: that has including. Hypersensitivity. Active and
Mefenamic acid analgesic, anti- muscular, ulceration or chronic the duration of Assess patient’s pain.
before therapy:
BRAND NAME: pyretic and rheumatic, inflammation of either treatment, location, duration,
Ponstan anti-inflammatory traumatic, dental, the upper or lower mefenamic acid precipitating, and
activities. These post- gastrointestinal tract. If frequently causes alleviating factors.
activities operative and diarrhea or skin rash diarrhea. Long – term
DRUG appear to be due to postpartum appears, the drug should treatment can lead Patient is relieved of
CLASSIFICATION its pain, headache, be stopped at once. to enteritis or colitis related to underlying.
ability to inhibit migraine, Blood disorders, poor (some condition patient maintains. normal
cyclooxy fever and platelet function. Kidney with steatorrhea) fluid volume throughout therapy.
genase and also dysmenorrheal, or liver impairment
Analgesic antagonize certain pain from
effects of rheumatoid
prostaglandins. arthritis including
PHARMACOKINETICS Mefenamic acid Still’s SIDE EFFECTS
displays disease, soft tissue
Absorption: Well central and injuries. Therapy Upset stomach,
absorbed peripheral should nausea,
activities. not exceed 7 days. heart burn, dizziness,
Distribution: Wide drowsiness, diarrhea,
Distribution 500mg 1 cap q6 and
headache may occur.
Metabolism: Liver

Excretion: Kidney
(50%),
Liver (20%)

Half-Life: 2-4 hours

25
 Table 5.2

INDICATION ADVERSE NURSING

DRUG NAME ACTION CONTRAINDICATION
AND DOSAGE EFFECTS RESPONSIBILITIES
BASELINE ASSESSMENT
GENERIC NAME: Stimulates alpha- Hypertension Epidural contraindicated Overdose produces
Clonidine adrenergic in pts with bleeding profound hypotension, Obtain B/P immediately before
BRAND NAME: receptors, 75 mg 1 tab STAT diathesis or infection at irritability, bradycardia, each dose is administered, in
Catapres, Dixarit, reducing the injection site, those respiratory depression, addition to regular monitoring
Duraclon, Kapvay, sympathetic CNS receiving anticoagulation hypothermia, miosis (be alert to B/P fluctuations).
Nexiclon, Nova-Clonidine response. Epidural: therapy. (pupillary constriction),
Prevents pain arrhythmias, apnea. INTERVENTION/EVALUATION
signal transmission Cautions: Severe Abrupt withdrawal may
DRUG to brain and coronary insufficiency; result in rebound Monitor B/P, pulse, mental
CLASSIFICATION produces analgesia recent MI; hypertension status. Monitor daily pattern of
at pre and cerebrovascular disease; associated with bowel activity, stool
post-alpha- chronic renal failure; pre- nervousness, agitation, consistency. If clonidine is to
Antiadrenergic, Anti- adrenergic existing bradycardia; anxiety, insomnia, be withdrawn, discontinue
hypertensive receptors in sinus node dysfunction; paresthesia, tremor, concurrent betablocker therapy
spinal cord. conduction disturbances flushing, diaphoresis. several days before
concurrent use with discontinuing clonidine
PHARMACOKINETICS Therapeutic Effect: digoxin, diltiazem, SIDE EFFECTS (prevents clonidine withdrawal
Reduces metoprolol, verapamil; hypertensive crisis). Slowly
Absorption: well, peripheral depression. Frequent: Dry mouth, reduce clonidine dosage over
absorbed in GI tract resistance; drowsiness, dizziness, 2–4 days.
decreases B/P, sedation and
Distribution: (20%-40% heart rate. constipation. PATIENT/FAMILY TEACHING
protein binding) Produces • Sugarless gum, sips of tepid
analgesia. Occasional: water may relieve dry mouth.
Metabolism: Liver Depression, pedal • Avoid tasks that require
edema, loss of appetite, alertness, motor skills until
Excretion: primarily decreased sexual response to drug is
excreted in urine function, itching eyes, established.
nausea, vomiting, • To reduce hypotensive
Half-Life: 6-20 hours nervousness, Pruritus effect, rise slowly from lying to
and redness. sitting position, permit legs to
dangle momentarily before
Rare: Nightmares, vivid standing.
dreams, feeling of

26
coldness in distal • Skipping doses or voluntarily
extremities. discontinuing drug may
produce
severe, rebound hypertension.
• Avoid alcohol.
• If patch loosens during 7-day
application period, secure with
adhesive cover.

27
 Table 5.3

INDICATION AND ADVERSE NURSING

DRUG NAME ACTION CONTRAINDICATION
DOSAGE EFFECTS RESPONSIBILITIES

GENERIC NAME: Inhibits calcium Hypertension Contraindications: None Overdose may produce BASELINE ASSESSMENT
Amlodipine movement across known. Cautions: excessive peripheral
cardiac and vascular 10mg 1 tab OD Hepatic impairment, vasodilation, marked Assess baseline renal/hepatic
BRAND NAME: smooth muscle cell aortic stenosis, hypotension with reflex function tests, B/P, apical
Nirvasc, Novo- membranes. hypertrophic tachycardia. pulse.
Amlodipine cardiomyopathy
Therapeutic
INTERVENTION/EVALUATION
Effect: Dilates
coronary arteries,
DRUG peripheral arteries/ Assess B/P (if systolic B/P is
CLASSIFICATION arterioles. less than 90 mm Hg, withhold
Decreases total medication, contact physician).
Calcium Assess for peripheral edema
channel blocker. peripheral vascular
resistance and B/P behind medial malleolus (sacral
Antihypertensive, area in bedridden pts). Assess
antianginal. by vasodilation.
skin for flushing. Question for
headache, asthenia (loss of
PHARMACOKINETICS SIDE EFFECTS strength, energy)

Absorption: slowly Frequent: Peripheral PATIENT/FAMILY TEACHING

absorbed from GI tract edema, headache,
flushing. • Do not abruptly discontinue
Distribution: Widely medication.
distributed (95%-98% Occasional: Dizziness,
protein binding) palpitations, nausea,
• Compliance with therapy
unusual fatigue or
regimen is essential to control
Metabolism: Liver weakness (asthenia).
hypertension.
Excretion: Primarily Rare: Chest pain,
excreted in urine bradycardia, orthostatic • Avoid tasks requiring
hypotension. alertness, motor skills until
Half-Life: 30-50 hours response to drug is
established.

• Avoid concomitant ingestion

of grapefruit juice.

28
 Table 5.3

INDICATION NURSING
DRUG NAME ACTION CONTRAINDICATION ADVERSE EFFECTS
AND DOSAGE RESPONSIBILITIES

GENERIC NAME: Cephalexin is Cefalexin is a semi Cefalexin should be • Gastro-intestinal: • Before instituting
Keflex a bactericidal synthetic given cautiously to Symptoms of therapy with
agent that acts cephalosporin patients who have pseudomembranous cefalexin, every
BRAND NAME: by the antibiotic for oral shown hypersensitivity to colitis may appear either effort should be
Cefalexin inhibition of administration. other drugs. during or after antibiotic made to determine
bacterial cell- Cefalexin is Cephalosporins should treatment. Nausea and whether the patient
wall synthesis. indicated in the be given with caution to vomiting have been has had previous
treatment of the penicillin-sensitive reported rarely. The hypersensitivity
DRUG following infections: patients, as there is most frequent side- reactions to the
CLASSIFICATION Respiratory tract some evidence of partial effect has been cephalosporins,
infections; otitis cross-allergenicity diarrhea. It was very penicillins or other
media; skin and soft between the penicillin rarely severe enough to drugs. Cefalexin
tissue infections; and the cephalosporins. warrant cessation of should be given
bone and joint Patients have had therapy. Dyspepsia and cautiously to
infections; genito- severe reactions abdominal pain have penicillin-sensitive
urinary infections, (including anaphylaxis) also occurred. patients. There is
including acute to both drugs. some clinical and
prostatitis and • Hypersensitivity: Allergic laboratory evidence
dental infections. Cefalexin is reactions have been of partial cross-
contraindicated in observed in the form of allergenicity of the
50 mg 1 cap q6 patients with acute rash, urticaria, penicillins and
porphyria. angioedema, rarely cephalosporins.
Antibiotic
erythema multiforme, Patients have had
Stevens-Johnson severe reactions
syndrome and toxic (including
epidermal necrolysis. anaphylaxis) to both
These reactions usually drugs.
subside upon
discontinuation of the • If an allergic reaction
drug, although in some to cefalexin occurs
cases supportive the drug should be
therapy may be discontinued, and
necessary. Anaphylaxis the patient treated
has also been reported. with the appropriate

29
• Haemic and Lymphatic agents. Prolonged
System: Eosinophilia, use of cefalexin may
neutropenia, result in the
thrombocytopenia, overgrowth of non-
haemolytic anaemia and susceptible
positive Coombs' test organisms. Careful
have been reported. observation of the
patient is essential.
• Hepatic; As with some If superinfection
penicillins and some occurs during
other cephalosporins, therapy, appropriate
transient hepatitis and measures should be
cholestatic jaundice taken.
have been reported
rarely. Slight elevations • Cefalexin should be
of AST and ALT have administered with
been reported. caution in the
presence of
• Skin and subcutaneous markedly impaired
tissue disorders: renal function.
• Not known – Acute Careful clinical and
generalised laboratory studies
exanthematous should be made
pustulosis (AGEP) because safe
dosage may be
• Other: These reactions lower than that
have included genital usually
and anal pruritus, recommended.
genital moniliasis,
vaginitis and vaginal
discharge, dizziness, • Patients with rare
fatigue, headache, hereditary problems
agitation, confusion, of galactose
hallucinations, fever, intolerance, the
arthralgia, arthritis and Lapp lactase
joint disorder. deficiency or
Hyperactivity, glucose-galactose
nervousness, sleep malabsorption
disturbances and
hypertonia have also

30
 been reported. should not take this
Reversible interstitial medicine.
nephritis has been
reported rarely and toxic
epidermal necrolysis
have been observed
rarely.

PHARMACOKINETICS SIDE EFFECTS

Absorption: 50% Nausea, vomiting, weight gain,

impaired memory, depression,
Distribution: Widely nasal congestion
distributed (93% protein
binding)

Metabolism: Liver

Excretion: Kidneys
(70%) Large Intestines
(30-50%)

Half-Life: 4-6 hours

31
 Table 5.4
INDICATION
DRUG NAME ACTION AND CONTRAINDICATION ADVERSE EFFECTS NURSING RESPONSIBILITIES
DOSAGE
High dosage may produce BASELINE ASSESSMENT
GENERIC NAME: Direct Hypertension, Contraindications: lupus erythematosus–
Hydralazine vasodilating Congestive Coronary artery disease, like reaction (fever, facial Obtain B/P, pulse immediately
effects on Heart Failure mitral valvular rheumatic rash, before
BRAND NAME: arterioles. and Renal heart disease, dissecting muscle/joint aches, each dose, in addition to regular
Apo-Hydralazine, Therapeutic Impairment. aortic aneurysm. glomerulonephritis, monitoring (be alert to fluctuations).
Apresoline, Effect: Cautions: Renal splenomegaly). Severe
NovoHyalazin Decreases B/P, 5mg IV STAT impairment, orthostatic hypotension, INTERVENTION/EVALUATION
systemic cerebrovascular skin flushing, severe Monitor B/P, pulse, ANA titer.
vascular disease, positive ANA headache, Monitor for headache, palpitations,
resistance. titer. myocardial ischemia, tachycardia. Assess for peripheral
DRUG cardiac arrhythmias edema of hands, feet. Monitor daily
CLASSIFICATION may develop. Profound pattern of bowel activity, stool
shock may consistency.
Vasodilator: occur with severe
ANtihypertensive overdosage. PATIENT/FAMILY TEACHING

•To reduce hypotensive effect, rise

PHARMACOKINETICS SIDE EFFECTS slowly from lying to sitting position,
permit leg to dangle from bed
Occasional: Headache, momentarily before
Absorption: Well, anorexia, nausea, standing.
absorbed vomiting, diarrhea,
palpitations, tachycardia, •Unsalted crackers, dry toast
Distribution: Widely angina pectoris. Rare: may relieve nausea. • Report
distributed (85%- 90% Constipation, muscle/joint
protein binding) ileus, edema, peripheral aches, fever (lupus-like reaction),
neuritis flu-like
Metabolism: Liver (paresthesia), dizziness, symptoms.
muscle cramps,
Excretion: Kidneys anxiety, hypersensitivity • Limit alcohol use.
reactions (rash,
Half-Life: 3-7 hours urticaria, pruritus, fever,
chills, arthralgia),
nasal congestion, flushing,
conjunctivitis.

32
 Table 5.5

INDICATION NURSING
DRUG NAME ACTION CONTRAINDICATION ADVERSE EFFECTS
AND DOSAGE RESPONSIBILITIES

GENERIC NAME: Binds to Bind to History of Antibiotic-associated colitis, BASELINE ASSESSMENT

Cefuroxime bacterial cell bactericidal wall hypersensitivity/ other superinfections Question for history of
BRAND NAME: membranes, membrane anaphylactic reaction, (abdominal cramps, severe allergies, particularly
Ceftin, Zinacef inhibits cell wall watery diarrhea, fever) may cephalosporins, penicillin.
synthesis. causing to cell hypersensitivity result from altered bacterial
Therapeutic death. to cephalosporins. balance. Nephrotoxicity INTERVENTION/EVALUATION
. Cautions: Severe may occur, esp. in pts with Assess oral cavity for white
DRUG
CLASSIFICATION
Effect: renal impairment, preexisting renal disease. Pts patches on mucous
Bactericidal. 1.5 g STAT history of with a history of allergies, membranes, tongue (thrush).
penicillin allergy. esp. to penicillin, are at Monitor daily pattern of bowel
increased risk for developing activity, stool consistency. Mild
Antibiotic a severe hypersensitivity GI effects may be tolerable
reaction (severe pruritus, (increasing severity may
angioedema, bronchospasm indicate onset of antibiotic-
anaphylaxis). associated colitis). Monitor
I&O, renal function tests for
PHARMACOKINETICS SIDE EFFECTS
nephrotoxicity. Be alert for
superinfection: fever, vomiting,
Absorption: Rapidly Frequent: Discomfort with IM diarrhea, anal/ genital pruritus,
Absorbed administration, oral oral mucosal changes.
candidiasis (thrush), mild (ulceration, pain, erythema).
Distribution: Widely diarrhea, mild abdominal
distributed (33%-50% cramping, vaginal PATIENT/FAMILY TEACHING
protein binding) candidiasis. • Discomfort may occur with IM
injection.
Metabolism: Liver Occasional: Nausea, serum • Doses should be evenly
sickness-like reaction (fever, spaced.
Excretion: Kidneys joint pain; usually occurs after • Continue antibiotic therapy for
second course of therapy and full length of treatment. • May
Half-Life: 1-3 hours resolves after drug is cause GI upset
discontinued). Rare: Allergic (may take with food, milk).
reaction (rash, pruritus,
urticaria), thrombophlebitis
(pain, redness, swelling at
injection site).

33
 Table 5.3

INDICATION NURSING
DRUG NAME ACTION CONTRAINDICATION ADVERSE EFFECTS
AND DOSAGE RESPONSIBILITIES

GENERIC NAME: Inhibits Short-Term Relief Advanced renal

Ketorolac prostaglandin of Mild to Moderate impairment, active peptic Peptic ulcer, GI bleeding, BASELINE ASSESSMENT
synthesis, Pain ulcer disease, chronic gastritis, severe hepatic
BRAND NAME: reduces inflammation of GI tract, reaction (cholestasis, Assess onset, type, location,
Acular, Acular LS, prostaglandin 30 mg IV q6 GI bleeding/ulceration, jaundice) occurs rarely. duration of pain. Obtain
Acular PF, Acuvail, levels in history of Nephrotoxicity (glomerular Baseline renal/hepatic function
Apo-Ketorolacc, Novo aqueous humor. hypersensitivity to nephritis, interstitial nephritis, tests.
Ketorolac and Sprix aspirin, NSAIDs. nephrotic syndrome) may
toradol Therapeutic Perioperative pain in occur in pts with preexisting
Effect: Reduces setting of CABG surgery. INTERVENTION/EVALUATION
renal impairment. Acute
intensity Cautions: Renal/ hepatic hypersensitivity reaction
of pain stimulus, impairment, history of GI (fever, chills, joint pain) Monitor renal/hepatic function
DRUG reduces tract disease, occurs rarely. tests, urinary output. Monitor
CLASSIFICATION intraocular predisposition to fluid daily pattern of bowel activity,
inflammation. retention, asthma, stool consistency. Observe for
NSAID coagulation disorders, occult blood loss. Assess for
receiving anticoagulants. therapeutic response: relief of
pain, stiffness, swelling;
PHARMACOKINETICS SIDE EFFECTS increased joint mobility;
reduced joint tenderness;
improved grip strength. Be alert
Absorption: Readily Frequent: Headache, to signs of bleeding (may also
Absorbed nausea, occur with ophthalmic route
abdominal cramps/pain, due to systemic absorption).
Distribution: Widely dyspepsia (heartburn,
distributed (99% protein indigestion, epigastric pain). PATIENT/ FAMILY TEACHING
binding)
Occasional: Diarrhea. Nasal: • Avoid aspirin, alcohol during
Metabolism: Liver Nasal discomfort, rhinalgia, therapy with oral or ophthalmic
increased lacrimation, ketorolac (increases tendency
Excretion: Primarily throat irritation, rhinitis. to bleed). • If GI upset occurs,
excreted in urine Ophthalmic: Transient take with food, milk. • Avoid
stinging, burning. tasks that require alertness,
Half-Life: 2-8 hours motor skills until response to
drug is established.

34
Rare: Constipation, vomiting, Ophthalmic: Transient stinging,
flatulence, stomatitis. burning may occur upon
Ophthalmic: Ocular irritation, instillation. • Do not administer
allergic reactions (manifested while wearing soft contact
by lenses.
pruritus, stinging), superficial
ocular infection, keratitis.

35
 Table 5.3

INDICATION NURSING
DRUG NAME ACTION CONTRAINDICATION ADVERSE EFFECTS
AND DOSAGE RESPONSIBILITIES

GENERIC NAME: Binds to opioid Alcohol, other CNS Acute alcohol Seizures reported in those BASELINE ASSESSMENT
Tramadol receptors, depressants may intoxication, concurrent receiving tramadol within
inhibits increase CNS, use of centrally acting recommended dosage range. Assess onset, type, location,
BRAND NAME: reuptake of depression. Carba analgesics, hypnotics, May have prolonged duration of duration of pain. Assess drug
ConZip, Ralivia ER, norepinephrine, mazepine opioids, psychotropic action, cumulative effect in pts history, esp. carbamazepine,
Rybix ODT, Tridural, serotonin. decreases drugs, hypersensitivity to with hepatic/ renal impairment, analgesics, CNS depressants,
Ultram Reduces concentration/ opioids. ConZip, Ryzolt: serotonin syndrome (agitation, MAOIs. Review past medical
history, esp. epilepsy, seizures.
intensity of pain effects. CYP2D6 (Additional) Severe/ hallucinations, tachycardia,
Assess renal/hepatic function
stimuli inhibitors (e.g., acute bronchial asthma, hyperreflexia). lab values.
incoming from paroxetine), hypercapnia, significant
DRUG sensory nerve CYP3A4 inhibitors respiratory depression.
INTERVENTION/EVALUATION
CLASSIFICATION endings. (e.g., Caution: CNS
erythromycin), depression, anoxia,
Monitor pulse, B/P,
Centrally acting Therapeutic triptans, selective advanced hepatic
renal/hepatic function. Assist
synthetic opioid Effect: serotonin reuptake cirrhosis, respiratory with ambulation if dizziness,
analgesic. Reduces pain. inhibitors (SSRIs), depression, increased vertigo occurs. Dry crackers,
tricyclic ICP, history of seizures cola may relieve nausea.
PHARMACOKINETICS antidepressants or risk for seizures, SIDE EFFECTS Palpate bladder for urinary
may increase risk hepatic/renal retention. Monitor daily pattern
of seizures, risk of impairment, acute of bowel activity, stool
Absorption: Rapidly, serotonin abdominal conditions, Frequent: Dizziness, vertigo, consistency. Sips of tepid water
almost completely syndrome. opioid-dependent pts, nausea, constipation, may relieve dry mouth. Assess
absorbed after headache, drowsiness. for clinical improvement, record
head injury, myxedema,
administration onset of relief of pain.
HERBAL: Gotu hypothyroidism,
kola, kava kava, St. hypoadrenalism, Occasional: Vomiting, pruritus,
PATIENT/FAMILY TEACHING
Distribution: Widely John’s wort, pregnancy. CNS stimulation (e.g.,
distributed (20% protein valerian may nervousness,
binding) increase CNS anxiety, agitation, tremor, • May cause dependence. •
euphoria, mood swings, Avoid alcohol, OTC medications
depression. St.
(analgesics, sedatives).
Metabolism: Liver John’s wort may hallucinations), asthenia
increase risk of (loss of strength, energy),
Excretion: Primarily serotonin diaphoresis, dyspepsia • May cause drowsiness,
excreted in urine (heartburn, indigestion, dizziness, blurred vision.
syndrome.
epigastric pain), dry mouth,
Half-Life: 6-7 hours diarrhea.

36
FOOD: None Rare: Malaise, vasodilation, • Avoid tasks requiring
known. anorexia, flatulence, rash, alertness, motor skills until
blurred vision, urinary response to drug is established.
LAB VALUES: retention/frequency,
May increase menopausal symptoms. • Inform physician if severe
serum creatinine, constipation, difficulty breathing,
AST, ALT. May excessive sedation seizures,
muscle weakness, tremors,
decrease Hgb. May
chest pain, palpitations occur.
cause proteinuria.

50 mg IV for severe
pain

37
 Table 5.3

INDICATION NURSING
DRUG NAME ACTION CONTRAINDICATION ADVERSE EFFECTS
AND DOSAGE RESPONSIBILITIES

GENERIC NAME: Stimulates motility Postop Concurrent use of Extrapyramidal reactions BASELINE ASSESSMENT
metoclopramide of upper GI tract. Nausea/Vomiting. medications likely to occur most frequently in
Decreases produce extra pyramidal children, young adults Antiemetic: Assess for
BRAND NAME: reflux into 10 mg IV reactions, GI (18–30 yrs) receiving large dehydration (poor skin turgor, dry
Apo-Metoclop, esophagus. hemorrhage, GI doses (2 mg/kg) during mucous membranes, longitudinal
Metozolv ODT, Reglan Raises obstruction/ perforation, chemotherapy and usually furrows in tongue). Assess for
threshold activity history of seizure are limited to akathisia nausea, vomiting, abdominal
in chemoreceptor disorder, (involuntary limb distention, bowel sounds.
trigger pheochromocytoma. movement, facial
DRUG zone. Therapeutic Cautions: Renal grimacing, motor
CLASSIFICATION INTERVENTION/EVALUATION
Effect: impairment, CHF, restlessness). Neuroleptic
Accelerates cirrhosis, hypertension, malignant syndrome
Dopamine receptor intestinal transit, depression. (diaphoresis, fever, Monitor for anxiety, restlessness,
antagonist. peristaltic gastric emptying. unstable B/P, muscular extrapyramidal symptoms (EPS)
stimulant, antiemetic. Relieves nausea, rigidity). during IV administration. Monitor
vomiting daily pattern of bowel activity,
stool consistency. Assess skin for
PHARMACOKINETICS SIDE EFFECTS rash. Evaluate for therapeutic
response from gastroparesis
Absorption: Well, Frequent: Drowsiness, (nausea, vomiting, bloating).
absorbed in GI tract restlessness, fatigue, Monitor renal function, B/P, heart
lethargy. rate.
Distribution: (30%
protein binding) Occasional: Dizziness, PATIENT/FAMILY TEACHING
anxiety, headache,
Metabolism: Liver insomnia, breast • Avoid tasks that require
tenderness, altered alertness, motor skills until
Excretion: Primarily menstruation, response to drug is established
excreted in urine constipation, rash, dry • Report involuntary eye, facial,
mouth, galactorrhea, limb movement (extrapyramidal
Half-Life: 4-6 hours gynecomastia. reaction).
• Avoid alcohol.
Rare: Hypotension,
hypertension, tachycardia.

38
XII. Nursing Care Plan Table 6.1

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Grieving Within 3 days Independent: Goals are half met after
“wala ako ibang related to of nursing • Assess • Emotional reactions 3 days of nursing
masisi kundi sarili stillbirth as intervention patient’s/couple’s may prevent the intervention as
ko” evidence by client will be information and couple’s ability to evidence by the clients
client’s able to understanding of process information positive response with
Objective: verbalization express her events and interpret the her health treatment
of “wala ako feeling freely surrounding the significance of and reluctancy to
● Irritable but ibang masisi and death of the events. Concrete express her feelings
cooperative kundi ang sarili participate in fetus/infant. thinking patterns freely
● Lethargic ko” the decision- Provide more (literal interpretation)
● Apathetic making accurate may be the only
behavior process. information and available means of
● Tearful at correct coping with
misconceptions information at this
times
based on couple’s time.
● Altered readiness and
sleeping ability to listen
pattern. effectively.
• Recognize stage • If the process of
of grief being grieving is not
displayed, e.g., completed, grief may
denial, anger, become
bargaining, dysfunctional,
depression, resulting in behaviors
acceptance. Use that are disturbing to
therapeutic personal safety and
communication to the future of the
skills (e.g., Active- family and
listening, marriage/relationship.
acknowledgment),
respecting
patient’s
desire/request not

39
 to talk.
• Reinforce family’s • Grieving families
expression of need repeated
feelings and listen opportunities to
(remaining calm verbalize their
or commenting as experience. Verbal
appropriate). and nonverbal cues
Observe body provide hints about
language. family’s degree of
Promote relaxed sadness, guilt, and
atmosphere. fear. Active listening
conveys caring,
which demonstrates
an awareness of the
unique significance of
the loss to the
patient.

• These areas may be

● Observe patient’s neglected because of
activity level, the process of
sleep pattern, grieving and
appetite, and associated
personal hygiene. depression. Sleep
patterns may be
disrupted, leading to
fatigue and further
failure to cope with
distress. Patient may
require support in
meeting physical
needs and may need
assurance that it is
acceptable to resume
with usual activities.

● Talk about • Aids the couple in

anticipated recognizing normalcy
physical and of their initial and
emotional subsequent

40
 responses to loss. responses. Grieving
Evaluate coping is individual, and the
skills. Consider extent and nature of
religious beliefs the response is
and ethnic influenced by
background. personality traits,
past coping skills,
religious beliefs, and
ethnic background.
Collaborative:

• Encourage the • Support systems are

family and necessary to improve
support system to the client’s health.
visit the client
frequently.

• Refer to, or • The family may want

contact, clergy, to meet with a
according to minister or spiritual
family’s wishes. advisor to provide
baptism, last rites,
cultural rituals, and/or
counseling.

41
 Table 6.2

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Situational After 2 days of Independent: Goals are half met after
“Nawalan ako ng tiwala low Self- nursing 2 days of nursing
sa sarili ko na Esteem intervention client ● Assess the • Patients with intervention client was
magkaroon ng anak related to will be able to patient’s self-esteem able to demonstrate
feeling ko di ako prenatal loss demonstrate feelings of issues may behaviors to restore
karapat dapat maging as evidence behaviors to comfort and appear as positive self esteem as
isang ina” by restore positive content with though their evidence by focusing in
verbalization self-esteem and her own actions are not in strengths and ascertain
of negative express positive performance. keeping with some sense of self
Objective: feelings appraisal their own control.
personal, moral,
● Indecisiveness or ethical values;
● (+) Guilt they may also
● (+) Self- deny these
negation behaviors,
project blame,
and rationalize
personal failure.

● Assess for • Ongoing grief

presence of may hinder the
unfinished patient’s ability to
grief. move forward in
life.

● Apply active • These

listening and communication
open-ended methods permit
questions. the patient to
verbalize
interests,
concerns,
worries, and
thoughts without

42
 interruption. This
technique will
convey a sense
of respect for the
patient’s abilities
and strengths in
addition to
recognizing
problems and
concerns.
● Support the • The patient
patient in his needs
or her continuous
attempts to positive feedback
and support to
secure
manage
autonomy, behaviors to
reality, promote self-
positive self- esteem.
esteem,
sense of
capability, and
problem-
solving.

Collaborative:
• Personal,
● Mobilize Professional and
support community
systems. sources of
support provide
the patient with
more resources
to sustain the
work of
rebuilding
positive self-
esteem.

43
 Table 6.3

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk for spiritual Within 8 hours of Independent: Goals are met after 8
distress related to nursing intervention hours of effective
prenatal death. client will be able to ● Observe client • Verbalization nursing intervention
identify meaning and for self- of feelings of the client was able to
Objective: purpose in own life esteem, self- low self- identify meaning and
that reinforces hope, worth, feelings esteem, low purpose in own life
● (+) Death self-worth,
● (+) Guilt peace and of futility, or that reinforces hope,
contentment and hopelessness. and peace and
● (+) Grieving hopelessness
● Low self state feeling of trust in contentment and state
self, God. may indicate feelings of trust in self,
esteem a spiritual God as evidence by
need. client’s verbalization “I
● Monitor • To effectively know this is all in
support help a client God’s plan.”
systems. Be with spiritual
aware of own needs, an
belief systems understanding
and accept of one's own
client's spiritual
spirituality. dimension is
essential
(Highfield,
Carson,
1983).
● Be physically • Physical
present and presence can
available to decrease
help client separation
determine and
religious and aloneness,
spiritual which clients
choices. often fear
(Dossey et al,
1988)
● Provide quiet • Clients need

44
 time for time to be
meditation, alone during
prayer, and times of
relaxation. health
change.
● Ask how to be • Listening
most helpful, attentively
then actively and being
listen, reflect, physically
and seek present can
clarification. be spiritually
nourishing
(Berggren-
Thomas,
Griggs, 1995)

45
XIII. Discharge Plan

MEDICATION
• Patient is encouraged to timely take her Blood pressure medication,
complete the full course of prescribed antibiotics, and complying to her
routine blood sugar medication.
EXERCISE/ENVIRONMENT
• Educate the mother about exercise and activity limitations that she
needs to follow; she should not lift any object heavier than 10lbs for the
first two weeks or climb upstairs more than once a day.
• Encourage patient to resume activities of daily living (ADL) at the
minimal.
• Patient should be provided with quiet and comfortable environment at
home.
• Advise patient to maintain an active and healthy lifestyle, like daily
exercise and eating nutritious foods. This will also promote wound
healing and peace of mind.

TREATMENT
• Educate the mother on proper wound dressing; demonstrate the clean
technique on how to disinfect the incision site, inform the patient that
she can use povidone iodine and a cotton ball and make single sweep
on the area and discard it, do not sweep back and forth using the same
cotton balls.
• Educate the patient about blood sugar monitoring and complications if
not controlled.
HEALTH TEACHING
• Teach the mother to recognize signs of possible complications related
to the surgery such as:
• Redness or drainage at the incision line
• lochia heavier than a normal menstrual period
• abdominal pain
• temperature of ≥38℃ (100.4℉)
• frequency or burning on urination.
OUT-PATIENT
• Advise patient to secure a follow up check-up with her OB GYNE for
further assessment of her uterus.
• Encourage the family to always keep the patient company.
46
 • Educate the couple about family planning.

DIET
• Encourage the mother to eat green leafy vegetables, high fiber diet,
lean meat for protein, non-fat or low-fat dairy,
• And emphasize the importance of drinking at least 1.5-2liters of water
daily to maintain proper hydration.
SPIRITUAL
• Advised patient to adapt family planning in respect in her spiritual
belief.

47