MHR Case 1

MHR FEB 22-
FEB 23- no patient
FEB 29- Alvarez
MAR 1- assist
Feb 29
 Upon the start of duty, we had a group discussion on endorsements of patients distributed to us
 At 7 am, our group distributed breakfast to our clients and reminded them of some routines to
do in the morning such as brushing their teeth and peeing. I received my patient sleeping and
not in distress.
 At 8 am, I took and recorded the vital signs of my patient with the following data:
 BP: 110/60
 Temperature: 36.4
 RR: 20
 PR: 77
 O2 Sat: 95%
 Gave medicines after breakfast and instructed the client to increase oral fluid intake. Also, I
taught the client its specific purposes. These medicines include:
Cefuroxime, 500mg/tab, BID for 7 days (taught the client that it’s an antibiotic that stops the
growth of bacteria and infection)
Mefenamic Acid, 500mg/tab, TID (for pain and anti-inflammatory)
Multivitamins, 1 tab, OD for 90 days (a supplement to treat or prevent vitamins deficiency)
Ferrous sulfate, tab, OD for 90 days (treat and prevents iron deficiency)
Malunggay, tab, OD for 14 days (to increase milk supply for lactations)
 Around 9 am, the staff nurse assisted me in bathing the baby of Ms. Alvarez. I helped in the
aftercare of the newborn by assisting in wearing her clothes and cleaning the materials used.
 I interviewed the client and asked questions about her condition which is beneficial in doing
my case report. Since she is a MGH client, I took advantage of the time to instruct her to
watch her diet closely since she has GDM. Told her to avoid too much carbohydrates and
start exercising 1-2 days after birth as what she’s doing before hospitalization like pelvic floor
and abdominal exercises. Also instructed the client to maintain proper hygiene such as
taking a bath, brushing her teeth, cleaning her wounds and breast. Taught the client to
always take medicines on time and to always clean her breast using water only to avoid
infections.
 Kept my client monitored by visiting her from time to time to check her condition and ask if
her family need something. Encouraged to breastfeed in demand.
 At 12 pm, we distributed lunch for our clients.
 Took the vital signs and I&O of my client at 12 pm also. The data includes:
BP: 110/70
T: 36.1
RR: 17
PR: 80
02 sat: 99
Intake: (4) 3,840 mL- oral
Output: 360 mL
Stool: 0
 Also helped my other groupmates manage their client by measuring the vital signs of their
patients and I & O, especially those clients who have foley catheter. Assisted some of my
classmates in measuring the intravenous fluid rate of their clients. Attended also to the
needs of the patient’s family member.
March 1
 At the start of shift, nurses gave endorsements and Mrs. Yu distributed the patients to us.
Unfortunately, the client assigned to me was in the labor room.
 Served as assistant nurse and helped my groupmates in delegating their tasks to their
respective clients.
 Distributed breakfast around 7 am.
 At 8 am, assisted and recorded vital signs of Ms. Jocelyn Tagami from Kan 2. Data are as
follows:
Bp: 120/80
T: 36.6
O2 sat: 96%
Pr: 77
Rr: 20
 Performed bedmaking and assisted the husband of patient Marynhelle Lopez Carpio from MHR7,
as we are waiting for her to finish in the delivery room.
 Helped my classmate in regulating the intravenous fluid rate and measuring the IVF intake of
Ms. Tagami. Assisted the client in moving her body such as sitting and supine position as she
experiences discomfort due to surgery. Gave some health teachings regarding wound care by
observing drainages and cleaning the wound site regularly, especially after discharge.
 At 11 am, performed an IV push on client Nenita Garcia Dela Piedra, MHR9, with a medication
of Tranexamic Acid which blocks the breakdown of blood clots, thus prevents bleeding.
Also taught the client about the purpose of the medicine.
 Gave lunch foods to clients and reminded them to increase fluid intake and observe the
diet to follow, as prescribed by their doctors.
 Measured the urine output through the foley catheter of client Ms. Paigalan at 2 pm with a
measurement of 50 mL. Computed her total UO from 7 am-2 pm resulting to 1000 mL.
 Observed my classmate perform an IV removal on Ms. Dela Piedra.
 Watched my groupmate changed the hep-lock of Ms. Baltes, MHR5.
 Rotated in the ward from time to time to ask clients on their status and offered help whenever
they need one.

I. Health-Perception-Health Management Pattern

The patient is recovering from the surgery she underwent (Vaginal
Hysterectomy). The client's family has a history of hypertension. She has no allergies to
any foods and drinks. The patient rarely visits a doctor and she does not do annual
check-ups. No vices were reported. The patient takes Alaxan Fr capsule which contains
ibuprofen 200 mg and paracetamol 325 mg, or a 500 mg of Biogesic tablet whenever
pain is felt.
II. Nutritional and Metabolic Pattern

The client stated that she follows a balanced diet and her typical food intake is
more on vegetables, rice, and protein. The patient stated that she drinks less than 8
glasses of water daily. The patient reported that she is taking vitamins for her bones and
joints. She stated having a normal general appetite, and no food or eating discomforts. Upon
the onset of pain regarding her chief complaint, the patient started to feel defecating.
The patient's body mass index (BMI) is 19.9 kg/m2 with a weight of 49 kg and height of
157 cm, considered normal according to her age.
III. Elimination Pattern

The patient usually defecates one to two times a day. It is usually light brown and
soft. The patient reported having no discomfort in defecating and urination except when
the vaginal mass has grown. The client usually has yellow urine and does not have a
foul odor. No other abnormalities reported.

MHR Case 1

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MHR FEB 22-

FEB 23- no patient

FEB 29- Alvarez

I. Health-Perception-Health Management Pattern

II. Nutritional and Metabolic Pattern

III. Elimination Pattern

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