St.

Paul College of Ilocos Sur

(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

DEPARTMENT OF NURSING

Department of Nursing

A Clinical Case Study on Emergency

Cesarean Maternal Patient

In Partial Fulfillment of the Requirements in NCM

NCM 112: Care of Clients with Problems in Cellular

Aberration ,Oxygenation ,Fluid and Electrolyte,

Infectious Inflammatory and Immunologic Response,

Acute and Chronic Problems

Presented by:

SERRAN, KAREN S.
SONIDO, JERDY LEANDREA R.
TABIOS, JOY LUMAMBA

Bachelor of Science in Nursing III - B

Presented to:

Clinical Instructor

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 St. Paul College of Ilocos Sur
(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

DEPARTMENT OF NURSING

EVALUATION OF NURSING CASE STUDY

Name of Student: Serran, Karen S.,Sonido, Score:

Jerdy Leandrea R.

Tabios, Joy Lumamba

Course/Year: BSN -B Date:

Faculty-In-Charge:

_________________________________________________________
_________________________________________________________

PARTICULARS HIGHEST RATING

POSSIBLE
SCORE
_________________________________________________________
_________________________________________________________

I. Patient 10 points __________

II. Background Knowledge 10 points __________

III. Nursing Health History 10 points __________

IV. Developmental Task 10 points __________

V. Physical Assessment 10 points __________

VI. Pathophysiology & Review Of Records 10 points __________

VII. Health Teaching Guide 10 points __________

VIII. Discharge Planning 10 points __________

IX. Nursing Care Plan 10 points __________

X. Drug Study 10 points __________

_________________________________________________________
_________________________________________________________

TOTAL 100%

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 St. Paul College of Ilocos Sur
(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

DEPARTMENT OF NURSING

NURSING CASE STUDY

I. PATIENTS GENERAL INFORMATION

Name : Patient X Age : 35 years old Gender: Female

Address: Villamar , Caoyan Ilocos Sur

Civil Status : Married Educational Attainment: High School Graduate

Religion: Roman Catholic Occupation: : Fish Vendor

Hospital: Ilocos Sur Provincial Hospital - Gabriela Silang Room and Bed #: OB Ward

Chief of Complaint :

Diagnosis:

Attending Physician : Dr. C.

II. BACKGROUND KNOWLEDGE

1. Definition (Diagnosis)

2. Causative Agent/Etiology

3. Clinical Manifestation

4. Risk Factors/Contributing Factors/Precipitating Factors

5. Medical/Surgical/Nursing Management

6. Prognosis/Complications

7. Prevention

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III. NURSING HEALTH HISTORY
1.Chief complaint

2. History of Present Illness

3. Past Medical History (include dates and complications)

Mumps The patient have no history

Measles The patient have no history
Chicken Pox The patient have no history
Rubella The patient have no history
Pertussis The patient have no history
Rheumatic The patient have no history
Pneumonia The patient have history
Tuberculosis The patient have no history
Hypertension The patient have history
Heart Disease The patient have no history
Hepatitis The patient has no history
Others please specify

4. Immunizations / Tests

BCG ✓
DPT ✓
OPV ✓
HEPA B ✓
Measles ✓
Flu ✓
Covid -19 Booster ✓

5. Hospitalizations
6. Injuries
 The patient had no injuries upon assessment.
7. Transfusions
8. Obstetric / Gynecologic History (if any)
9. Medications

1. Family History

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 Name of Parents, Spouse, Age Health Status or Cause of
Children etc.
Death
R.Q. 39 Healthy
R.Q 16 Healthy
L.M.Q 10 Healthy
K.J.Q 8 Healthy
S.Q 9

2. Nutrition And Metabolic Pattern

2.1. Food intake/ preferences before admission

Before Admission:
 The patient usually eats leafy vegetables (e.g. malunggay , parya), rice and fish ,
meat (e.g. Pig , chicken) and egg. Limited food intake of processed foods, fast foods,
junk foods, and soft drinks,

At present:
 The patient's food intake inside the institution includes lugaw and fruits and usually
cooked by the hospitals.

2.2. Fluid intake before admission

Before Admission:
 The patient indicated that she consumes 5 glasses of water per day

At present
 The patient drinks 2 bottled water of 1000ml of water per day,

2.3. Any food restrictions before admission

 Limited food intake of processed foods, fast foods, junk foods, soft drinks and
chocolates
At present:
 Foods usually cooked by the hospital like lugaw. Restricted to have Solid foods

2.4. Any problem with ability to eat

 Throughout his stay in the hospital and even before admission, he had a good
appetite, and he doesn’t have any problem with the ability to eat.

2.5. Any supplements ( Vitamins, Feedings)

 The patient has multivitamins with iron

3. Elimination pattern
3.1. Bladder
Before admission:

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  The patient micturates at least three (3) to four (4) times a day. The patient stated
that his regular urine color ranges from clear to yellow.

At present:
 The patient micturates at least four times a day. She stated that her regular urine
color ranges from clear to yellow.
3.2. Bowel
Usual pattern (Time, Frequency, Color and Consistency)
 The patient defecates four (4) times in a week usually an hour after eating in the
evening The patient observed that the stool is green , yellow and solid in
consistency.

Complains on the usual pattern of bowel movement

 The patient sometimes complaints.

3.3. Any Assistive Device

 The patient does not use any assistive devices.

3.4. Skin (Rectum)

 The patient’s rectum is not assessed due to privacy,.
4. Activity and Exercise
4.1. Usual Daily/ Weekly Activities
Exercise:
 The patient’s form of exercise is stretching inside their house .

Leisure:
 Prior to admission the leisure activity of the patient is watching using a cellphone.
Then, during his admission, he was advised to take full bed rest and the patient is
using a cellphone because the patient is bored.
4.2. Any limitations of physical Ability
Before Admission:

At present:
 He was advised not to engage in strenuous activities.

4.3. History of Dyspnea or Fatigue

 According to the patient ,the patient experience this .

5. Sleep- Rest Pattern

5.1. Usual Sleep Pattern

Before Admission

At Present

*Number of Pillow:

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Before Admission
 The patient only has two (2) pillows at home.

At Present
 The patient only has two (2) pillows at the hospital OB ward.

Sleep Routine
5.2 Any Problem Regarding Sleep
Before Admission

At Present
5.3 Usual Remedies
 Whenever the patient had trouble sleeping, the mother is watching a cellphone

6. Cognitive Perceptual Pattern

6.1 Any Deficits in Sensory Perception (Hearing, Sight, Touch)
Hearing
 The patient has no sensory deficit when it comes to hearing and can clearly hear
sounds and voices.
Sight
 The patient has no sensory deficit when it comes to vision because he was able to
read .

Touch
 The patient has no sensory deficit when it comes to touch because she was able to
feel the texture of a certain object and can feel pain upon pinching during the
assessment by withdrawing the leg that is pinched.

6.2. Ability to read and write. Any Difficulty in reading?

 She can write and read. She has no difficulty with reading.

6.3. Any Complaint/s

7.Self-Perception Pattern
7.1. What is the client most concerned about?

7.2 Present health goals

 The patient’s present health goals include the following: to get well and be healthy
so that they can go home to see their children’s.

7.3 Effects of Present Illness to Self (Physical/Emotionally)

7.4 How Does the Client see/ feel about Self

8. Role- Relationships Pattern

8.1. Language Spoken
 The patient can speak Iloco, Tagalog, and English.

8.2 Manner of Speaking

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  The patient’s manner of speaking is normal and soft spoken. Not that cooperative
because of being shy.

8.3. Significant Person to Client

 The most significant person to him is family.

8.4 Complaints regarding Family

 The patient has no complaints about his family.
8.5. Living with (Members of the Family)
 The patient’s family is a nuclear family, it consists of a father, mother, a sister, and
brother.

9. Sexuality- Sexual Pattern

9.1. Anticipated change in sexual relations because of illness

9.2. Knowledge of sexual functioning

10. Coping- Stress Management Pattern

10.1. Decision making ability
 When making an important decision, the patient’s approach is to think first and
remember what was told to him before deicing.
10.2. Any significant stress in the past year
 The patient had stress due to financial

10.3. Management stress

 The patient will just go to her neighbor.
10.4. Expectations from nurses to provide comfort and security during hospitalizations
 The patient told the nurses should be kind and comfortable.

11. Value belief system

11.1. Sources of Strength & Meaning
 The patient’s source of strength is God and his family. In good times and in difficult
times, the Lord is always there for him as well as his family.
11.2. Importance of God to Client
 The patient stated that God will help her to recover.
11.3. Religious Practices
 The patient attends mass two times in a month during Sunday.
11.4. Request for Religious Practices/ Persons
 The patient prays at night with her children’s

IV.DEVELOPMENTAL TASK

General Task

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Indicator of Positive Resolution

V. PHYSICAL ASSESSMENT
Date performed:
1.General Survey:
Height: ______ Weight: ______ Body Make-Up: ______

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Communication Pattern: Circular Communication Pattern
Skin: Color: ______ Turgor: ______ Bruises: ______ State of Hydration: Hydration is
normal.
Eyes: Sclera: ______ Pupils: ______
Respiratory: Easy Breathing: _______/_______ In Distress: _______________
No Distress: _________________________

2.Vital Signs:
HR: ______ Temperature: ______
BP Supine R/L arm: ______ Capillary Refill: ______
BP Sitting R/L arm: ___________________ mmHg RR: ______
BP Standing R/L arm: ___________________ mmHg

3.Body Position/Alignment:
Supine: ________/___________ Fowler’s: _______________ Semi-Fowler’s: ______________
Alignment: Appropriate: ______________ Not Appropriate: ________________

4.Mental Acuity:
Oriented: ______/_______ Coherent: ______/_______ Appropriately Responsive:
_______/_______
Disoriented: ___________ Incoherent: ____________ Inappropriately Responsive: _________

5.Sensory/Motor Restrictions:
Amputation: __________ Deformity: ____________ Paresis: __________ Paralysis: ______
Gait: Hearing Disorders: ______________ Speech: ______________

6. Emotional Status:
Euphoric: _____________ Depressed: _____________ Apprehensive:______/_______
Angry/Hostile: _____________ Others: _____________

7.Medically Imposed Restrictions:

CBR without BRP: _____________ CBR with BRP: _____________

8.Other Health Related Patterns:

Fatigue: _____________ Restlessness: _____________ Weakness: _____________
Insomnia: _____________ Coughing: _____________ Dyspnea: _____________
Dizziness: _____________ Pains:_____________ Others: _____________

9. Safety:
Violations of Medical Asepsis: ______________________________________________
Violations of Safety Measures: ______________________________________________

10.Activities of Daily Living:

Can/Cannot Perform
Feeding: ______ Brushing teeth: ______ Bathing: ______
Dressing: ______ Combing: ______ Transferring: ______

REVIEW OF SYSTEMS
1.General Description:
Weight loss:_____________ Fatigue: _____________ Anorexia: _____________
Night Sweats: _____________ Weakness: _____________

2.Skin:
Itchiness: _____________ Bruising: _____________
Rash: _____________ Bleeding: _____________
Lesions: _____________ Color change: _____________

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3. Eyes:
Pain: _____________ Itch: _____________ Vision Loss: _____________
Diplopia: _____________ Blurring: _____________ Excessive Tearing: _____________
Glasses/Contact Lens: ___________________________________________

4.Ears:
Ear Aches: _____________ Discharge: _____________ Tinnitus: _____________
Hearing loss: _____________

5.Nose:
Obstruction: _____________ Epistaxis: _____________ Discharges: _____________

6.Throat and Mouth:

Sore throat: ____________ Bleeding Gums: _____________ Toothaches: Decay: ____________

7.Neck:
Swelling: ___________ Dysphagia: ____________ Hoarseness: _____________

8.Chest:
Cough: _____________ Sputum(Amount& Character): _____________

9.CVS:
Chest Pain: ___________Palpitation: _____________ Dyspnea prescribe on Exertion: ________
Orthopnea: _____________ Others: _____________

10.GIT:
Food Tolerance: __________Heartburn:___________ Nausea:_____________
Jaundice:_____________
Vomiting: _________ Pain: __________ Bloating: __________ Excessive Gas: _____________
Constipation: __________Diarrhea: ___________Change in BM: __________ Melena: _______

11.GU:
Dysuria:___________Noscturia:____________Retention: ___________Polyuria: ___________
Dribbling: __________ Hematuria: ___________ Flank pain: _____________
Male: _____________ Penile Discharge: _____________ Lesion: _________ Testicular Pain: _
Female: ______ Menarche(age): ______ LMP(Date): ______Cycle: ______

12. Extremities:
Joint Pains: _____________ Varicose Veins: _____________ Claudication: _____________
Edema: Stiffness: _____________ Deformities: _____________

13. Neurologic:
Headaches: _____________ Dizziness: _____________ Memory Loss:_____________
Syncope: _____________ Vertigo: _____________ Numbness: ___________

Summary of Abnormal Findings:

Date Performed: November 2024

1. General Survey
Height: 5’5

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 Weight: 75 kg
Body Make-Up:
Communication Pattern: Sociable and cooperative
Grooming: Clean
Skin:
Color: Brown Turgor: Normal Bruises: None
State of Hydration: Not normal (more than 4 glasses of water a day)
Eyes:
Sclera: White Pupils: PERLA
Respiratory:
Easy Breathing: __√___ In distress: ______ No distress: _______
2. Vital Signs:
HR: bpm Temperature: °C
BP Supine R/L arm: RR: cpm
BP Sitting R/L arm:
BP Standing R/L arm:

3. Body Position/Alignment: The patient’s shoulders, spine, hips coordinate with each
other. Knees, and ankles relate and line up with each other. Posture is erect.

4. Mental Acuity: The patient has a good memory and can remember correctly what foods
are not allowed to him.

5. Sensory/Motor Restriction: Based on the assessment patient does not have any
sensory/motor restrictions. The patient can easily talk, smile, and laugh. She did feel pain
when pinch when assessing skin turgor. For the patient's upper extremities, the patient can
easily flex his hands as was noticed during vital signs assessment. For the lower extremities,
he can stand straight, walk, and flex his feet.

6. Emotional Status: The mental status of the patient is oriented.

7. Medically Imposed Restriction:

8. Other Health-Related Patterns: The patient has Insomnia , Dyspnea and fatique

9. Safety: Clean bed and linen and noise free environment. The room has an electrician nd
not that hot. There’s no sharps and other harmful objects that can injure the patient. Safety
measures are implemented to prevent injuries or falling from bed. Sepsis is observed.

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 10. Activities of Daily Living: The patient can complete everyday tasks without difficulty
such as Feeding ,brushing teeth and combing.She can actively participate in medication
administration. The patient adheres to treatment and medical and nursing instructions.

Review of Systems

1. General Description: The patient is actively engaging and oriented. Well-appearing, well-
nourished but overweight.

2. Skin: Good turgor of less than 2 seconds after the skin is pinched, no rashes, and no unusual
bruising or prominent lesions. Scars are seen in the knee. Skin is brown and intact. No
abnormal findings and the reported health problems regarding the skin has rashes when
there’s long exposure of direct sunlight.

3. Eyes: The sclera is white, and the upper and lower conjunctiva is pink. No drainage from
the eyes. The patient demonstrates good vision when asked to choose what animal does the
patient want to color. No abnormal findings noted and no reported health problems
regarding the eyes during the assessment.

4. Ears: Ears are in symmetry, parallel, same size, and directly proportional to the size of the
head, and bean-shaped, the helix is in line with the outer canthus of the eye. No redness,
lesions, perforations, and drainage noted. The skin of the ear is the same color as the
surrounding area and no abnormal findings noted. There’s no report of health problems in
the ear and the patient can hear very well.

5. Nose: The nose is in symmetry, the same color as the rest of the face with no discolorations
such as redness and no lesions. No swelling or malformations. Nostrils are patent and no
discharge and obstructions. No abnormal findings observed and no reported health problem
regarding the nose.

6. Throat and Mouth: Lips are reddish pink and plump with moist with no lesions or
inflammations were noted. Tongue in the midline and moves freely and can distinguish
different tastes. No tooth decays, dental problems, bleeding gums, or sore throat were noted.
No abnormal findings and has no reported health problems regarding the throat and mouth.

7. Neck: The nose is on symmetry with the head and central position. There’s no pain and
discomfort noted. No abnormal findings and no reported health problems regarding the
throat and mouth.

8. Chest: The chest in symmetry during lung expansion. Respiration 26 cycles/minute. No

masses, lumps, pain or tenderness and dyspnea. No abnormal findings and no reported
health problems regarding the chest.

9. CVS: Normal rate and rhythm. No palpitations and chest pain were noted. No abnormal
findings and no reported health problem regarding on the cardiovascular.

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10. GIT: Food intolerance to foods with soy sauce and acids, mongo beans and bitter gourd
leaves or fruit which triggers hemolytic anemia due to the patient’s G6PD deficiency. No
epigastric pain noted. Non-distended, no scars, and no masses palpated. No more abdominal
pain and vomiting.

11. GU: No abnormal findings and there’s no reported health problem regarding on the
genitourinary.

12. Extremities: Upper and lower extremities are normal, intact, and well flexed. No abnormal
findings and no reported health problem regarding on the extremities.

13. Neurologic: The patient can see, smell, taste, feel, hear, and talk well. No headaches,
seizures, memory loss and dizziness noted.

Summary of Abnormal Findings:

VI. PATHOPHYSIOLOGY AND REVIEW OF RECORD

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Predisposing Factors
Fetal Malposition (Occiput Posterior) Advanced Maternal AgePosterior)
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VII. REVIEW OF RECORDS (LABORATORY FINDINGS)

Diagnostic Result Normal Range Analysis Nursing Responsibilities

Evaluation
Ordered
Complete
Blood Count

WBC 13.85 4.5-11.0 × 10^9/L Normal Patient Observation: Be vigilant

for signs and symptoms of
infection, such as fever, chills,
fatigue, and localized pain or
redness.
NEU% 86.3 50-70% High High neutrophils indicate
infection. Assess for clinical
signs and symptoms of
infection or inflammation, such
as fever, chills, pain, redness,
swelling, and changes in mental
status.
Lym% 10.5 20-60 Low Indicates viral infections.
Conduct thorough physical
examinations to identify signs
and symptoms of infection or
other complications, such as
fever, fatigue, weight loss, and
swollen lymph nodes.
Mon% 2.9 3.0-12.0% Low Monitor vital signs as it
indicates infection.

EOS% 0.2 0.5-5.0 Low Regularly check vital signs,

including temperature, heart
rate, blood pressure, and
respiratory rate, to monitor for
signs of dehydration and
infection. Encourage rest and
provide comfort measures to
help the patient recover.
HGB 114 120-160 10^9/L Low Monitor for symptoms of
anemia such as fatigue, pallor,
shortness of breath, and
dizziness. Encourage hydration.
HCT 32.7 40.0-54.0 Low Provide guidance on
maintaining hydration and
consuming a diet rich in iron
and other essential nutrients to
support red blood cell
production.
MCV 80.1 80.0-100.0 fL Low The most common cause of low
MCV is iron deficiency anemia,
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 which can be exacerbated by
poor dietary intake,
malabsorption, or chronic blood
loss. Intake of iron-rich foods is
recommended. Encourage
hydration.
MCHC 349 320-360 g/L High Regularly monitor vital
signs, particularly looking
for signs of anemia,
hemolysis (such as jaundice
or dark urine), and
dehydration.

Yellow Clear, light yellow, Normal Drink more water as yellow

yellow color indicates dehydration.

Turbid Clear Abnormal Encourage hydration as acute

gastroenteritis can cause
dehydration because of
vomiting and diarrhea.
+1 Negative Abnormal Assess the patient's hydration
status carefully, considering
factors such as skin turgor,
mucous membrane moisture,
and urine output. Monitor vital
signs. Encourage hydration.
Normal Normal Normal Monitor vital signs,
especially looking for signs
of liver dysfunction or
biliary obstruction, such as
jaundice, abdominal pain,
and fever.
Negative Negative Normal Provide hydration as ketones is
normal and glucose is
metabolized.
Negative Negative Normal Indicates no bleeding in
gastrointestinal tract and
monitoring of vital signs and
urine output is recommended.
Negative Negative Normal Nitrates are within normal
levels and constant monitoring
of vital signs and dehydration is
continued.
Negative Negative Normal Bilirubin is seen when there’s
breakdown of red blood cells.
Constant monitoring of urine
output is continued, and
hydration is recommended.
Intake of iron-rich foods is
encouraged.
1.015 1.001-1.035 Normal Concentration of urine is

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 normal, and hydration is
encouraged to maintain normal
range of urine concentration.
None Seen None or Few/ HPF Normal No presence of protein or
amorphous crystals. Encourage
hydration and have dietary
intake.

VIII. HEALTH TEACHING GUIDE

Time Allotment: 30 minutes
OBJECTIVES CONTENT TEACHING EVALUATION
STRATEGY
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1.Identify proper  Importance of  Interactive  Verbal recall:
wound care techniques. keeping the lecture using Ask the
incision site visuals of a mother to
clean and dry. cesarean explain the
 Use of mild incision. steps of
soap and water  Demonstration cleaning and
for cleaning. of cleaning and drying the
 Proper drying drying the incision site.
techniques. wound.

2.Recognize signs of  Redness,  Discussion with

infection swelling, or visual aids  Q&A:Present
warmth around showing signs scenarios and
the incision. of infection. ask the mother
 Foul-smelling  Case scenario to identify
discharge. discussion for which signs
 Fever or identifying indicate
unusual pain. symptoms. infection.

3. Apply strategies to  Importance of  Group

promote healing. rest and proper discussion on  Checklist: Ask
nutrition (high- healthy eating the mother to
protein foods). and activity list three
 Avoid heavy modification. activities to
lifting and  Provide a list of avoid and
strenuous high-protein three foods
activities. foods. that promote
 Wearing loose healing.
clothing.

 Persistent  Role-play:
4. Understand when to bleeding or Simulate calling  Observation:
seek medical help. oozing from a healthcare Ask the
the wound. provider. mother to
 Increasing pain  Provide a describe when
despite handout with she would call
medication. emergency her doctor and
 Separation of contact what details
wound edges. information. she should
share.

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IX. DISCHARGE PLANNING
Date of possible discharge:

1. Medication to be taken home:

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2. Diet

Sample Meal Plan

BREAKFAST LUNCH DINNER

• One cup rice • One cup rice • One cup rice
• One boiled egg • One serving • One serving Chicken
• One mashed potato Dinengdeng. Curry
• One apple • One Banana

Foods to Avoid

 Fatty/Salty foods
 Chocolates
 Processed foods
 Nuts and seeds.
 Citrus fruits

3. Activities Restricted:

4. Treatment
 Follow up check-ups
 Intake of vitamin such as

5. Special Health Teaching

 The intake of the vitamins daily.
 The importance of taking the medication continuously.
 The effects of eating foods restricted by the doctor.
 The health benefits of eating recommended foods.
6. Check-up schedule

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X. NURSING CARE PLAN
ASSESSMENT NURSING IPLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE Risk for infection SHORT-TERM GOAL: INDEPENDENT: INDEPENDENT: SHORT-TERM GOAL:
DATA: related to an invasive Within 24 hours of nursing  Monitor the surgical site daily for  Early detection helps identify After 24 hours of nursing
procedure of cesarean interventions, the patient will redness, swelling, or discharge. infection. interventions, the patient
delivery and surgical demonstrate no signs of  Monitor vital signs regularly, demonstrated no signs of
OBJECTIVE incision as evidenced by infection, such as abnormal especially temperature.  Fever is an early indicator of infection, such as abnormal
DATA: elevated WBC count wound drainage, fever above infection. wound drainage, fever above
 Educate the patient on proper hand
 Elevated and presence of redness 37.5°C, or increasing redness,
hygiene and wound care practices.  Prevents contamination and 37.5°C, or increasing redness,
WBC count at on surgical wound. as evidenced by a normal
 Encourage the patient to avoid promotes healing.
as evidenced by a normal
13.85 × temperature and stable lab temperature and stable lab
Inference: results. touching the incision results.
10^9/L unnecessarily.  Reduces the risk of introducing
(normal: 4.5-  Promote adequate rest and pathogens to the wound.
ETIOLOGY: Invasive LONG-TERM GOAL: LONG-TERM GOAL:
11.0 × cesarean procedure Within one week of nursing hydration to support immune After one week of nursing
10^9/L) ↓ interventions, the patient will function.  Rest and fluids enhance the interventions, the patient
 Surgical Surgical incision (break achieve complete wound body’s ability to fight infection. achieved complete wound
incision on the in skin integrity) healing of the surgical site DEPENDENT: healing of the surgical site
abdomen with ↓ without signs of infection, as  Administer Antibiotics (e.g., DEPENDENT: without signs of infection, as
redness Exposure to bacteria evidenced by absence of Cefuroxime 500 mg IV, BID) as  Treats or prevents bacterial evidenced by absence of
observed ↓ redness, swelling, or discharge. ordered. infection. redness, swelling, or discharge.
 Temperature Immune response
 Perform sterile dressing changes
37.3°C via activates:  Maintains a clean wound GOAL HAS BEEN MET.
Redness
as ordered.
axillary environment to prevent
Increased WBC count infection.
(normal:  Administer antipyretics (e.g.,
↓
36.5–37.5°C) Risk of bacterial growth Ketorolac 30 mg IV, q6) as  Reduces fever and discomfort
in wound ordered, if the patient develops caused by infection.
↓ fever.
INTERDEPENDENT:
Delayed healing
INTERDEPENDENT: Laboratory results confirm the
↓
Risk of Infection Collaborate with the Laboratory to presence of infection and guide
perform WBC count and culture of wound treatment.
if infection is suspected.

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X. NURSING CARE PLAN
ASSESSMENT NURSING IPLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE Impaired skin integrity SHORT-TERM GOAL: INDEPENDENT: INDEPENDENT: SHORT-TERM GOAL:
DATA: related to surgical Within 24 hours of nursing  Inspect the wound site daily for  Early detection prevents After 24 hours of nursing
incision as evidenced by interventions, the patient’s signs of delayed healing or complications. interventions, the patient’s
the presence of a wound will remain clean and infection. wound remained clean and dry,
cesarean wound. dry, as evidenced by absence  Educate the patient on the  Promotes optimal healing. as evidenced by absence of
of active bleeding or foul- active bleeding or foul-
importance of keeping the incision
Inference: smelling discharge. smelling discharge.
clean and dry.
ETIOLOGY: Cesarean LONG-TERM GOAL: 
Promote adequate protein intake to  Protein is essential for wound LONG-TERM GOAL:
OBJECTIVE delivery (surgical Within one week of nursing support tissue repair. healing. After one week of nursing
DATA: incision) interventions, the patient will 
Reinforce patient education on  Prevents wound dehiscence. interventions, the patient
 Presence of a ↓ demonstrate proper wound avoiding heavy lifting until cleared demonstrated proper wound
low transverse Incision made through healing, as evidenced by intact by the physician. healing, as evidenced by intact
incision on the the skin and underlying skin and absence of skin and absence of
lower tissues complications. complications.
↓ DEPENDENT: DEPENDENT:
abdomen +  Perform sterile dressing changes  Maintains a clean wound GOAL HAS BEEN MET.
Tissue disruption at
BTL (Bilateral incision site as ordered. environment.
Tubal ↓  Administer Antibiotics (e.g.,  Reduces bacterial
Ligation). Healing process begins Cefuroxime 500 mg IV, BID) as contamination risks.
 Incision site ↓ ordered.
covered with a Scarring  Follow up with surgical removal  Ensures proper wound healing
clean ↓ of sutures or staples as ordered. and closure.
dressing. Impaired skin integrity  Apply topical antiseptics to the
Normal with the wound site if prescribed.  Prevents local infection.
healing presence of cesarean
wound INTERDEPENDENT:
process Collaborate with the Laboratory to INTERDEPENDENT:
observed, perform culture of wound if infection is Laboratory results confirm the
with no suspected. presence of infection and guide
pus or treatment..
active
bleeding.

Nursing Case Study PAGE \* MERGEFORMAT 18

 XI. DRUG STUDY
Name Dose, Mechanism Indications Contraindications Side Adverse Effects Nursing
and Route, of Actions Effects Management.
Classification of Frequency,
Drugs Duration
of
Administr
ation

Generic Name: Dosage: Hydralazine works by  Hypertensi  Coronary artery  Headache  Severe Before:
Hydralazine 5 mg directly relaxing ve crisis disease  Nausea hypotension Assess baseline blood
vascular smooth muscle,  Severe  Mitral valve  Dizziness  Reflex pressure and heart rate.
causing vasodilation,  Palpitations tachycardia Monitor for allergies.
hypertensio rheumatic heart
and reducing peripheral  Lupus-like
resistance, primarily in n disease syndrome with
arterioles.  Known prolonged use
hypersensitivity
to hydralazine
Brand Name: Route: During:
Apresoline IV Monitor blood pressure and
heart rate closely. Watch for
signs of hypotension.

Classification: Frequency After:

Antihypertensive As ordered Evaluate therapeutic response
, Vasodilator and check for adverse effects.
Monitor lab results, if
required.

Nursing Case Study PAGE \* MERGEFORMAT 18

 XI. DRUG STUDY
Name Dose, Mechanism Indications Contraindications Side Adverse Effects Nursing
and Route, of Actions Effects Management.
Classification of Frequency,
Drugs Duration
of
Administr
ation

Generic Name: Dosage: Hydralazine directly  Hypertensi  Coronary artery  Headache  Severe Before:
Hydralazine 10 mg relaxes vascular smooth ve crisis disease  Nausea hypotension  Verify the doctor’s
muscle, leading to  Severe  Mitral valve  Dizziness  Reflex order for SIVP.
vasodilation. It tachycardia  Check the patient’s
hypertensio rheumatic heart  Palpitations
primarily acts on  Myocardial baseline blood
arterioles, reducing n disease ischemia pressure and heart
systemic vascular  Heart  Known  Drug-induced rate.
resistance and lowering failure (off- hypersensitivity lupus-like  Ensure IV access is
blood pressure. label, with to hydralazine syndrome patent.
other (long-term
Brand Name: Route: use) During:
Apresoline Slow IV medication  Administer
Push s) hydralazine slowly
over 1–2 minutes to
prevent abrupt
hypotension.
 Continuously monitor
the patient’s blood
pressure and heart rate
during administration.

Classification: Frequency After:

Antihypertensive Single  Reassess blood
, Vasodilator Dose pressure and heart rate

Nursing Case Study PAGE \* MERGEFORMAT 18

 to evaluate therapeutic
effectiveness.
 Monitor for adverse
effects such as
dizziness or
tachycardia.
 Document the
patient’s response to
the medication.

XI. DRUG STUDY

Nursing Case Study PAGE \* MERGEFORMAT 18

 Name Dose, Mechanism Indications Contraindications Side Adverse Effects Nursing
and Route, of Actions Effects Management.
Classification of Frequency,
Drugs Duration
of
Administr
ation

Generic Name: Dosage: Magnesium sulfate acts  Prevention  Severe renal  Flushing or  Respiratory Before:
Magnesium 6g as a CNS depressant by and impairment warmth depression  Verify the doctor’s
Sulfate blocking neuromuscular treatment  Heart block  Nausea and  Hypotension order and ensure the
transmission. It vomiting  Loss of deep proper dose.
of  Myocardial
stabilizes excitable cell  Headache tendon reflexes
eclampsia damage  Assess baseline blood
membranes, reduces  Muscle (sign of
acetylcholine release at  Manageme  Hypermagnesem weakness toxicity) pressure, heart rate,
synaptic junctions, and nt of severe ia  Cardiac arrest respiratory rate, and
is effective in preeclamps (in severe deep tendon reflexes
preventing seizures in ia toxicity) (DTRs).
conditions such as  Tocolysis  Check serum
eclampsia. magnesium levels and
in preterm
labor (off- ensure calcium
label use) gluconate (antidote) is
 Hypomagn readily available.
esemia
Brand Name: Route: During:
Magtrate, Magox Slow IV  Administer slowly
push over 20–30 minutes,
monitoring closely for
signs of toxicity (e.g.,
respiratory depression
or loss of reflexes).
 Observe for flushing,

Nursing Case Study PAGE \* MERGEFORMAT 18

 dizziness, or other
side effects during
administration.
 Monitor vitals
continuously,
especially respiratory
rate and blood
pressure.

Classification: Frequency After:

Electrolyte, Loading  Reassess blood
Anticonvulsant dose pressure, respiratory
rate, and deep tendon
reflexes.
 Monitor serum
magnesium levels
(therapeutic range: 4–
7 mEq/L).
 Document patient
response and report
any adverse effects or
signs of toxicity.

XI. DRUG STUDY

Nursing Case Study PAGE \* MERGEFORMAT 18

 Name Dose, Mechanism Indications Contraindications Side Adverse Effects Nursing
and Route, of Actions Effects Management.
Classification of Frequency,
Drugs Duration
of
Administr
ation

Generic Name: Dosage: Ranitidine works by  Gastroesop  Known  Headache  Bradycardia Before:
Ranitidine 1 ampoule selectively blocking H2 hageal hypersensitivity  Diarrhea or  Hepatotoxicity  Verify the doctor’s
(usually receptors on the parietal reflux to ranitidine or constipation  Thrombocytop order and dosage.
contains 50 cells of the stomach,  Dizziness enia  Assess the patient for
disease other H2
mg) leading to reduced  Fatigue  Allergic baseline symptoms of
gastric acid secretion. (GERD) blockers reactions (e.g., gastric discomfort or
This helps in the healing  Peptic  Acute porphyria anaphylaxis) reflux. Ensure IV
of gastric and duodenal ulcer  Caution in access is patent.
ulcers and provides disease patients with
relief in hyperacidity-  Zollinger- renal or hepatic
related conditions. Ellison impairment
Brand Name: Route: During:
syndrome
Zantac IV  Administer ranitidine
 Stress ulcer
slowly over 2–5
prophylaxis
minutes to prevent
side effects like
hypotension or
bradycardia.
 Monitor the patient
for immediate allergic
reactions or side
effects during
administration.

Classification: Frequency After:

H2 receptor Single  Reassess the patient’s
Nursing Case Study PAGE \* MERGEFORMAT 18
antagonist, Dose symptoms for relief of
Antiulcer agent gastric discomfort.
 Monitor for any
delayed side effects
such as dizziness or
headache.
 Document the
administration,
including dose, time,
and patient response.

XI. DRUG STUDY

Nursing Case Study PAGE \* MERGEFORMAT 18

 Name Dose, Mechanism Indications Contraindications Side Adverse Effects Nursing
and Route, of Actions Effects Management.
Classification of Frequency,
Drugs Duration
of
Administr
ation

Generic Name: Dosage: Ranitidine works by  Gastroesop  Known  Headache  Extrapyramida Before:
Metoclopramide 1 ampoule selectively blocking H2 hageal hypersensitivity  Diarrhea or l symptoms  Verify the doctor’s
(usually 10 receptors on the parietal reflux to ranitidine or constipation (e.g., dystonia, order for PRN
mg/2 mL) cells of the stomach,  Dizziness akathisia) administration.
disease other H2
leading to reduced  Fatigue  Tardive  Assess the patient’s
gastric acid secretion. (GERD) blockers dyskinesia symptoms (e.g.,
This helps in the healing  Peptic  Acute porphyria (with nausea, vomiting, GI
of gastric and duodenal ulcer  Caution in prolonged use) discomfort).
ulcers and provides disease patients with  Neuroleptic  Check for any
relief in hyperacidity-  Zollinger- renal or hepatic malignant contraindications or
related conditions. Ellison impairment syndrome history of adverse
(rare) drug reactions.
syndrome
Brand Name: Route:  Hypotension During:
Reglan, Maxolon IV  Stress ulcer  Administer slowly (if
prophylaxis IV) over 1–2 minutes
to prevent side effects
like restlessness or
hypotension.
 Monitor for
immediate side effects
such as drowsiness or
restlessness.

Classification: Frequency After:

Antiemetic, Single  Reassess the patient’s
Prokinetic agent Dose symptoms for relief of
Nursing Case Study PAGE \* MERGEFORMAT 18
 nausea or vomiting.
 Monitor for any
extrapyramidal
symptoms or adverse
effects.
 Document the
administration,
including time, dose,
route, and patient
response.

XI. DRUG STUDY

Nursing Case Study PAGE \* MERGEFORMAT 18

 Name Dose, Mechanism Indications Contraindications Side Adverse Effects Nursing
and Route, of Actions Effects Management.
Classification of Frequency,
Drugs Duration
of
Administr
ation

Generic Name: Dosage: Cefuroxime works by  Respiratory  Known  Nausea and Before:
Cefuroxime 1.5 g inhibiting the synthesis of tract hypersensitivity to vomiting
the bacterial cell wall. It cefuroxime or other  Assess the patient's
binds to penicillin-binding infections  Abdominal pain
cephalosporins. allergy history,
proteins (PBPs), (e.g.,  Rash or hives
 History of severe especially for
disrupting the final stages bronchitis, allergic reactions to  Diarrhea penicillins and
of peptidoglycan pneumonia
synthesis, which leads to penicillin. cephalosporins.
cell lysis and death of the )  Active  Review renal function
bacteria. This action is  Skin and soft gastrointestinal tests to determine if
effective against a broad tissue disease, particularly dosage adjustments are
spectrum of both Gram- infections colitis. necessary.
positive and Gram-  Urinary tract  Severe renal  Confirm the indication
negative bacteria, infections impairment without for cefuroxime and
including those resistant to (UTIs) appropriate dosage ensure proper dosing
some other antibiotics.  Gonorrhea adjustments. based on the infection
 Lyme disease type.
 Infections
caused by
Brand Name: Route: susceptible During:
Ceftin, Zinacef IV strains of
bacteria such  Monitor for signs of
as Haemophi allergic reactions
lus during and after
influenzae an administration.
d Streptococ  Ensure proper IV
cus administration
pneumoniae. technique to minimize
Nursing Case Study PAGE \* MERGEFORMAT 18
 complications such as
phlebitis.

Classification: Frequency After:

Cephalosporin PRN
antibiotic (second  Reassess the patient for
generation). therapeutic
effectiveness,
monitoring for
resolution of infection
symptoms.
 Observe for any delayed
adverse reactions,
particularly
gastrointestinal
symptoms.
 Educate the patient
about potential side
effects and emphasize
the importance of
completing the full
course of antibiotics to
prevent resistance.

XI. DRUG STUDY

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 Name Dose, Mechanism Indications Contraindications Side Adverse Effects Nursing
and Route, of Actions Effects Management.
Classification of Frequency,
Drugs Duration
of
Administr
ation

Generic Name: Dosage: Ketorolac works by Ketorolac is  Active or history  Dizziness Before:
Ketorolac 30 mg inhibiting cyclooxygenase indicated for the of peptic ulcer  Abdominal • Assess the patient's
enzymes (COX-1 and short-term pain pain level and history of
COX-2), which are management of disease.
 Nausea gastrointestinal or renal
responsible for converting moderate to severe  Severe renal
 Somnolence issues.
arachidonic acid into pain, particularly in impairment.
Serious • Verify that the patient
prostaglandins. This postoperative  Risk of bleeding
inhibition reduces the settings or when oral adverse effects is NPO and confirm the need
due to its effect on
production of substances administration is not may include for IV ketorolac.
platelet function.
that mediate pain, possible. gastrointestinal • Review any
 Hypersensitivity to
inflammation, and fever, bleeding, contraindications to ensure
ketorolac or other
thereby providing kidney failure, safe administration
NSAIDs.
Brand Name: Route: analgesic and anti- heart attacks, During:
inflammatory effects.
 Use during labor
Toradol IV and
and delivery or in
anaphylaxis.  Administer the IV
patients with a
history of asthma, infusion slowly over a
urticaria, or recommended time frame
allergic-type to minimize adverse
reactions after effects.
taking aspirin or  Monitor the patient for
other NSAIDs. any immediate reactions
during and after
administration.

Classification: Frequency After:

Nonsteroidal anti-
inflammatory drug Every 6  Reassess pain levels to
Nursing Case Study PAGE \* MERGEFORMAT 18
(NSAID). hours when
the patient is evaluate effectiveness.
NPO  Monitor vital signs and
(nothing by watch for signs of
mouth).
gastrointestinal bleeding
or renal impairment.
 Document findings and
educate the patient about
potential side effects and
when to seek help.

XI. DRUG STUDY

Nursing Case Study PAGE \* MERGEFORMAT 18
 Name Dose, Mechanism Indications Contraindications Side Adverse Effects Nursing
and Route, of Actions Effects Management.
Classification of Frequency,
Drugs Duration
of
Administr
ation

Generic Name: Dosage: Celecoxib selectively  Osteoarthritis  Known  Gastrointestinal Before:

Celecoxib 200 mg inhibits the COX-2  Rheumatoid hypersensitivity to discomfort
enzyme, which is arthritis celecoxib or (nausea, diarrhea)  Assess the patient's
responsible for the  Ankylosing sulfonamides.  Headache medical history for any
synthesis of
spondylitis  Active peptic ulcer  Dizziness contraindications,
prostaglandins that
mediate pain and
 Acute pain disease or history of Serious adverse particularly
inflammation. By  Primary gastrointestinal effects may gastrointestinal and renal
reducing the production of dysmenorrhea bleeding. include issues.
these inflammatory (painful  Severe renal cardiovascular  Evaluate the patient's
mediators, celecoxib menstruation) impairment. events (e.g., heart current medications to
alleviates pain and  Reducing the  Pregnancy, attack, stroke) and avoid potential drug
inflammation with a lower risk of especially in the gastrointestinal interactions.
risk of gastrointestinal colorectal third trimester. bleeding.  Confirm the indication for
side effects compared to adenomas in  Concurrent use with celecoxib and ensure that
non-selective NSAIDs. patients with other NSAIDs. the patient understands
familial the dosing regimen.
adenomatous
polyposis.
Brand Name: Route: During:
Celebrex, Elyxyb Oral
 Monitor the patient for
any immediate adverse
reactions after
administration.
 Ensure that the
medication is taken
consistently at the same
Nursing Case Study PAGE \* MERGEFORMAT 18
 times each day for
optimal effectiveness.

Classification: Frequency After:

Nonsteroidal anti- BID
inflammatory drug  Reassess pain levels
(NSAID), to determine
specifically a effectiveness and
selective
document findings.
cyclooxygenase-2
(COX-2) inhibitor.
 Monitor for any signs
of gastrointestinal
bleeding or
cardiovascular issues.

Educate the patient about

potential side effects and
instruct them to report any
unusual symptoms

XI. DRUG STUDY

Nursing Case Study PAGE \* MERGEFORMAT 18

 Name Dose, Mechanism Indications Contraindications Side Adverse Effects Nursing
and Route, of Actions Effects Management.
Classification of Frequency,
Drugs Duration
of
Administr
ation

Generic Name: Dosage: Paracetamol acts Paracetamol is  Severe hepatic  Hypotension Before:
Paracetamol 4 mg primarily in the central indicated for the impairment or  Rash
nervous system, where relief of severe active liver disease.  Malaise (very  Assess the patient's
it inhibits prostaglandin pain, especially  Hypersensitivity to rare occurrences) pain level and history
synthesis, resulting in when oral paracetamol or any Infusion site pain of liver disease.
analgesic (pain- administration is of its excipients. may also occur in  Verify that the patient
relieving) and not feasible due to  Caution is advised about 2% of cases has no
antipyretic (fever- conditions like in patients with contraindications to
reducing) effects. It nausea, vomiting, moderate hepatic paracetamol.
does not possess or gastrointestinal impairment, severe  Ensure proper IV
significant anti- dysfunction renal impairment, access and prepare the
inflammatory properties chronic alcoholism, infusion according to
malnutrition, or guidelines.
dehydration

Brand Name: Route: During:

Panadol,Tylenol, IV
 Monitor the patient
Alvedon, and
for any immediate
Perfalgan adverse reactions or
infusion site
complications.
 Administer the IV
infusion over 15
minutes to reduce the

Nursing Case Study PAGE \* MERGEFORMAT 18

 risk of adverse effects.
 Reassess pain levels
to evaluate
effectiveness.
 Monitor for delayed
adverse reactions and
document findings.
 Educate the patient
about potential side
effects and when to
report them

Classification: Frequency After:

Miscellaneous PRN
analgesics  Reassess pain levels
to evaluate
effectiveness.
 Monitor for delayed
adverse reactions and
document findings.
 Educate the patient
about potential side
effects and when to
report them

Nursing Case Study PAGE \* MERGEFORMAT 18

 XI. DRUG STUDY
Name Dose, Mechanism Indications Contraindications Side Adverse Effects Nursing
and Route, of Actions Effects Management.
Classification of Frequency,
Drugs Duration
of
Administr
ation

Generic Name: Dosage: Tranexamic acid  Tranexamic  Tranexamic acid  Nausea and Before:
Tranexamic acid 500 mg works by acid is should not be vomiting
competitively indicated used in patients  Diarrhea  Assess the patient's
inhibiting the for: with:  Abdominal medical history for
activation of
 Prevention  Known pain any
plasminogen to
and hypersensitivity contraindications,
plasmin, which is
essential for treatment to tranexamic particularly
fibrinolysis (the of excessive acid or any regarding
breakdown of blood bleeding in component of thromboembolic
clots). By binding to various the formulation. disease.
lysine receptor sites situations,  Active  Evaluate renal
on plasminogen, it including: thromboembolic function to
prevents the  Major disease (e.g., determine if dosage
dissolution of fibrin, trauma deep vein adjustments are
thereby stabilizing  Postpartum thrombosis, necessary.
clots and reducing
hemorrhage pulmonary  Confirm the
excessive bleeding.
 Surgical embolism). indication for
procedures  Severe renal tranexamic acid
with a high impairment and ensure proper
risk of without careful dosing based on
bleeding monitoring. clinical guidelines
 Dental
Brand Name: Route: procedures During:
Cyklokapron, IV in patients
Lysteda with  Monitor the patient
Nursing Case Study PAGE \* MERGEFORMAT 18
 bleeding
disorders closely for signs of
allergic reactions or
Heavy thromboembolic
menstrual events during and
bleeding (when after
taken orally administration.
 Ensure proper IV
administration
technique to
minimize
complications such
as phlebitis.

Classification: Frequency After:

Antifibrinolytic Q8
agent.  Reassess the
patient for
therapeutic
effectiveness,
monitoring for
resolution of
bleeding symptoms.
 Observe for any
delayed adverse
reactions,
particularly
thromboembolic
events.
 Educate the patient
about potential side
effects and instruct
them to report any
unusual symptoms
Nursing Case Study PAGE \* MERGEFORMAT 18
 or signs of bleeding

XI. DRUG STUDY

Name Dose, Mechanism Indications Contraindications Side Adverse Effects Nursing
and Route, of Actions Effects Management.
Classification of Frequency,
Drugs Duration
of
Administr
ation

Generic Name: Dosage: Cefuroxime inhibits  Lower  Known  Diarrhea  Clostridioides Before:
Cefuroxime 500 mg bacterial cell wall respiratory hypersensitivity  Nausea and difficile-  Verify the doctor’s
synthesis by binding to tract to cefuroxime or vomiting associated order and check for
penicillin-binding  Headache diarrhea known allergies to
infections other
proteins (PBPs). This  Rash (CDAD)
(e.g., cephalosporin cephalosporins or
leads to the weakening  Anaphylaxis
of the bacterial cell pneumonia.  History of severe (rare but penicillins.
wall, causing cell lysis  Urinary allergic reaction severe)  Assess the patient’s
and death. It is effective tract to penicillins  Stevens- baseline vitals and
against a broad infections (caution due to Johnson renal function (dose
spectrum of gram- syndrome adjustment may be
Nursing Case Study PAGE \* MERGEFORMAT 18
 positive and gram- (UTIs) cross-sensitivity) (rare) required in renal
negative bacteria.  Skin and  Elevated liver impairment).
soft tissue enzymes  Prepare the
infections medication for IV
 Sinusitis infusion as per
 Surgical protocol.
prophylaxis
Brand Name: Route: During:
Zinacef, Ceftin IV  Administer
cefuroxime through
IV infusion over the
recommended time
(usually 30–60
minutes).
 Monitor the patient
for immediate
reactions, such as
itching, rash, or
difficulty breathing.

Classification: Frequency After:

Antibiotic,  Reassess for signs of
Second- infection
generation improvement (e.g.,
cephalosporin
reduced fever,
decreased
redness/swelling).
 Monitor for side
effects such as
diarrhea or abdominal

Nursing Case Study PAGE \* MERGEFORMAT 18

 pain.
 Document the dose,
time of
administration, and
the patient’s response
to the medication.

XI. DRUG STUDY

Name Dose, Mechanism Indications Contraindications Side Adverse Effects Nursing
and Route, of Actions Effects Management.
Classification of Frequency,
Drugs Duration
of
Administr
ation

Generic Name: Dosage: Ferrous sulfate provides  Iron  Known  Constipation  Iron toxicity Before:
Ferrous Sulfate 325 mg a source of iron, which deficiency hypersensitivity  Dark stools (in overdose  Verify the doctor’s
is required for the anemia to ferrous sulfate  Nausea situations, order and ensure
production of  Abdominal especially in correct dosage.
 Anemia  Hemochromatosi
hemoglobin in red blood discomfort children)  Assess for baseline
cells. It is absorbed in due to s (iron overload  Gastritis hemoglobin levels and
the small intestine and chronic disorder)  Gastrointestina signs of anemia.
incorporated into blood loss  Peptic ulcer l bleeding (in  Check for any
hemoglobin to increase  To increase disease severe cases) contraindications,
the oxygen-carrying iron levels  Gastrointestinal particularly GI issues
capacity of the blood. during obstruction (e.g., ulcers).
Brand Name: Route: During:
pregnancy
Feosol Oral  Encourage the patient
(if
to take iron with food
or a full glass of water
Nursing Case Study PAGE \* MERGEFORMAT 18
 prescribed) to minimize
gastrointestinal side
effects.
 Monitor for
constipation or other
gastrointestinal
disturbances.

Classification: Frequency After:

Iron supplement, OD  Reassess iron levels
Hematinic (hemoglobin and
ferritin) and monitor
for any adverse
effects.
 Instruct the patient to
follow up with blood
tests to assess iron
stores.
 Document patient
response and any side
effects.

Nursing Case Study PAGE \* MERGEFORMAT 18

 XI. DRUG STUDY
Name Dose, Mechanism Indications Contraindications Side Adverse Effects Nursing
and Route, of Actions Effects Management.
Classification of Frequency,
Drugs Duration
of
Administr
ation

Generic Name: Dosage: Paracetamol works  Mild-to-  Known  Nausea (rare)  Liver damage Before:
Paracetamol 500 mg centrally in the brain by moderate hypersensitivity  Rash (rare) (especially  Verify the doctor’s
inhibiting the enzyme pain to paracetamol  Abdominal with overdose order and ensure
cyclooxygenase (COX), pain (rare) or chronic high appropriate dosage.
(headache,  Severe liver
which leads to reduced  Hepatotoxicity doses)
toothache, disease (e.g.,  Assess baseline liver
production of (in cases of  Acute liver
prostaglandins. These muscle cirrhosis, overdose) failure (in function (if necessary)
are chemicals that pain hepatitis) severe and inquire about
promote inflammation,  Fever  Alcohol use toxicity) alcohol use.
pain, and fever. reduction disorder (due to  Kidney  Ensure the patient is
Paracetamol has a weak (associated liver toxicity damage (in not taking other
anti-inflammatory effect rare cases of medications
with risk)
but is highly effective prolonged use)
infections containing
for reducing fever and
relieving mild-to- or other paracetamol to avoid
moderate pain. causes) overdose.

Nursing Case Study PAGE \* MERGEFORMAT 18

Brand Name: Route:  Postoperati During:
Tylenol, Panadol Oral ve pain  Monitor for signs of
(often as liver toxicity (e.g.,
part of a jaundice, dark urine,
combinatio abdominal pain).
n therapy)  Ensure the patient
adheres to the
prescribed dosage and
does not exceed the
maximum daily limit
(typically 4000 mg
per day).

Classification: Frequency After:

Analgesic, TID  Reassess for pain or
Antipyretic fever relief and
document the
effectiveness.
 Monitor liver function
in patients with risk
factors for
hepatotoxicity.
 Educate the patient on
proper dosing and not
exceeding the
recommended dose.

Nursing Case Study PAGE \* MERGEFORMAT 18

Nursing Case Study PAGE \* MERGEFORMAT 18