INTRODUCTION:

PATIENT’S PROFILE

Name: Maria Marla H. Gallegues

Address: #505 M.H Del Pilar St. Malanday, Valenzuela City

Age: 37 years old

Sex: Female

Civil Status: Single

Religion: Roman Catholic

Father’s Name: (Deceased)

Mother’s Name: Milagros Hermanio

Date of Admission: June 28, 2014

Chief Complaints: Labor Pain

Impression/Diagnosis: Pregnancy Uterine 38wks, Cephalic in labor

Operation: Median episiotomy plus repair of perineal laceration

A case of Mrs. Gallegues is Gravida 4 Parity 3. The patient complains about Labor Pain. Patient

was admitted last June 28, 2014 at 3:50am. Based on internal examination the patient has cervix

of 4cm dilatation and 70% effacement cephalic. (+) Bow. June 28, 2014 at 9:58 AM she gave

birth through Normal Spontaneous Vaginal Delivery.

Name of Drug

Therapeutic Action

Indication Adverse Effect

Contraindication

Nursing Consideration

Generic Name: Mefenamic Acid

Brand Name: Ponstan

Classification: Anti-inflammatory; Analgesic.

Aspirin like drug that has analgesic antipyretic and anti-inflammatory activities

Moderate to moderately severe pain.Relief of pain including muscular, rheumatic, traumatic, dental, post-operative and postpartum pain, headache, migraine, fever and dysmenorrhea, pain from rheumatoid arthritis including Still’s disease, soft tissue injuries. Therapy should not exceed 7 days.

CNS: DizzinessCV: VasodilationEENT: Visual disturbancesGI: Nausea and VomitingGU: Urinary retentionSKIN: Pruritus

Pregnancy and Lactation.Hypersensitivity with drugs, acute intoxication with alcohol, physical opioid dependenceKidney or liver impairment.Children less than 14 years old.

Tell patient that drug works best when taken before pain becomes severe

Recommend abstinence from alcohol when taking medication

Caution patient that drug can cause dependence

Tell patient to report occurrence of drug induced adverse reactions.

Advise patient to immediately report persistence or failure to

relieve pain.

Assessment

Diagnosis Planning Nursing

Intervention Rationale Evaluation

Subjective:“Sumasakt yung tahi paminsan minsan.” As verbalized by the client.

Objective: Faci

al grimace

Pain scale of 6/10

Slowed movement

V/S taken as follows:

T: 37.3

RR: 21

PR: 96

BP: 100/

Acute vaginal pain related to right median lateral episiotomy as evidenced by facial grimacing.

After 8 hours of nursing care, the client will be able to:

Express alleviation of pain from scale of 6 to 2

To know different techniques in alleviating pain

Comfortably fall asleep

Provide rapport with the patient

Monitor vital signs

Provide a therapeutic environment

Encourage verbalization of feelings

Encourage to do diversional activities

Encourage

To gain trust and full cooperation during the pain alleviation period

Vital sings altered during

After 8 hour of nursing care, the client:

Expressed alleviation of pain from scale of 6 to 3

Knew different techniques in alleviating pain

Comfortably feel asleep

80 rest and sleep

acute pain

To aid alleviation of pain

To assist in evaluation

To alleviate pain

To assist in alleviation of pain