MANILA TYTANA COLLEGES Manila Doctors College of Nursing

I.

Case Abstract

Gestational diabetes is an increase in blood glucose level during pregnancy. It is called gestational because the first onset of diabetes occurs during pregnancy and usually disappears right after delivery. Approximately 2% to 3% of all the women who do not begin a pregnancy with diabetes become diabetic during pregnancy, usually at the midpoint of pregnancy when insulin resistance becomes most noticeable. The symptoms fade again at the completion of pregnancy, but the risk of developing type 2 diabetes later in life may be as high as 50% to 60%. Risk factors for gestational diabetes include: Obesity, age over 35 years old, history of large babies (10 lb. or more), history of unexplained fetal or perinatal loss, history of congenital anomalies in previous pregnancies, history of polycystic ovary syndrome, and family history of diabetes.

The patient (JB) was diagnosed with gestational diabetes mellitus secondary to cephalopelvic disproportion. . She is 39 years old with an obstetric history of G4 P3. She has a repeat caesarean case and gave birth to a child that has a birth weight of 3,620g. Shes 59 cm tall and weight 62 kg. She complained that she urinates frequently, she often thirsts, and she has edema in her extremities and experience blurring of vision. Her lifestyles while shes pregnant were one of the factors that caused her to have GDM. She stated that she doesnt want to do some exercises because she thought that it may harm her child in her womb. She also eats a lot aside from the heavy meals especially chocolates and she woke up often times late at night only just to eat. On July 25, 2012 her blood sugar level is 149mg/dL. Her caesarian operation is scheduled on the 31th of July but upon her prenatal check up on the 25th the obygyne found out that the baby is in 2cm already, so her caesarian operation was moved on that day

As a health care providers, we taught her some additional wound care practices to prevent any infection to her wound, we advised her to take a bath at least 2 to 3 times a day, proper hand washing, and some of a self-care practices. We advised her to decrease her rice intake and sweet foods or any food that is not healthy for her. We also advised her to eat more vegetables and fruits rather than eating processed foods and if possible, if she has time, we advised her to do some simple exercise or routine for her to lose weight. And we told her that if and only if her GDM will lead to her to have a type 2 diabetes mellitus, she ought to consult her doctor.

II.

Nursing History a. Biographic Data Patients Initial: J.B.B Educational Attainment: vocational (HRS) Date of Admission: July 25, 2012 Gender: F Occupation: Housewife No. of days in Hospital: 5 Days Order of Admission: ambulatory Age: 39 Date of Birth: 05-231973 Place of Birth: Anhawon Panay capiz Source of Information: J.B.B

b. Chief Complaints(s) - the patient came in ambulatory with uterine contractions, no vaginal discharge or bloody show with good fetal movement

c. History of Present Illness

Childhood Illness(es): Childhood/Adult Immunization: Accidents and Injuries: Childhood: complete adult immunization

Previous Caesarean section 2000,2005,2008,2012 hospitalization/surgery: Medication prior to Ferrous sulfate confinement: d. History of Past Illnesses e. Family History General Family Information

Name:

Relation:

Ag e :

Gen d e r :

Occupation:

Education al Attain ment:

Diseases/ Disorder:

J.B.B

Patient

39

Housewife

Vocational (HRS)

None

D.B.

Husband

39

Jeepney Driver

None

J.B

Daughter

11

N/A

Grade 6

None

T.B

Daughter

12

N/A

Grade 1

None

K.Z.B

Daughter

N/A

N/A

None

D.B

Son

3 D a y s

N/A

N/A

none

Genogram

Legend:

Female:

Male:

f. Developmental History

Theory

Age

Developmental task Genital Stage

Patients Description The patient is now staying with her husband

Interpretation

The

patient was able to achieve this stage meeting her roles as a mother by

Freuds Psychose xual Theory 38 years old

Energy directed toward sexual

is

together with their 4 children

full

and has the responsibility as a productive mother. She also stated that she has no problem with

maturity and function and development of skills

and as a wife. She

fulfils with the of needs her

needed cope the

to with

her sexual relation to her husband. The

family especially the sexual need of her husband.

environment. (Kozier and Erb, Fundamental s of Nursing, Volume 1, 2008, 8th edition, p. 352)

patients physical sexual changes reawaken her repressed needs; she can also balance both her responsibility as a mother and own desires independentl y.

Generativity versus Stagnation

The client is aware of her roles as a mother and tries her best to meet the

The

patient able

was

to achive this stage by helping to guide

-In this stage, adults strive to create or nurture things that Ericksons Psychoso cial Theory 38 years old will outlast them; often by having children or contributing to positive changes that benefits other people. (Kozier and Erb, Fundamental s of Nursing, Volume 1, 2008, 8th

needs of her children for them to have a better future.

future generatio ns such as her children.

edition, p. 353)

Formal Operational Phase

The patient is concerned with the ethical problems of

The

patient able

was

to achive this stage by developin g such logical thought, rational reasoning, and systematic planning. skills as

- In this stage, people develop the ability to think about Piagets Cognitive Theory abstract 38 years old concepts. Reasoning is deductive and futuristic. (Kozier and Erb, Fundamental s of Nursing, Volume 1, 2008, 8th edition, p. 357) Post Conventional (Universal Ethical Principle Orientation)

the world. And she verbalizes her plans for her family now that another member of the family came in their lives, her newborn child. She can reason out and answer systematically to our questions. The client has moral judgment upon every situation and follows selfchosen ethical
The

patient was able to achieve this stage by

accepting society's conventio ns concernin g right and wrong.

Kohlbergs Moral Theory

principles
38 years old -Decisions and behaviour are based on internalized rules, on conscience rather than social laws, and on self-

when making decisions. She verbalized that she obeys rules and follows society's rules even when there are no

chosen ethical and abstract principles that are universal, comprehensi ve, and consistent. (Kozier and Erb, Fundamental s of Nursing, Volume 1, 2008, 8th edition, p.359)

consequences for obedience or disobedience.

ParadoxicalConsolidativ e

The patient believes that prayer helped her alot as she faced several

The

patient was able to achieve this stage by

being able to reflect on own beliefs,

and practice her spiritual life and being

-Awareness of truth from a variety of Fowlers Spiritual Theory viewpoints. 38 years old (Kozier and Erb, Fundamental s of Nursing, Volume 1, 2008, 8th edition, p.361)

difficulties in life.

her

able to rely on Creator during tough times. her

g. Environmental History

The client, along with her husband and three daughters, live in a four storey apartment in Pasay City. She described their apartment as strong and sturdy. It is made of concrete and it can withstand mild to moderate earthquakes. The family privately occupies the ground floor with an estimated floor area of 100 square feet. It has an entrance door, a window and one bathroom. The client claimed that they have good drainage system in their area wherein the canal is underground. There is no presence of stagnant water outside the house that could potentially be a breeding ground for mosquitoes. In addition, they do not experience flooding in their area. The family does not practice waste segregation; however, the household garbage is regularly collected by the local government. The water source of the house is from NAWASA which is safe to use in preventing waterborne diseases such as amoebiasis. The apartment is located in a congested urban area near the airport. It is not located beside the main road. Therefore, the family is less exposed to air and noise pollution from traffic vehicles. Behind the apartment is a squatters area. The barangay hall and the barangay clinic are three blocks away from their home. The client stated that their neighborhood is safe and that they can walk freely outside the house.

h. OB/Gyne History

Menarche Age: 12 years old Duration: 7 days Obstetric History G 4 T 0 P 0

Amount: 4 pads per Characteristic: Bright Red day Associated Symptom: none A Type of delivery: 0 4 0 caesarean section (2000,2005,2008,20 12) Exposure to Teratogenic Agents: none L M

Complications: 2000 Cs secondary to CPD and 2012 CS secondary to GDM

III.

Gordons Typology of 11 Functional Health Pattern a. Health Perception/Health Management Pattern

Analysis: Interpretation:

b. Nutritional/Metabolic Pattern

Analysis: Interpretation:

c. Elimination Pattern

Analysis: Interpretation:

d. Activity-Exercise Pattern

Analysis: Interpretation:

e. Sleep-Rest Pattern

Analysis: Interpretation:

f. Cognitive-Perceptual Pattern

Analysis: Interpretation:

g. Self-Perception/Self-Concept Pattern

Analysis: Interpretation:

h. Role-Relationship Pattern

Analysis: Interpretation:

i. Sexuality-Reproductive Pattern

Analysis: Interpretation:

j. Coping-Stress Tolerance Pattern

Analysis: Interpretation:

k. Value-Belief Pattern

Analysis: Interpretation:

IV.

Physical Assessment A. General Survey

Body Built: endomorph

Grooming/Hygiene: good

Posture and Gait: normal

Body Odor and Breath Odor: none

Signs of Distress: none

Obvious signs of Illness(es):

Orientation: Time: 11:00 Person: ward Quantity and Quality of Speech: Place: ob

Level of Conscious ness:

Affect:

Mood:

Organization of Thoughts:

b. Anthropometric Measurement

Height: 411 (150cm)

Weight: before giving birth 62 kg After giving birth 54 kg

IBW/BMI: 27.5 24

For Neonate

Head Circumference: 34.5 cm

Chest Circumference: 33 cm

Abdominal Circumference: 31 cm

c. Vital Signs Temperature: Pulse Rate: Respiratory Rate: Blood Pressure:

d. Physical Examination

Body Part Skin -

Normal Findings -

Actual Findings Deep brown skin color Generally uniform except in areas exposed to the sun Warm to touch No edema Some flat nevi Thick, dry, resilient hair Evenly distributed No infestation Smooth texture; clean and short Well rounded and convex Angle of nail plate is about 160 Positive capillary refill Rounded & smooth skull contour; symmetric Absence of nodules or masses Slightly asymmetric facial features Eyebrows symmetrically aligned and equal movement No redness, swelling and dischargeon eyelids; lids close symmetrically No edema over lacrimal gland Transparent and shiny cornea Pupils black in colorequal in size; 7 mm in diameter; round, smooth border, iris flat and round Both eyes coordinated, move in unison, with parallel alignment Color same as facial skin; symmetrical Auricles are mobile, firm, and not tender; pinna recoils after it is folded Dry cerumen, grayish-tan color Normal voice tones audible Symmetric No discharge or flaring External nose not tender; no lesions Air moves freely as the client breathes through the nares Mucosa pink; clear and watery discharge Intact nasal septum and in

Analysis and Interpretation

Color varies from light to deep brown Generally uniform Warm to touch No edema

NORMAL

Hair

Silky, resilient hair Properly distributed No presence of parasites Smooth texture Convex curvature Round nails with 160 degrees nail base Positive capillary refill with less than 3 seconds

NORMAL

Nails

NORMAL

Head & Face -

Normocephalic and symmetric Absence of nodules or masses Symmetric or slightly asymmetric facial features Eyebrows symmetrically aligned and equal movement No eyelids discharge and discoloration; lids close symmetrically No edema over lacrimal gland Transparent and shiny cornea Pupils black in colorequal in size; normally 3 to 7 mm in diameter; round, smooth border, iris flat and round Both eyes coordinated Color same as facial skin; symmetrical Auricles are mobile, firm, and not tender; pinna recoils after it is folded Dry cerumen, grayish-tan color Normal voice tones audible Symmetric No discharge or flaring External nose not tender; no lesions Air moves freely as the client breathes through the nares Mucosa pink; clear and watery discharge Intact nasal septum and in

NORMAL

Eyes -

NORMAL

Ears Nose -

NORMAL

NORMAL

midline Uniform pink colour lips; soft, moist, smooth texture 32 adult teeth; smooth, white, shiny tooth enamel Pink gums No retraction of gums Smooth, intact dentures Tongue in central position; pink color; no lesions; raised papillae Tongue moves freely Palates are light pink, smooth Uvula positioned in midline of soft palate Pink and smooth posterior wall in the orpharynx Tonsils are pink and of normal size Muscles are equal in size and strength; head centered Coordinated, smooth head movements No enlargment, masses or nodules in the thyroid gland

midline Uniform dark colored lips; soft, moist, smooth texture 32 adult teeth; smooth, white, shiny tooth enamel Brown patches on gums No retraction of gums Tongue in central position; pink color with brown pigmentation on borders; no lesions; raised papillae Tongue moves freely Palates are light pink, smooth Uvula positioned in midline of soft palate Pink and smooth posterior wall in the orpharynx Tonsils are pink and of normal size Muscles are equal in size and strength; head centered Coordinated, smooth head movements No enlargment, masses or nodules in the thyroid gland

Mouth & Phary nx -

NORMAL

Neck

NORMAL

Spine

Thorax/Lungs

- The spine should be vertically aligned; right and left shoulders and hips are at the same height. The overall shape of thorax is elliptical; its diameter is smaller at the top than at the base. Respiratory Range within 20-60 breaths/min

- spine vertically aligned - Right and left shoulders and hips are at the same height.

NORMAL

Thorax is oval in shape Chest is symmetric; it is intact with the chest wall, no tenderness and masses No Difficulties in breathing Respiratory rate is 25 breaths/min

NORMAL

Breath sounds is equal inspiratory and expiratory phases

Has a moderate intensity and moderate-pitch

Cardiovascular/Heart -

Dull, low pitched, and first sound sounds like lub second sound is like dub.

Dull, low pitched; no abnormal sounds rather than luband dub silent interval then higher pitch sound

Pulse Rate within 60-90 bpm.

NORMAL Pulse rate of: 75

Breast & Axillae (optional)

Rounded shape; slightly unequal in size; generally symmetric; No masses and Swelling. Same colour

larger, heavier, and a little tender (breast feeding)

Skin colour is brown; uniform in colour same as the abdomen w/ stretch marks.

NORMAL

Abdomen

Unblemished skin, uniform in color, stretch marks, surgical scars, symmetric.

Patients abdomen has no presence of lesions, brown in color, it has stretch marks and surgical scar (due to Caesarean Section type of delivery),

Flat, rounded (convex and scaphoid (concave)

Rounded and symmetric

NORMAL

Musculoskeletal

Normally firm; no contractures, tremors, swelling; equal

Can sit and write, walk and stand but needs assistance because of feeling slight pain in her abdomen due to

strength on each body side. Genitals (optional) Rectum/Anus (optional)

caesarean section process of delivery. Joints move smoothly

NORMAL

e. Neurologic Status

I II III,IV,VI V VII VIII

Cranial Nerves IX X XI XII

Reflexes Biceps Reflex Triceps Reflex Brachioradialis Reflex Patellar Reflex Achilles Reflex Plantar/Babinski Reflex

Sensory Function Touch Pain Temperature Position Tactile Discrimination

V.

Anatomy and Physiology

Human endocrine system: is composed of endocrine glands, which are ductless glands secreting chemical signals into the circulatory system. In contrast, exocrine glands have ducts that carry their secretions to surfaces. It produces chemical signals within the glands that influence tissues separated from the glands by some distance. Both the endocrine and the nervous system regulate the activities of structures in the body, but they do so in different ways. The hormones secreted by most endocrine glands can be described as amplitude-modulated signals, which consist mainly of increases or decreases in the concentration of hormones in the body fluids. The all-or-none action potentials carried along axons can be described as frequency-modulated signals, which vary in frequency but not in amplitude. A low frequency of action potentials is a weak stimulus, whereas a high frequency of action potentials is a stronger stimulus. The hypothalamus: 1. The hypothalamus is located in the forebrain, directly above the pituitary gland. The hypothalamus receives input from other parts of the brain and from peripheral nerves. This input affects neurosecretory cells within the hypothalamus. 2. Major sites where the nervous and endocrine systems interact; regulates the secretory activity of the pituitary gland.

The pituitary gland: 1. The anterior pituitary synthesizes its own hormones. Capillaries within the anterior pituitary receive signals from the hypothalamus that tell the anterior pituitary whether or not to release certain hormones. 2. Secretes nine major hormones that regulate numerous body functions and the secretory activity of several other endocrine glands. a) Antidiuretic hormone (ADH) -in the posterior pituitary gland -increased water reabsorption (less water is lost in the form of urine) b) Oxytocin -in the posterior pituitary gland -increased uterine contractions; increased milk expulsion from mammary glands; unclear function in males c) Growth hormones (GH) -in the anterior pituitary gland -increased growth in tissues; increased amino acid uptake and protein synthesis; increased breakdown of lipids and release of fatty acids from cells; increased glycogen synthesis and increased blood glucose levels; increased somatomedin production. d) Thyroid-stimulating hormone (TSH) -increased thyroid hormone secretion e) Adrenocorticotropic hormone (ACTH) -increased glucocorticoid hormone secretion f) Melanocytes-stimulating hormone (MSH) -increased melanin production in melanocytes to make the skin darker in color g) Luteinizing hormone (LH) - Ovulation and progesterone production in ovaries; testosterone synthesis and support for sperm cell production in testes h) Follicle-stimulating hormone (FSH) -follicle maturation and estrogen secretion in ovaries; sperm cell production in testes. i) Prolactin -milk production in lactating women; increased response of follicle of LH and FSH; unclear function in males

The thyroid gland: One of the largest endocrine glands, with a weight of approximately 20g. it is highly vascular and appears more red than its surrounding tissues. The adrenal gland: The adrenal glands are located on top of the kidneys. Each gland is subdivided into an outer adrenal cortex and an inner adrenal medulla. The pancreas: The pancreas is both an endocrine organ and an exocrine organ. The exocrine portion of the pancreas secretes digestive enzymes into the pancreatic duct. The endocrine portion of the pancreas secretes hormones, including insulin and glucagon. The testes: The testes are responsible for the synthesis and secretion of androgens, such as testosterone. Interstitial cells, located between the seminiferous tubules of the testes, produce androgens.

The ovaries: The ovaries produce and secrete steroid hormones known as estrogens and progesterone.

Fallopian tube The Fallopian tubes are paired, tubular, seromuscular organs whose course runs medially from the cornua of the uterus toward the ovary laterally. The tubes are situated in the upper margins of the broad ligaments between the round and utero ovarian ligaments. Each tube is about 10 cm long with variations in length from 7 to 14 cm. The abdominal ostium is situated at the base of a funnel-shaped expansion of the tube, the infundibulum, the circumference of which is enhanced by irregular processes called fimbriae. The ovarian fimbria is longer and more deeply grooved than the others and is closely applied to the tubal pole of the ovary. Passing medially, the infundibulum opens into the thin-walled ampulla forming more than half the length of the tube and 1 or 2 cm in outer diameter; it is succeeded by the isthmus, a round and cord-like structure constituting the medial one-third of the tube and 0.5-1 cm in outer diameter. The interstitial or conual portion of the tube continues from the isthmus through the uterine wall to empty into the uterine cavity. This segment of the tube is about 1 cm in length and 1 mm in inner diameter. The tubal wall consists of three layers: the internal mucosa (endosalpinx), the intermediate muscular layer (myosalpinx), and the outer serosa, which is continuous with the peritoneum of the broad ligament and uterus, the upper margin of which is the mesosalpinx. The endosalpinx is thrown into longitudinal folds, called primary folds, increasing in number toward the fimbria and lined by columnar epithelium of three types: ciliated, secretory, and peg cells. In the ampullary and infundibular sections, secondary folds of the tubal mucosa also exist, markedly increasing the surface areas of these segments of the tube. The myosalpinx actually consists of an inner circular and an outer longitudinal layer to which a third layer is added in the interstitial portion of the tube.The serosa of the tube is composed of an epithelial layer histologically indistinguishable from peritoneum elsewhere in the abdominal cavity. The tubes act as ducts for sperm, oocyte, and fertilized ovum transport, in addition to being the normal site of fertilization. These functions depend mainly on three factors: tubal motility, tubal cilia, and tubal fluid.

Pelvic bone
The skeleton of the pelvis is a basin-shaped ring of bones connecting the vertebral column to the femora. Its primary functions are to bear the weight of the upper body when sitting and standing; transfer that weight from the axial skeleton to the lower appendicular skeleton when standing and walking; and provide attachments for and withstand the forces of the powerful muscles of locomotion and posture. Compared to the shoulder girdle, the pelvic girdle is thus strong and rigid. Its secondary functions are to contain and protect the pelvic and abdominopelvic viscera (inferior parts of the urinary tracts, internal reproductive organs); provide attachment for external reproductive organs and associated muscles and membranes. gynecoid pelvis a type of pelvis characteristic of the normal female and associated with the smallest incidence of fetopelvic disproportion. The inlet is nearly round, the sacrum is parallel to the posterior aspect of the symphysis pubis, the sidewalls are straight, and the ischial spines are blunt and do not encroach on the space in the true pelvis. It is the ideal pelvic type for childbirth. Also spelled gynaecoid pelvis.

VI.

Pathophysiology

VII.

Laboratory Results

Laboratory and dates

Normal Values

Result

Analysis and interpretation

07/25/12: Urinalysis : Antibody Screening Color Yellowish Transparency Slightly Cloudy PH 6.0 Specific gravity 1.020 Glucose Slightly Cloudy Dark Yellow Negative

Protein Negative Blood

Ketone 3.9 mol/vol Bilirubin

Negative

Negative Urobilirubin 3.2 mol/vol Leucocytes

WBC 0.00-0.17 u mol RBC 0.00-11.00 u mol Epithilial cell 0.00-17.00 u mol Bacteria 0.00-278.00 u mol 17.5 u mol 5.4 u mol 1.5 u mol 10.3 u mol

Negative

Negative

Normal

Normal

Normal

Normal

07/26/2012 Creatinine 46.00-92.00 mol/vol 47 normal

Date 7/25/12

Progress Notes

Diagnostic Procedures

Medications

0830H

The patient was admitted directly to OB-Gyn Complex with a blood pressure of 150/90 mmHg She was given Metropolol for hypertension. Indication

The patient tested negative for antibody screening. The urinalysis has no Side effect and Adverse Effect

>Metropolol >PNSS 1L + 30 oxy x8 Nursing Consideration/ health teaching

Drugs

Action

Potassium

3.50-5.10 mol/vol

3.9

normal

VIII. IX.

Drug Study Nursing Care plan

X.

Ongoing Appraisal

>VS after surgery BP 120/80, RR 19, PR 78 >with anesthesia and waiver and procedure wheeled @ US

2220H

The client was admitted from OBGyn-complex to OBW2 via stretcher S/P STAT RCS BOY with BTL under the service of Dr. Ocampo (SS) She was awake, conscious and coherent with spontaneous breathing. She is on an NPO diet. She has an ongoing IVF that is intact and infusing well. Also, she has foley catheter attached to urine bag with adequate urine output. The initial vital signs recorded were 140/100 mmgH for BP, 76 beats per minute for pulse rate, 20 circulation per minute for respiratory rate and 36.3:C for temperature. Dr. Celestino ordered for ECG and x-ray tests. No complaints were made by the patient.

significant result that deviates from normal. The characteristics of the urine were yellow and slightly cloudy. It has a pH level of 6.0 which is neither acidic nor too basic. The specific gravity, amount of ketone and bilirubin are within the normal range. The urine is also negative for glucose, protein, blood, nitrite, bilirubin and leucocyte. The WBC, RBC, epithelial cell and bacteria are within the normal range.

>IV fluid : 1. D5NR 1L + 20 IV oxy x8 2. D5NR 1L + 20 IV oxy x8 3. D5NR 1L + 10IV oxy x8 >Ketaroloc 30mg IV Q8 RTC x 4 doses (1st dose give @ 4pm) >Morphine 0.02 x 10cc via EC x Q12o5 doses (1st dose to be given @ 8pm) >Tramadol 50g IV Q8

2300H

7/26/12 0600H

The patient is awake, conscious and coherent with ongoing IVF, infusing well at desired rate. She is negative for flatus and bowel movement. Her histopathology is due on August 3,2012 She was instructed to have sips of water. The medication was given. She had chest x-ray, ECG and blood test for the serum level of potassium and creatinine as ordered by the doctor. The foley catheter is attached to urine bag, with sufficient output. The patient was awake lying on bed with spontaneous non-labored respiration. She continues to sip water as instructed. Her post-operative dressing and abdominal binder are dry & intact She has ongoing IVF intact & infusing well and with foley catheter attached to urine bag, draining clear yellow output in adequate amount The histopath result is due on 8/3/12 The patient is afebrile with a body temperature

>Blood sugar monitoring CBG TID pre-meals

>Morphine SO4 ; 2 doses >Dolcet

Time taken 1800H 1700H 0500H 1300H 1800H

Results 145g/dl 129g/dl 106g/dl 99 g/dl 135g/dl

>Creatinine : 47 mol/L >Potassium : 3.9 mol/L

1400H

of 36.6:C Dr. Celestino ordered that she may have clear fluids, general liquids if tolerated except coffee, milk & carbonated drinks. The patient is encouraged to breastfeeding She is well rested & comfortable and there is no active bleeding from the wound She is still negative for flatus and bowel movement She is on clear to general liquids. She has an ongoing IVF #3 D5NR 1L R 10: She is negative for flatus and bowel movement The histopath is due on 7/31/12 The patient is negative for flatus and no foley catheter with

IVF hooked, infusing well as ordered Due medicines were given and CBG was performed with a result of 106 mg/dl The patient is positive for flatus

1600H

1700H

2200H

2400H

0500H

7/27/12 0600H

The patient still has an ongoing IVF that is infusing well as ordered by the doctor. She is on general liquid and noted positive in flatus while the foley catheter attached to urine bag is draining well with adequate amount of output. She was seen and examined by Dr. Celestino, with ordered meds that was carried out. The doctor ordered that she may have soft diet and to be given Dulcolax. The doctor also ordered for the discontinuation of CBG monitoring and the replacement of Dolcet to Faspic. The foley catheter was removed aseptically, as ordered and has voiding due time of 1300H The patient is voiding freely twice already. Her IVF was consumed & removed aseptically with the awareness of Dr. Evangelista Awaiting for Dr. Evangelistas confirmation if Dolcet is to be given PRN or not No complaints of pain were made by the patient There were no contraptions noted from the patient The doctor ordered for diet as tolerated for the patient The patient maintains the diet as tolerated order. There is no IV contraption but with abdominal binder & post operative dressing that is dry & intact There is no active bleeding and the client is voiding freely. Vital signs were taken and recorded. She has a 130/90 mmHg blood pressure, a pulse rate of 81 beats per minute, a respiratory rate of 20 circulation per minute and a body temperature of 36.8:C Due medications were given which are Dulcolax for the bowel movement

>Dulcolax 1tab PO in AM >Fastpic 480mg PO Q6 for pain

and Faspic for pain.

1400H

2230H

2400H

7/28/12 1400H

The medications that are due are given to the patient Dr. Celestino ordered at 12nn for the patient as may go home anytime and has to be back after 2 weeks for the follow-up at the MDH OPD Medications were given Medications were given

>Take home medications: -Unasyn 750mg PO BID to complete for 7days -Fastpic 400mg PO for pain with full stomach

1600H

2400H

XI.

Health teaching Plan

TOPIC: Basic Information of Gestational Diabetes and Hypertension GOAL: CLIENT UNDERSTANDING AND AWARENESS TIME ALLOTMENT: 30 minutes LEARNING OBJECTIVES LEARNING CONTENT METHODOL OGY RESOURCES METHOD OF EVALUATION

For the client to have a fundamental understanding of the importance of diet and exercise

Choose food wisely: eat healthy foods low in fat and high in fiber. It is essential to eat fruit, vegetables, and whole grains. Exercise: start an exercise routine before becoming pregnant and continue it throughout the pregnancy (with doctor approval). Most health professionals recommend at least 30 minutes of moderate activity five days a week. Women who have had gestational diabetes previously are at risk for developing it in subsequent pregnancies. Making healthy choices and incorporating them into your lifestyle can lower the risk of diabetes in future pregnancies and later in life.

lecture

http://www. diabetesc are.net/c ontent_d etail.asp? id=44645 1

the client verbalizes understanding on the importance of diet and exercise

XII.

Discharge Plan

Medication

Unasyn 750mg PO BID to complete 7 days Fastpic 400mg PO for pain with full stomach Moderate exercise improves the bodys ability to process glucose which help maintain normal blood sugar level. Recommended daily exercise such as 30 minute brisk walking, swimming or aerobic activity. Use Betadine and sterile dressing for wound care Proper wound care for surgical incision and health diet for gestational diabetes After two weeks for follow up check up.

Exercise

Treatment Health Education OPD follow up

Diet

Maintain a balance diet of protein, fats and carbohydrates for the body to receive proper vitamins, minerals and calories. Eat small frequent meals per day. Do not skip meals, especially breakfast, to keep glucose levels stable. Avoid sugary food like candy, cookies, cakes and soda. Continue to go to church every Sunday with the family ; pray and meditate before going to sleep

Spiritual