I.

INTRODUCTION

PRETERM LABOR
Definition:

Preterm labor is labor that occurs before the end of week 37 of gestation
Preterm labor is also defined as presence of uterine contractions of sufficient
frequency and intensity to effect progressive effacement and dilation of the cervix

prior to term gestation (between 20 and 37 wk)

Preterm labor is also defines as regular contractions accompanied by cervical

change occurring at less than 37 weeks gestation.

Premature activation of the maternal or fetal hypothalamic-pituitary-adrenal axis (HPA

axis).
Exaggerated inflammatory response/infection
Decidual hemorrhage.
Pathological uterine distention

Risk Factors:

Previous preterm labor or preterm birth

Pregnancy with twins, triplets or other multiples
Certain problems with the uterus, cervix or placenta
Smoking cigarettes, drinking alcohol or using illicit drugs
Some infections, particularly of the amniotic fluid and lower genital tract
Some chronic conditions, such as high blood pressure and diabetes
Being underweight or overweight before pregnancy, or gaining too little or too

much weight during pregnancy

Stressful life events, such as the death of a loved one
An interval of less than six months since the last pregnancy

Common Symptoms:

Persistent, dull, low backache

Vaginal spotting
Feeling of pelvic pressure or abdominal tightening
Menstrual-like cramping
Increased vaginal discharged
Intestinal cramping
Uterine contractions
-- Observing the characteristics of uterine contractions and cervical change

facilitates the diagnosis of Preterm labor. Often, the diagnosis of preterm labor can be
made only in retrospect as only 25%-50% of patients with regular painful contractions
actually proceed to preterm delivery.
Initial Evaluation for Preterm Labor:

Evaluation of maternal clinical status and membrane status

Complete blood
Cell count
Urinalysis
Group B B-hemolytic Streptococcus status

Fetal status should be ascertained by non-stress test or biophysical profile, and if

not recently done, include evaluation of fetal growth and amniotic fluid.

Therapeutic Management for Preterm Labor:

(For mother :)

Promote bed rest to relieve pressure of the fetus on cervix

Institute IV therapy to keep mother well hydrated
Encourage mother to stop smoking if mother is smoking
Administration of tocolytic agents (beta-sympathomimetic drugs, Ritodrine

hydriochloride, terbutaline)
Administration of antibiotics more likely if your membranes have ruptured or if the
contractions are caused by infection

(For fetus :)
Adiministration of steroid like bethamethasone to hasten lung maturity of the fetus
If labor cannot be halted which means, membranes are ruptures, cervix is effaced 50%,
and cervix is dilated for more then 3-4 cm:

Artificial rupture of membrane is not done because of risk for prolapsed cord
Episiotomy is needed because of fragile head of infant

II.
Name: A.P.
Address: San Jose, Enrile, Cagayan

PATIENTS PROFILE

Gender: Female
Age: 25 y/o
Birthday: November 12, 1985
Marital Status: Single
Educational Level: College (Computer Engineering)
Occupation: None
Religion: Roman Catholic
Nationality: Filipino
Last Menstrual Period: March 01, 2011
Expected Date of Confinement: December 08, 2011
Age of Gestation: 26 5/7 weeks
Fundic Height: 40 cm
Chief Complaint: Abdominal pain
Date of Admission: September 05, 2011
Time of Admission: 2:05 AM
V/S upon Admission:

BP: 110/ 70
PR: 84
RR: 20

Admitting Diagnosis: Preterm Labor

Admitting Physician: Damaso, Christiana C.
Admitting Institution: Cagayan Valley Medical Center

III.

NURSING HEALTH HISTORY

History of Present Illness

Last September 04, 2011 (Sunday) at around 4 oclock in the morning, patient AP and
her mother went to Piat, Cagayan for a first Sunday Mass. They both rode on a jeep and arrived
there at around 5:30 AM. After attending the mass, they went home riding on a jeep again. They
reached their home at around 8 oclock in the morning. For the succeeding hours patient AP did
her usual activities for the day such as watching television and reading pocketbooks. Then at
around three oclock in the afternoon, patient AP suddenly felt a pain on her upper right
abdomen radiating to her lower right abdomen. When asked about the intensity, duration and
frequency of the pain and what she did after she felt it, patient AP verbalized Kung irere-rate ko
yung sakit ng 1 to 10, mga 3-4 lang siguro. Hindi siya gaano masakit. Hindi din siya tumagal eh,
seconds lang. Isang beses ko lang naman naramdaman kaya hindi ko pinansin. Humiga na
lang ako pagkatapos nun. According to patient AP, she did not feel pain anymore for the
subsequent hours. However, at around 12 midnight, while she was asleep, patient AP suddenly
felt a pain on the same location again. The patient verbalized Bigla na naman siyang sumakit.
Mas masakit na, mga 8 ang rate ng sakit. Mga 5 minutes na siguro yung tagal tapos dalawang
beses sumakit. Hindi ko na kinaya kaya nagmadali na kami ng mama ko na pumunta dito sa
Tuguegarao. Upon going to Tuguegarao they rode on her uncles tricycle. When asked if she
felt any pain again while they were on their way to Tuguegarao, patient AP verbalized, Oo, mga
tatlong beses siguro pero paiba-iba ng tagal. They went first to Peoples General Hospital but
were informed that there was no available Ob-gyne in the hospital at that time. From PGH they
proceeded to Cagayan Valley Medical Center where she was assessed and was advised to be
admitted. Patient AP was admitted at around 2:05 AM. Her admitting physician was Dra.
Christiana C. Damaso. Patient AP was diagnosed to have a Preterm Labor.

Past Health History

Patient AP stated that she had already experienced the following illnesses: Chicken Pox,
Mumps, Sore Eyes, Cough and Colds. She had completed her childhood immunizations. Patient
AP is allergic to salty foods such as bagoong and tuyo. When asked what type of reaction
usually occurs and how she manages it, she verbalized Nangangati yung bibig ko pati yung
paligid niya. Nilalagyan ko lang ng lip balm, nakasanayan ko na kasi. She doesnt have any
allergies to drugs or any environmental agents (e.g. dust). Patient AP never met any accidents
or serious injuries. She was not yet hospitalized before and she never experienced any surgical
procedures. Before hospitalization, patient AP was taking a Ferrous Sulfate vitamin that was
given to her by their Barangay Health Center midwife.

Family Health History

According to patient AP, Hypertension runs on her fathers family. While on her mothers
side, patient APs grandfather and grandmother died from Cancer (lung). She also stated that
her mother has an Anemia.

Gynecologic History
Patient AP had her first menstrual period when she was 15 years old. When asked if
how well prepared she was for that event in her life, she verbalized Hindi ko in-expect.
Pagkatanggal ko ng panty ko nagulat ako may dugo na. Hindi ko sinabi agad kasi nahihiya ako
noon. She shared that her menstruation occurred for almost five days with normal volume and
characteristics. She used 2-3 pads per day. Patient AP also said that she experienced
dysmenorrhea during her first menstrual period but she did not do anything about it. After her
menarche, patient AP had her regular menstrual period each month which usually lasted for 3 to
4 days. She typically used 2-3 pads every day. Patient AP also said that she does not feel any
discomforts during her usual menstrual periods. She had her first sexual intercourse at the age
of 20. Patient AP shared that since then, she and her partner have been using withdrawal
method to prevent conception. Patient AP never had any surgery on her reproductive tract.

Obstetric History
Its her first time to get pregnant, G1P0T0P0A0L0M0. Patient AP said that she usually has
her prenatal visit at their Barangay Health Center every month. When asked if what is usually
checked and given to her, she verbalized Kinukuha yung weight at BP ko. Noong unang punta
ko binigyan ako ng Ferrous na vitamins. Tapos noong August lang may ininject sa akin. Hindi ko
alam kung ano yun, sinabi ng midwife na para daw sa baby ko.

Gordons 11 Functional Health Pattern

1. Health Perception- Health Management Pattern
Before Hospitalization:
When asked what is health for her and how important it is, patient AP verbalized
Para sa akin, ito ay importanteng bagay na dapat i-maintain para maiwasan ang mga
sakit. Importante talaga siya sa akin para hindi ako magkasakit. Patient AP also said
that she sees herself as a healthy person. She specified the following things that she
does to manage her health: eats healthy foods like fresh fruits and vegetables, takes
enough sleep and rest, does not perform strenuous activities at home, and always sees
to it that her body is clean. Patient AP never had any major illnesses. If ever she

experiences minor illnesses, such as headache, she just ignores it and takes a rest.
Ayaw ko kasi ng laging umiinom ng gamot, as verbalized by the patient.
During Hospitalization:
Patient AP said that she feels she is unhealthy now because of her condition.
When asked if she adheres to medications given to her and if she finds them useful, she
verbalized Oo, iniinom ko lahat kasi para sa mga baby ko yun eh.
2. Nutritional- Metabolic Pattern
Before Hospitalization:
Patient AP usually drinks a glass of Bearbrand milk every morning and eats
enough meal consisting of rice, vegetables and some meat for her lunch and dinner.
She also said that she sometimes takes her midnight snack, especially if they had an
early dinner. She typically eats at home and her mother cooks her food. According to
patient AP, her favorite foods are pastas. Patient AP is allergic to salty foods such as
bagoong and tuyo. She usually drinks about one and a half (1.5) liters of fluids every
day. Patient AP said that her latest weight is approximately sixty (60) kilograms. Patient
APs skin is mildly dry and with a fair complexion. Her hair is silky and evenly distributed.
Her nails are smooth and with a pinkish nail bed and convex curvature.
During Hospitalization:
According to patient AP, her usual diet has changed. Minsan konti lang kinakain
ko o kaya hindi ako kumakain. Ayaw ko kasi yung mga pagkain na binibigay nila kung
minsan kaya hindi ko kinakain. She is currently having a Soft Diet. She drinks
approximately one (1) liter of fluid each day. Patient APs skin, hair and nails are still
exhibiting normal appearances.
3. Elimination Pattern
Before Hospitalization:
Patient AP regularly defecates once a day. According to her, the usual
characteristic of her stool is yellow to brown in color and soft in consistency. She
urinates six (6) to seven (7) times a day and with a slightly yellow color. Patient AP said
that she doesnt experience any difficulties when urinating or defecating.
During Hospitalization:
Patient AP defecates once in every three days. When asked about the
characteristics of her stool, she verbalized Maitim yung kulay pero okay lang yung
lambot. She doesnt have any difficulties with her defecation. Patient AP usually urinates
five (5) times a day without any difficulties. Her urine is yellowish in color.

4. Activity- Exercise Pattern

Before Hospitalization:
When asked about her usual activities every day, patient AP verbalized Kapag
umaga, nanunuod lang ako ng mga palabas sa TV o kaya nagbabasa ng mga pocket

book o magazine. Kung may gagawin yung mama ko, gaya ng paglalaba, tinutulungan
ko din siya, pero ako yung taga-sampay lang. Kapag hapon natutulog ako o kaya
nanunuod pa din. She said that helping her mother in some simple household chores
serves as her exercise. In doing her activities every day, patient AP doesnt easily get
tired.
During Hospitalization:
Patient AP cannot do the things she used to do every day. She was
recommended to have a complete bed rest without bathroom privileges.
5. Sleep- Rest Pattern
Before Hospitalization:
She usually goes to bed at around eight (8) oclock in the evening and falls
asleep at around eleven (11) PM. When asked about what she does in between the hour
she went to bed and the time she fell asleep, the patient verbalized Nakahiga lang ako
o kaya nakapikit lang. Hindi ako nakakatulog agad eh. Patient AP typically wakes up at
around eight (8) oclock in the morning. According to the patient, she feels rested and
gained enough energy with that duration of sleep. During the first three months of her
pregnancy patient AP usually takes a nap. However, with the succeeding months, she
said that she already stopped taking a nap in the afternoon.
During Hospitalization:
Naiirita kasi ako sa mga pumapasok na tao o sa mga sumisigaw na nanay.
Kung may bagong dumadating na pasyente, pinapanood ko na lang sila. Kaya
nakakatulog lang ako ng mga alas dos ng umaga. Tapos nagigising ako ng mga five na,
kapag pinapapasok na yung mga bantay, pumapasok kasi yung mama ko., as
verbalized by the patient. Patient AP said that she does not feel rested with that duration
of sleep thats why she takes some naps during daytime.
6. Cognitive- Perceptual Pattern
Before Hospitalization:
According to patient AP, she does not have any problems with regards to her
senses (vision, smell, taste, hearing and touch). Patient AP usually feels difficulties in
speaking when she is using another language/ dialect like Ybanag because she said that
she is used in speaking Itawes. When asked what is decision-making for her and her
inclination in making decision, she verbalized Dapat pag gagawa ka ng desisyon wise
ka, wag padalos-dalos at dapat hindi palpak. Hindi ako masyadong magaling gumawa
ng desisyon, minsan kasi palpak ako. Yung mama ko minsan ang nagdedesisyon para
sa akin. To test her memory she was asked to describe what happened during her last
birthday. Patient AP said, Nagluto yung mama ko ng mga pangmeryenda. Tapos
nagrent kami ng videoke machine, yun nagkantahan kami sa hapon.
During Hospitalization:

Patient AP has no sensory deficit and responds appropriately to physical and

verbal stimuli. She responds to questions clearly and follows instructions accordingly.
Patient AP is oriented with time, place and other people.
7. Self- Perception Self- Concept Pattern
Before Hospitalization:
When asked to describe herself, patient AP verbalized Masungit ako. Hindi ako
plastic, kung ayaw ko yung tao pinapakita ko na ayaw ko siya. Pero mabait din naman
ako kung alam kong mabait ang isang tao. She enumerated her strengths: her baby
and husband, family. Her weaknesses: illnesses and problems. Patient AP also stated
the following attitude she does toward herself: see to it that she eats enough food to be
healthy, and she will do anything to supply her needs and wants.
During Hospitalization:
Kahinaan ko ngayon itong sakit ko. Ang pinagkukunan ko na lang ng lakas eh
ang mga babies ko., as verbalized by the patient.
8. Role Relationship Pattern
Before hospitalization:
When asked of the hindrances related with accomplishing responsibilities, patient
verbalize Nahihirapan akong magpakumbaba, ma-pride ako feeling ko ako lagi ang
tama. Kapag may nakasakitan na ako ng loob hindi ko na siya pinapansin.
During Hospitalization:
Patient verbalized, Noong na-hospital ako na-realize ko na mahal pala nila ako,
nag-aalala din pala sila sa akin. Parang nag-improve ako sa attitude ko, dati wala akong
pakialam ngayon na-realize ko ung mga ginagawa nila sa akin.

9. Sexuality- Reproductive Pattern

Before Hospitalization:
When asked if how she views herself as a women, patient verbalized
Komportable naman ako sa sarili ko. Feel ko nasa right age naman na ako para sa mga
desisyon ko. Patient AP prefers being with girls and feels comfortable with them. She
sometimes views males as not trustworthy beings and most of them are two-timers. She
feels satisfied with her partner. Patient APs menarche occurred when she was 15 years
old. Her regular menstruation usually takes 3-4 days. She consumes 2-3 pads per day.
She describes the color of her blood as dark red. She had her first sexual contact when
she was 20 years old.
10. Coping- Stress Pattern
Before Hospitalization:
When asked what causes her stress, patient AP verbalized Kapag nag-aaway
kami ng asawa ko o ng hipag ko. Nag-aaway kami ng asawa ko kasi nagrereklamo siya

na matapang daw ako at madaldal. She said that she manages it by having positive
thoughts that she can surpass each problem and thinking of her baby. Sometimes, she
said that she just ignores it.
During Hospitalization:

Her situation causes her to be more stressed. She verbalized, Gusto ko

na umuwi. Ang dami kong iniisip, yung mga bills na naiipon, naawa din ako sa
bantay ko. Patient AP manages it by thinking that her prolonged stay in the
hospital is for her babies so that they will be born in good condition.
11. Value- Belief Pattern
Before Hospitalization
When asked about her motto, Patient AP verbalized, Life is a gamble, it depends on
how you drive it. She values her husband, her baby, her family and friends because she
said without them she is nothing. She also gives importance to health because it helps
her and her baby live longer. Patient AP doesnt believe in superstitious beliefs. She
views God as the most powerful person in this world. By merely praying and believing,
patient AP shows her faith to God. When asked about the reason why she has to show
her faith to God she verbalized, Kasi siya yung lumikha sa atin.
During Hospitalization
Patient APs condition made her closer to God.

IV.

PHYSICAL ASSESSMENT

Date Assessed: September 23, 2011

Time Assessed: 9:00 AM
Vital Signs:
BP: 100/60 mmHg
Temperature: 37.0 C
PR: 80 bpm
RR: 20 cpm
General appearance: Assessed patient while lying on bed, awake and following simple
instructions.

Area Assessed

Techniques
Used

SKIN

Normal Findings

Actual Findings

Analysis

Light brown

Normal

Ranges in tone
from light pink to
ruddy pink in

Color

Inspection

white skin, light

to deep brown of

Turgor

Palpation

Hair distribution

Inspection

Temperature

Palpation

Moisture

Edema

Palpation

Palpation

olive in dark skin

Skin snaps back

Skin snaps back

immediately

immediately

when pinched
Evenly

when pinched
Evenly

distributed

distributed

Warm and equal

Warm and equal

bilaterally

bilaterally

Mildly dry, skin

Mildly dry, skin

folds are

folds are

normally moist
No presence of

normally moist
No presence of

edema

edema

Normal

Normal

Normal

Normal

Normal

NAILS
Color of nail bed

Inspection

Pink

Pink

Normal

Texture

Palpation
Inspection

Smooth
Convex

Normal

Shape

Smooth
Convex

Nail base
HAIR

Inspection

curvature
Firm

curvature
Firm

Color
Distribution

Inspection
Inspection

Variable
Evenly

Black
Evenly

Normal
Normal
Normal
Normal

distributed
Silky

distributed
Silky

Texture
HEAD

Inspection

Normal

Scalp
Skull size

Inspection
Inspection

Intact
Normocephalic
Absences of

Intact
Normocephalic
Absence of

Normal
Normal

Nodules/ masses

Palpation

nodules and

nodules and

Normal

masses

masses

Symmetrical

Symmetrical

Same as color of

Same as color of

the skin in the

the skin in the

body
Symmetrically

body
Symmetrically

aligned, equal

aligned, equal

movement with

movement with

even skin

hair evenly

distribution
Slightly curved

distributed
Slightly curved

upward
Close

upward
Close

symmetrically;

symmetrically;

skin intact

skin intact

Symmetrical,

Symmetrical,

smooth and

smooth and

same as color of

same as color of

face

face

FACE
Symmetry

Skin color

Inspection

Inspection

EYES
Eyebrows

Inspection

Eyelashes

Inspection

Eyelids

Inspection

Normal

Normal

Normal

Normal

Normal

NOSE
Symmetry,
texture and color

Inspection

Normal

MOUTH
Lips

Inspection

Color
Symmetry
Teeth

Inspection

Color and
position

Inspection

NECK
Color

Inspection

Position
Movement
Range of motion
ABDOMEN

Inspection
Inspection
Inspection

Pinkish to slightly
brown
Symmetrical
Ivory/yellowish,
firmly set

Slightly brown

Normal

Symmetrical

Normal

Ivory, firmly set

Normal

Same as color of

Same as color of

the skin in the

the skin in the

body

body

Midline
Moves freely
Full range

Midline
Moves freely
Full range
Pear- shaped

Normal

Normal
Normal
Normal
Normal due to

Contour

Inspection

Texture

Palpation

Skin

Inspection

Flat, rounded,

increased fetal

scaphoid

size

Smooth

Even with other

parts of the body

Smooth

Normal
Normal due to

With visible

hormonal

striae and linea

changes in

negrae

response to
pregnancy

NEUROLOGIC
Level of
consciousness

Interview

Behavior and
appearance

Mood

Interview

Interview

Can follow

Can follow

instruction and

instruction and

command
Makes eye

command
Makes eye

contact with the

contact with the

examiner
Expresses

examiner
Expresses

feelings which

feelings which

correspond to

correspond to

situation

situation

Normal

Normal

Normal

Mental Status
Orientation

Interview

Oriented with
time, place and
other people

Oriented with
time

Normal

V.

ANATOMY AND PHYSIOLOGY

FEMALE REPRODUCTIVE SYSTEM

Definition of terms:

Vagina: A muscular passageway that leads from the vulva (external genitalia) to the

cervix. It can stretch during childbirth to deliver a baby weighing over ten pounds.
Cervix: A small hole at the end of the vagina through which sperm passes into the
uterus. Also serves as a protective barrier for the uterus. During childbirth, the
cervixdi lates (widens) to permit the baby to descend from the uterus into the vagina

for birth.
Uterus: A hollow organ that houses the baby during pregnancy. During childbirth, the
uterine muscles contract to push out the baby. Each month, unless a fetus has been
conceived, the uterine wall sheds its). It is a pear shaped organ, which can grow

large enough to accommodate a developing baby or babies.

Ovaries: Two organs that produce hormones and store eggs. Each ovary releases

one egg per month.

Fallopian tubes: Muscular tubes that eggs released from the ovaries must traverse
to reach the uterus.

VI.

LABORATORY EXAMINATIONS

CLINICAL MICROSCOPY SECTION

SPECIMEN: URINE
(SEPTEMBER 5, 2011)
SPECIMEN

ACTUAL FINDINGS

NORMAL FINDINGS

ANALYSIS

COLOR

YELLOW

YELLOW TO AMBER

NORMAL

TRANSPARENCY

HAZY

SLIGHTLY TURBID

PH

8.O

SPECIFIC GRAVITY

1.005

1.005-1.030

NORMAL

SUGAR
KETONE

HEMATOLOGY
(September 5, 2011)
ACTUAL FINDINGS

NORMAL FINDINGS

HEMOGLOBIN MASS
CONCENTRATION

111

120-160

ERYTHROCYTE VOLUME
FRACTION

0.33

0.38-0.47

ERYTHROCYTE NUMBER
CONCENTRATION

3.96

4.5-6.00

THROMBOCYTE
NUMBER
CONCENTRATION

232

150-400

MEAN CORPUSCULAR
VOLUME

87.6

80-100

MEAN CORPUSCULAR
HEMOGLOBIN(MCH)

28.0

26-32

MEAN CORPUSCULAR
HEMOGLOBIN CONTENT

320

320-360

LEUKOCYTE NUMBER
CONCENTRATION

9.89

4.5-11.00

NEUTROPHILS

81.5

35-65

ANALYSIS

LYMPHOCYTES

13.9

20-40

MONOCYTES

4.3

2-8

EOSINOPHILS

0.2

0-5

BASOPHILS

0.1

0-1

BODY FLUID ANALYSIS

SPECIMEN: AMNIOTIC FLUID
(SEPTEMBER 07, 2011)
ACTUAL FINDINGS
AMOUNT

3ml

COLOR

COLORLESS

TRANSPARENCY

SLIGHTLY TURBID

CELL COUNT
DIFFERENTIAL COUNT

0.069x10^9/L

PMN
MN

66.7 %
33.8 %

CLINICAL CHEM SECTION

TOTAL PROTEIN

10.0 GM/L

ALBUMIN

4.0 GM/L

TOTAL LACTATE
DEHYDROGENASE

446 U/L

ULTRASOUND/PELVIC ULTRASONOGRAPHY
(SEPTEMBER 07, 2011)
*

Twin live intrauterine pregnancy in BREECH PRESENTATION.

TWIN A 29 weeks by BPD, 27 4/7 weeks by FL

TWIN B 29 4/7 weeks by BPD, 27 4/7 weeks by FL

Good somatic and cardiac activities

Polyhydramnios

Placenta is poster fundal, Grade I, Monochorionic, Diamnionic

Estimated fetal weight is appropriate for gestational age

No gross fetal congenital anomalies noted on preliminary CAS

HEMATOLOGY REPORT
(September 10, 2011)

ANALYSIS

ACTUAL
FINDINGS

NORMAL
FINDINGS

HEMOGLOBIN MASS
CONCENTRATION

105

120-160

ERYTHROCYTE VOLUME
FRACTION

0.30

0.38-0.47

ERYTHROCYTE NUMBER
CONCENTRATION

3.79

4.5-6.00

THROMBOCYTE NUMBER
CONCENTRATION

281

150-400

MEAN CORPUSCULAR VOLUME

81.3

80-100

MEAN CORPUSCULAR
HEMOGLOBIN (MCH)
MEAN CORPUSCULAR
HEMOGLOBIN CONTENT
LEUKOCYTE NUMBER
CONCENTRATION
NEUTROPHILS

27.7

26-32

341

320-360

9.84

4.5-11.00

77.4

35-65

LYMPHOCYTES

15.1

20-40

MONOCYTES

5.5

2-8

EOSINOPHILS

1.7

0-5

BASOPHILS

0.3

0-1

ANALYSIS

HEMATOLOGY
(September 12,2011)
HEMOGLOBIN MASS
CONCENTRATION
ERYTHROCYTE VOLUME
FRACTION
ERYTHROCYTE NUMBER
CONCENTRATION
THROMBOCYTE NUMBER
CONCENTRATION
MEAN CORPUSCULAR
VOLUME
MEAN CORPUSCULAR
HEMOGLOBIN(MCH)
MEAN CORPUSCULAR
HEMOGLOBIN CONTENT
LEUKOCYTE NUMBER
CONCENTRATION
NEUTROPHILS
LYMPHOCYTES
MONOCYTES

ACTUAL FINDINGS
110

NORMAL FINDINGS
120-160

0.31

0.38-0.47

3.94

4.5-6.00

247

150-400

80.5

80-100

27.9

26-32

347

320-360

11.46

4.5-11.00

88.9
8.3
2.6

35-65
20-40
2-8

ANALYSIS

EOSINOPHILS
BASOPHILS

0.0
0.2

0-2
0-1

CLINICAL MICROSCOPY SECTION

SPECIMEN: URINE
(SEPTEMBER 15,2011)
SPECIMEN
COLOR
TRANSPARENCY
PH
SPECIFIC GRAVITY
SUGAR
KETONE
LEUKOCYTES
ERYTHROCYTES
SQUAMOUS
AMORPHOUS
PHOSPHATE

ACTUAL FINDINGS
YELLOW
TURBID
8.O
1.025
NEGATIVE
NEGATIVE
1-2
2-7
FEW

NORMAL FINDINGS
YELLOW TO AMBER
SLIGHTLY TURBID

FEW

FEW

ANALYSIS

1.005-1.030
NEGATIVE
NEGATIVE
4.5-11 x 10^9/L
4.5-6.0 X 10 ^9/L
FEW

ULTRASOUND/PELVIC ULTRASONOGRAPHY
(SEPTEMBER 15,2011)
*

TWIN LIVE INTRAUTERINE PREGNANCY WITH GOOD SOMATIC AND CARDIAC

ACTIVITY.

TWIN A in cephalic presentation, 30 4/7 weeks by BPD and FL

TWIN B in cephalic presentation, 29 3/7 weeks by BPD,31 weeks by FL

AMNIOTIC FLUID IS ADEQUATE (2 QUADRANTS)

Placenta is posterior, high lying, grade II, MONOCHORIONIC,DIAMNIONIC

Estimated fetal weight are appropriate for gestational age.

I.

DRUG STUDY

1. DEXAMETHASONE
Class:

Corticosteroid (systemic short-acting corticosteroids)

Indications:

Attempt to hasten fetal lung maturity

Suppress inflammation and the normal immune response.

Numerous intense metabolic effects.
Suppress adrenal function at chronic doses of 0.75mg/day.
Have negligible mineralocorticoid activity.

Action:

Pharmacokinetics:

Absorption: Well absorbed after oral administration

Distribution: Can cross the placenta, and probably enter breast milk
Metabolism: Metabolized by the liver
Half Life: 3-4.5 hr(plasma),36-54hr(tissue); adrenal suppression lasts 1.251.5

Contraindications:

Active untreated infections

Lactation-avoid chronic use
Known alcohol, bisulfite, or tartrazine hypersensitivity or intolerance may
contain these and should be avoided in susceptible patients.

Precautions:

Chronic treatment (will lead to adrenal suppression; use lowest possible dose

for shortest period of time)

Stress(surgery, infections) supplemental doses may be needed
Potential infections may mask signs(fever inflammation)
Pregnancy(safety not established)

Adverse Reactions and Side Effects:

CNS- depression, euphoria,headache ,personality changes,restlessness

EENT-cataracts, increased intraocular pressure
CV-hypertension:
GI-Peptic ulceration anorexia, nausea, vomiting;
DERM- acne, decreased wound healing, ecchymoses, fragility, hirsutism,
petechiae;

ENDO-adrenal suppression, hyperglycemia; F and E fluid retention,

hypokalemia, hypokalemic alkalosis;

HEMAT- thromboembolism ,thrombophlebitis;
METAB-weight gain;
MS- muscle wasting, osteoporosis, aseptic necrosis of joints, muscle pain.

Route and Dosage:

Four doses of 6mg , IM 12 hours apart

Patient Teachings:

Instruct patient on correct technique of medication administration.

Do not double doses
Stopping medication suddenly may result in adrenal insufficiency (anorexia,
nausea weakness fatigue dyspnea hypotension hypoglycemia)

2. FERROUS FUMERATE
Class:

Iron Supplement

Indications:

PO: Prevention/treatment of iron deficiency anemia.

An essential mineral found in hemoglobin, myoglobin, and many enzymes

Action:

Pharmacokinetics:

Absorption: 5-10% of dietary iron is absorbed. In deficiency states, these

increases up to 30%.Therapeutically administered PO iron may be 60%

absorbed.
Distribution: Remains in the body for many months. Crosses the placenta;

enters breast milk.

Metabolism and Excretion: Mostly recycled; small daily losses occurring via
sweat, urine and bile

Contraindications:

Primary hemochromatosis
Hemolytic anemias and other anemias not due to iron deficiency
Should be avoided in patients with known intolerance or hypersensitivity

Precautions:

PO-peptic ulcer

Ulcerative colitis or regional enteritis

Indiscriminate chronic use(may lead to iron overload)

Adverse Reactions and Effects:

GI-constipation, dark stools, diarrhea, epigastric pain

MISC- staining of teeth(liquid preparation)

Route and Dosage:

PO (Adults): prophylactic-200mg/day, therapeutic-200mg 3-4 times daily.

Controlled-release capsule may be given twice daily.

Patient Teachings:

Take missed doses as soon as remembered within 12 hours. Do not double

doses.
Advise patient that stools may become dark green or black and this change is
harmless.

3. MIDAZOLAM
Class:

Anti-anxiety Agents, Sedative/Hypnotics

Indications:

Induction of general anesthesia

Continues sedation of intubated and mechanically ventilated patients as a
component of anesthesia or treatment in critical setting.

Unlabeled Uses:
Treatment of epileptic seizure or refractory status epilepticus
Action:
Acts at many levels of the CNS to produce generalized CNS depression
Effects may be mediated by GABA, an inhibitory neurotransmitter.
Pharmacokinetics:

Absorption: Rapidly absorbed following oral administration undergoes

substantial intestinal and first-pass hepatic metabolism.

Distribution: Crosses the blood brain barrier and placenta

Metabolism and Excretion: Almost exclusively metabolized by the liver,

resulting in the conversion to hydroxymidazolam, an active metabolite and 2

other inactive metabolites. Metabolites are excreted in the urine.

Half Life: 1-12 hr (increased renal impairment or CHF)

Contraindications:

Hypersensitivity
Cross sensitivity with benzodiazepines may occur
Shock
Comatose patients or those with pre- existing CNS depression
Uncontrolled severe pain
Products containing benzyl alcohol should be ued in neonates
Pregnancy
Acute narrow angle glaucoma

Precautions:
Pulmonary disease
CHF

Renal impairment
Severe hepatic impairment
Obese pediatric patients
Lactation(safety not established)

Adverse Reactions and Side Effects:

CNS-agitation, drowsiness, excess sedation, headache

EENT-blurred vision
RESP-apnea, laryngospasm, respiratory depression, bronchospasm,

coughing
CV- cardiac arrest, arrhythmias
GI-hiccups, nausea, vomiting
DERM-rashes

Patient Teachings:

Inform patient that this medication will decrease mental recall of the

procedure.
May cause drowsiness or dizziness. Inform patient to request assistance prior
to ambulation and transfer and avoid driving or other activities requiring

alertness for 24 hrs following administration.

Instruct patient to inform health care professional prior to administration if

pregnancy is suspected.
Advise patient to avoid alcohol or other CNS depressants 24 hrs following
administration of midazolam.

4. ASCORBIC ACID
Class:

Vitamins

Indication:

Treatment and prevention of vitamin C deficiency (scurvy) with dietary

supplementation.
Supplemental therapy in some GI diseases during long term parenteral

nutrition, or chronic hemodialysis.

States of increased requirements such as: pregnancy, lactation, stress,
hyperthyroidism, trauma, burns, infancy.

Unlabeled Uses:

Prevention of common colds

Contraindication:

Tartrazine hypersensitivity

Precautions:

Recurrent kidney stones.

Avoid chronic uses in pregnant women.

Adverse Reactions and Side Effects:

CNS: drowsiness, fatigue, headache, insomnia

GI: cramp ,diarrhea, heartburn, nausea, vomiting
GU: kidney stones
DERM: flushing
HEMAT: deep vein thrombosis, hemolysis (in G6PD), sickle cell crisis

Route and Dosage:

PO (ADULTS): scurvy-500mg/dayfor at least 14 days. Prevention of

deficiency-30-45mg/day.

5. HYDROXYZINE
Class:

Anti-anxiety agents, antihistamines, sedative/ hypnotics

Indication:

Treatment of anxiety
Preoperative sedation
Antiemetic
Antipruritic
May be combined with opioid analgesics

Action:

Acts as a CNS depressant at the subcortical level of the CNS

Has an anticholinergic, antihistaminic, and antiemetic property.

Pharmacokinetics:
Absorption: Well absorbed following PO/IM administration.
Distribution: Unknown
Metabolism and Excretion: Completely metabolized by the liver; eliminated in

the feces via biliary excretion.

Half Life: 3 hrs.

Contraindications:
Hypersensitivity
Pregnancy
Precautions:

Severe hepatic dysfunction

Geriatric patients (dosage reduction recommended)
Labor(has been used safely)

Adverse Reactions and Side Effects:

CNS: drowsiness, agitation, ataxia, dizziness, headache ,weakness

RESP: wheezing
GI: dry mouth, bitter taste, constipation, nausea
GU: urinary retention
DERM: flushing

Route and Dosage:

PO (ADULTS): antianxiety, sedative/hypnotic-25-100mg single dose.

Antiemetic/ Antipruritic-25-100 mg 3-4 times daily.

Patient Teachings:

Instruct patient to take medication exactly as directed.

May cause drowsiness or dizziness. Caution patient to avoid driving and

other activities requiring alertness until response to medication is known

Inform patient that frequent mouth rinses, good oral hygiene, and sugarless
gum or candy may help decrease dry mouth.

6. NALBUPHINE
Class:

Opioid analgesics

Indications:

Moderate to severe pain

Also provides: analgesia during labor, sedation before surgery, supplement to
balanced anesthesia.

Actions:

Binds to opiate in the CNS

Alters the perception of and response to painful stimuli while producing

generalized CNS depression

In addition, has a partial antagonist property, which may result in opioid

withdrawal in physically dependent patients.

Pharmacokinetics:
Absorption: Well absorbed after IM and sub cut administration
Distribution: probably crosses the placenta, and probably enter breast milk
Metabolism and Excretion: Mostly metabolized by the liver; eliminated in the
feces via biliary excretion. Minimal amounts excreted unchanged by the
kidneys.
Half Life: 5hrs.
Contraindications:

Hypersensitivity to nalbuphine or bisulfites

Patients who are physically dependenton opioid and have not been detoxified
(may precipitate withdrawal)

Precautions:

Head trauma
Increased intracranial pressure
Severe renal ,hepatic, or pulmonary disease
Hypothyroidism
Adrenal insufficiency
Alcoholism
Geriatric or debilitated patients (dosage reduction suggested)
Undiagnosed abdominal pain
Prostatic hyperthrophy
Patients who have recently received opioid agonists
Pregnancy (has been used during labor but may cause respiratory
depression in the newborn)

Adverse Reactions and Side Effects:

CNS: dizziness, headache, sedation, confusion, dysphoria, euphoria, floating

feeling, hallucinations, unusual dreams

EENT: blurred vision, diploplia, miosis (high doses)
RESP: respiratory depression
CV: hypertension orthostatic hypotension, palpitations
GI: dry mouth, nausea, vomiting, constipation
GU: urinary urgency
DERM: clammy feeling, sweating
MISC: physical dependence, psychologicaldependence, tolerance.

Patient Teachings:

Instruct patient on how and when to ask for pain medication.

May cause drowsiness or dizziness

Caution patient to change position slowly to minimize orthostatic

hypotension

Inform patient that frequent mouth rinses, good oral hygiene, and sugarless
gum or candy may help decrease dry mouth.

7. CEFUROXIME SODIUM
Class:

Antibiotic, cephalosporin (2nd generation)

Indication:

For the treatment of many different types of bacterial infections such as

bronchitis, sinusitis, tonsillitis, ear infections, skin infections, gonorrhea, and
urinary tract infections.

Action:

Interferes with bacterial cell-wall synthesis and division by binding to cell wall,
causing cell to die. Active against gram-negative and gram-positive bacteria,
with expanded activity against gram-negative bacteria. Exhibits minimal
immunosuppressant activity.

Pharmacokinetics:

Absorption: higher absorption in the proximal region of the GI tract

Distribution: Crosses placenta, enters breast milk
Metabolism And Excretion: Hepatic, Urine

Contraindications:

Contraindicated with allergy to cephalosphorine and penicillin

Precautions:

With renal failure, lactation, pregnancy

Adverse reactions and Side effects:

CNS: Headache, dizziness, lethargy, paresthesias

GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, pseudo

membranous colitis,hepatotoxicity
GU: Nephrotoxicity
HEMA: Bone marrow depression (decreased WBC, platelets and HCT)

Route and Dosage:

IV 50 mg

Patient Teachings:

Take full course of therapy even if you are feeling better.

Instruct patient that it should not be used to self- treat other problems
Swallow the drug whole. Do not crush them
Take the drug with food

8. MULTIVITAMINS PLUS AMINO ACID

Class:

Dietary Drugs/ Vitamins

Indication:

Treating or preventing low levels of vitamins, folic acid, and amino acids in
the body. It may also be used for other conditions as determined by the
doctor.

Contraindication:

Allergic to any ingredient in multivitamins with amino acid

If you have high blood levels of arginine

Precautions:

Pregnant women, either an excess or deficiency can cause birth defects.

Adverse reactions and Side effects:

Severe allergic reactions (rash, hives, itching, difficulty breathing, tightness, in

the chest swelling of the mouth, face, lips, or tongue).

Route and Dosage:

PO, take Multivitamins with Folic Acid/Amino Acids with a full glass of
water (8 oz/240 mL).

Patient Teachings:
Do not take large doses of vitamins while you use Multivitamins with Folic

Acid/Amino Acids unless your doctor tells you to.

Multivitamins with Folic Acid/Amino Acids has folic acid in it. Before you
start any medicine check the label to see if it has folic acid in it too. If it

does not or if you are not sure, check with your doctor or pharmacist.
If you miss a dose of Multivitamins with Folic Acid/Amino Acids, take it as
soon as possible. If it is almost time for your next dose, skip the missed
dose and go back to your regular dosing schedule. Do not take 2 doses at

once.
Take Multivitamins with Folic Acid/Amino Acids by mouth with or without
food. If stomach upset occurs, take with food to reduce stomach irritation.

9. NIFEDIPINE
Class:

Anti anginal
Anti hypertensive
Calcium channel blocker

Indications:

Angina pectoris due to coronary artery spasm

Chronic stable angina
ER preparation only. Treatment of hypertension.
Treatment of interstitial cystitis.

Unlabeled Uses:

Anal fissures, urethral stones topical use to improve wound healing.

Actions:

Inhibits the movement of calcium ions across the membranes of cardiac and
arterial muscle cells; inhibition of transmembrane calcium flow results in the
depression of impulse formation in specialized cardiac pacemaker cells, in
slowing of the velocity of conduction of the cardiac impulse, in the depression
of myocardial contractility, and in the dilation of coronary arteries and

arterioles and peripheralarterioles; these effects lead to decreased cardiac

energy consumption, and increased delivery of oxygen to myocardial cells.
Pharmacokinetics:

Absorption: Dissolved nifedipine was found to enter the systemic circulation

completely along the intestine, being absorbed from jejunum to colon.

Distribution: Probably crosses the placenta, and probably enter breast milk
Metabolism and Excretion: hepatic; excreted in feces and urine

Contraindication:

With allergy to nifedipine

Use cautiously in:

Lactation

Pregnancy

heart failure

aortic stenosis

Adverse reactions and Side effects:

CNS: Dizziness, light headedness, head ache, asthenia, fatigue,

nervousness, sleep disturbances, blurred vision, weakness, tremor, mood

changes
CV: peripheral edema, angina, hypotension, arrhythmias,
DERM: Flushing, rash, dermatitis, pruritus, urticarial
G.I. Nausea, diarrhea, constipation,cramps, flatulence, hepatic injury
OTHER: nasal congestion, cough, fever, chills, shortness of breath,
muscle cramps, joint stiffness, sexual difficulties

Route and Dosage:

PO Maintenance range, 10-20mg tid

Patient Teachings:

Do not chew, cut or crush. Swallow whole.

Avoid grapefruit juice while taking the drug because it can cause increased
toxicity.

10. ACETAMINOPHEN (Paracetamol)

Class:

Analgesic (nonopioid)
Antipyretic

Indications:

Temporary reduction of fever, temporary relief of minor aches and pains

caused by common cold and influenza, headache, sore throat, toothache
(patients 2 year and older), backache, menstrual cramps, minor
arthritispain, and muscle aches.

Unlabeled use:

Prophylaxis in children and patients at risk for seizures who are receiving
DPT vaccination to reduce incidence of fever and pain

Actions:

Reduces fever by acting directly on the hypothalamic heat regulating center

to cause vasodilation and sweating and sweating which helps dissipate heat.

Pharmacokinetics:

Absorption: Acetaminophen is rapidly and almost completely absorbed from

the gastrointestinal tract. After oral administration of immediate or extendedrelease acetaminophen preparations in therapeutic doses, peak plasma or

serum concentrations occur within 1 to 2 hours, respectively.

Distribution: Crosses the placenta, and probably enter breast milk
Metabolism and Excretion: hepatic, excreted in the urine
Contraindicated In: Allergy to acetaminophen

Use Cautiously In:

Impaired hepatic function, chronic alcoholism, pregnancy, lactation

Adverse Reactions and Side Effects:

CNS: head ache

CV: chest pain, dyspnea, myocardial damage when doses of 5-8g/ day are
ingested daily for several weeks or when dosageof 4g/day are ingested for 1

year
GI: hepatic toxicity and failure, jaundice
GU: Acute renal failure, renal tubular necrosis
HEMA: cyanosis, hemolytic anemia-hematuria, anuria, neutropenia,

leukopenia, pancytopenia, thrombocytopenia, hypoglycemia

HYPERSENSITIVITY: Rash, fever

Route and Dosage:

PO or rectal suppositories ( adults and children older than 12 years old)

By suppositories, 325-650 mg every4-6 hr. PO, or 1300 mg ER tablets

every 8 hr.

Patient teachings:

Do not exceed 3900 mg/day

Do not take longer than 10 days unless recommended by prescriber
Chew the chewable tablets before swallowing, dissolve dispersable tablets in

mouth before swallowing, shake liquid forms well before using.

Avoid using over the counter or prescription preparations containing
acetaminophen. Serious overdose can occur

11. TERBUTALINE
Class:

Anti-asthma
Tocolytic

Indications:

For the relief of bronchial asthma, bronchitis, bronchospasm, emphysema,

bronchiectasis and other obstructive pulmonary diseases where
bronchoconstriction is a complicating factor.

Actions:

Stimulates B-receptors, thus producing relaxation of smooth muscle,

inhibition of the release of endogenous spasmogens, inhibition of edema
caused by endogenous mediators, increased mucociliary clearance and
relaxation of the uterine muscle.

Pharmacokinetics:

Absorption: Absorbed from the GI tract.

Distribution: Maycross the placenta, and probably enter breast milk
Metabolism And Excretion: in the tissue and excreted by urine

Contraindicated In:

hypersensitivity to terbutaline, tachyarrhythmias tachycardia caused by

digoxin toxicity; general anesthesia with halogenated hydrocarbons or
cyclopropane, which sensitize the myocardium to cathecolamines, unstable
vasomotor system disorders,

Use Cautiously In:

Diabetes, coronary insufficiency, COPD patientswho have developed

degenerative heart disease, hyperthyroidism, history os seizure disorders,
psychoneurotic individuals, hypertension

Adverse Reactions and Side Effects:

CNS: restlessness, apprehension, anxiety, fear, CNS stimulation,

hyperkinesia, insomnia, tremor, drowsiness, irritability, weakness, vertigo,

headache seizure.
CV:cardiac arrhythmias palpitations, angina pain, changes in BP and ECG
GI: nausea, vomiting, heartburn, unusual or bad taste in mouth
RESP: respiratory difficulties, pulmonary edema, coughing, bronchospasm
OTHER: pallor, sweating, flushing, muscle cramps

Route and Dosage:

PO adults-1-2 tabs. Children 12-15 yrs. old-1 tab.All doses to be taken 3

times daily.

Patient teachings:

Do not exceed recommended dosage.

Report chest pain, dizziness, insomnia, weakness, tremor or irregular
heartbeat, failure to respond to usual dosage