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TIME ORDER
January 20, 9:30AM Acute pain Data: 9:00AM
2019 Please admit CC: RUQ with a pain
9:00am patient scale of 8/10, A 41 years old female patient, wearing a maternity dress in pink slipper
Secure Nape pain 7/10 on, is rush in the VRH emergency room at 9:00AM on January 20, 2019.
consent Blurring of vision She was accompanied by her husband with a chief complaints of blurring
With Guarding behavior
Seen by Dr. of vision, RUQ pain with a scale of 8/10 and nape pain as 7/10.
Facial grimacing Guarding behavior, facial grimacing, restlessness, paleness were
HB Restlessness
Monitor BP q Paleness
observed. She has a BP-150/100mmHg, T-37, RR-24, PR-95 and FHT
1hr Non-pitting Edema on of 135.
DX: urinalysis, both lower extremities She was place on bed comfortably with elevated feet and side rails up
CBC with for safety.
APC, baseline Action:
CTG, Vital signs taken as 9:05am
PPT.ultrasoun follows: BP-150/100
d whole BP-150/100mmHg,
abdomen RR-24 cpm 9:20am
LDH, ALT, PR-95 bpm BP-150/100
Temp-37.0 C
AST(stat)
FHT-135 bpm
Meds order: SPO2-99%
methyldopa Position patient
250mg 2 tabs comfortably
now then TID Promote rest
MgSO4 4g Elevate feet to promote
slow IV then circulation
5g IM in each Raise side rails for
buttock safety
Dexamethaso
ne 12mg IM 9:20 am 9:20AM
every 12hrs x Oral meds given;
2 doses Methyldopa 250mg 2 She was seen by Dr. HB with an initial diagnosis of pre-eclampsia with
Paracetamol tabs orders of admitting the patient, secure consent, TPR q4, BP q1, FHT q2,
oral meds given for laboratory like urinalysis, CBC with APC, PPT, LDH, AST, ALT(STAT)
500mg q 6
Paracetamol 500mg q 6 and a baseline CTG. He ordered a medication of Methyldopa 250mg 2
RTC
RTC tabs now then TID, Magnesium sulfate 4g slow IV then 5g IM in each
D5LR 1L x MgSO4 4g slow IV then
8hrs buttock, Dexamethasone 12mg IM every 12 hrs. x 2 doses and
5g IM in each buttock Paracetamol 200mg q 6 RTC, D5LR 1L x 8hrs.
Monitor BP
every 15 min
The laboratory tests were explained to the patient, and the laboratory
Response: section was informed about the stat orders.
The patient was able to Consent was secured.
verbalized: She was then hooked to D5LR 1L x 8hrs at 30-31gtts/min infusing well
Reduced pain scale of to her left metacarpal vein.
Nape pain from 5/10, Prior to giving mgSO4 patellar reflex was assessed with positive patellar
and 6/10 for RUQ reflex
Absence of Guarding After administration of mgSO4, monitor for BP,urine output,and
behavior
respiratory rate
Absence of Facial
She was given oral medication such as methyldopa 250mg 2 tabs now
grimacing
Absence of then TID for her high BP, MgSO4 4g slow IV then 5g IM in each buttock,
Restlessness Dexamethasone 12mg IM every 12hrs x 2 doses for the fetus lung
Absence of Paleness maturity, Paracetamol 500mg q 6 RTC.
The nurse asked for a urine sample and sent it to the laboratory section
and a medical technologist drawn a blood sample for her specific
laboratory test.
10:00am
Action:
Notified to Dr.HB 11:00am
CBC and urinalysis result was forwarded to the nurse station and was
notified to Dr. HB. the patient was requested for BP monitoring, q 1hr
and fetal heart tone q 2hrs.
12:00pm
VS taken:
o BP-140/90mmHg
o RR-23
o PR-89
o temp-36.9
2:00PM
FHT-140
Lab result
ALT, AST (
stat) 2:00pm
Light meal
then NPO The nurse station received her lab result for the AST, ALT and LDH.
midnight This was notified immediately to Dr. HB as he ordered. After he read
Cefuroxime the result he went to the patient’s ward to explain the laboratory result
4:00PM
1.5 g/IV confirming that she has HELLP syndrome and then explain the
Data:
ANST prior to The patient verbalize management for her disease. She was then informed to have her
elective anxiety due to her cesarean section on January 21, 2019.
LTCS disease and the Further explanation was said about her CS and was able to understand.
Secure procedure to be perform Consent was secured
consent The patient verbalize VS taken as follows:
FHT Q2 that she didn’t o BP-140/90mmHg
Routine understand well how o RR-23
abdominal she got the disease. o PR-90
preparation Anxiety The patient cannot o temp-36.9
Please specify what to expect
inform after the operation Oral meds given: methyldopa 250mg 2 tabs now then TID
procedure or Action:
new born The patient was 4:00pm
care encouraged to
ABO RH type verbalized her feeling Received patient sitting on bed with an IVF of D5LR 1l at 375cc.she
Please about the procedure verbalized anxiety due to her sickness
secure 1 bag The procedure was Vital sign taken as follows:
PRBC discussed to the patient o BP-140/90mmHg
properly Promote relaxation o RR-22
typed and techniques o PR-90
cross Response: o temp-36.8
matched for The patient able to
OR use verbalize understanding Further explanation about the decrease was discussed.and she was able to
about the procedure verbalized understanding
Stabilize pt. The patient able to
And baby verbalize that she would FHT-140
(continue V/S expect a cut/incision Oral meds given: paracetamol 500mg q 6hrs
monitoring within her abdomen.
The patient able to
verbalize that her
anxiety about the
procedure was
decreased.
6:00pm
Patient seen lying on bed an intact IVF of D5LR at 30cc level.
Followed by D5LR 1L x 8hrs with the same infusion rate
She was instructed to have light meals like a cup of rice with vegetables
and instructed to have NPO after midnight as a preparation for her CS.
VS taken as follows:
o BP-140/90mmHg
o RR-21
o PR-92
o temp-36.9
FHT-145
8:00PM
VS taken as follows:
o BP-140/90mmHg,
o RR-30,
o PR-95,
o temp-37.0
FHT-145
10:00pm
NPO instructed
VS taken as follows:
o BP-140/90mmHg,
o RR-24,
o PR-92,
o temp-37.0
FHT-149
Data: 7:00 AM
BP: 140/90
VS taken as follows:
o BP-140/90mmHg,
o RR-20
o PR-87
o T-37.0
FHT-142
PREOPERATIVE:
8:00AM
Action: VS:
Procedure was o BP-140/90mmHg,
explained to the patient o RR-22
Skin testing o PR-90
o temp-37.0
FHT-140
The procedure was explained to the patient and skin testing was done.
8:30 AM
Data: Skin test result was (-) ANST
BP-140/90mmHg Cefuroxime 1.5 g IV was administered as prophylaxis to prevent further
complications.
Received patient on with an intact IVF of D5LR at 375cc level.
Action: VS:
Cefuroxime 1.5f IV o RR-20
administration o BP-140/90
o PR-87
o temp-37.0
FHT-142
9:30AM
INTRAIOPERATIVE:
10:50AM Risk for injury Data:
Induction of anesthesia 10:00AM
To PACU (s/p
“E” LTCS+BTL Action: Patient was assisted to fetal position,antiseptic was done and induction
under SAB) Patient assisted to fetal of regional(spinal) anesthesia(bupivacaine50mg, midazolam,
Flat on bed position nalbupin20mg) and the sterile draping applied. Patient was placed back
Administer O2 at Patient was place in
to supine position after inducted; O2 at 2lpm via nasal cannula was
2-3 l/min supine after induction of
hooked and Indwelling Foley Catheter was connected to urine bag
Monitor vital anesthesia
inserted aseptically.
sign every 15 Bed rails up
mins till stable IFC insertion done
NPO aseptically
IVF D5LRS The operation started by Dra. S. with A.A as assist and A.M as
1L+20u oxytocin instrument. Antisepsis was done, sterile draping was applied, and
for 8 hrs To counting of needles, sponges, and instruments was done.
follow
D5LRS 1L+10u 10:15AM
oxytocin for Risk for DATA: The surgeon performed a 13cm pfannenstiel incision two finger-breadth above
every 8hrs times infection symphysis pubis
3doses Incision site (13cm)
D5LRS 1L for
8hrs Indwelling catheter 10:20AM
Baby out, umbilical cord was cut. Chest x ray was done to the baby and
Meds: Action: then transferred to NICU
Cefuroxime
10:25AM
1.5g IV Maintain sterile
every 8 Placenta out
technique for all
hours 10:40AM
invasive procedure
Tranexamic Uterus was cleanse
Wound dressing using
acid 2mg IV Uterine wall closed
proper technique
every 8hrs x Abdominal closed
3 doses Blood loss 1000ml
Tramadol All needles,sponges and instrument complete
50mg IV
every 8 x 3
doses
Diclofenac POSTOPERATIVE:
75mg every
6hrs x 3
10:50AM
doses
ANST
Ranitidine The operation ended and procedure was done, abdomenoperineal care
50mg IV was done, sterile draping applied on the operation site, and to RR
every 8hrs endorsed.
while on VS taken:
NPO o BP-120/90mmHg,
May transfer o RR-22
back to ward o PR-80
when able to o T-37.0
elevate both
legs with stable For Post Anesthesia Care, patient was on the RR. she was place in
vital sign supine position on IVF of D5LR 1l at 875cc +20U oxytocin. with oxygen
inhalation via nasal cannula at 2lpm, and hooked to pulse oximeter. The
IV meds was started and safety measures provided.
12:00PM
2:00pm o BP-130/90mmHg,
o RR-21
DATA: o PR-82
Chief complain of pain in o T-37.0
the incision site,
Rate the pain as 7/10
guarding behavior
Acute pain facial grimacing 11:50AM
related to post paleness The patient was lying on bed and awake with an IVf of D5LR 1l at 750cc.she
op operation Dry lips can elevate her foot upon assessment patient was assisted back to ward via
stretcher.
ACTION:
Vital sign taken and 12:00PM
recorded as follows: The patient was assisted from stretcher to bed. IFC was maintained with
30cc output and was instructed to lie flat on bed until 7pm and on NPO
o BP- until 7pm lying on bed with an IVF of D5LR 1l at 675cc level
130/90mmHg, VS:
o RR-16 o BP-130/90mmHg,
o PR-86 o RR-16
o temp-36.7 o PR-86
Encourage the patient to o T-36.7
verbalize her feeling about
Lochia assessed: Rubra
her condition
Promote adequate rest CBC, urinalysis FL: BUN,CREA, PT,PPT,AST.ALT.NA,K, FBI-liquid
She was encourage to do profile done
breathing exercises
RESPONSE:
The patient able to divert
her attention by watching
TV
The patient able to report 2:00PM
that the pain is
relieved(5/10) Received patient on bed with an IVF of D5LR 1l at 425cc level with a
urine output of 90cc .patient was complaining of pain on her incision site
rated as 7/10.facial grimacing ,guarding behavior and dry lips upon
assessment with a vital sign of:
o BP-130/90mmHg,
o RR-21
o PR-82
o T-37.0
Patient was encouraged to do deep breathing exercise
Her lab result was received to the nurse station.
6:00pm
Received patient on bed with an IVF of D5LR 1l at 175cc level with a
urine output of 200cc .Vital sign was taken as follows:
DATA:
Incision site 13cm with o BP-120/90mmHg,
drainage o RR-24
Risk for Incision site is moist o PR-81
infection Presence of IFC o T-36.9
ACTION:
Instruct the patient for
Meds due given:
proper wound care for
the incision site
Instruct the patient to o Cefuroxime 1.5g IV
always make the area o Diclofenac 75mg IV
clean and dry at all o Tranexamic acid 2mg IV
times
RESPONSE:
Understand the 7:00PM
importance of wound
care Patient was received on bed with an IVF of D5LR 1l at 50 cc.IVF was
removed rehooked with D5LR 1l x 8hrs + 10U oxytocin.urine output of
230cc level and was drained. vital sign was taken as follows
o BP-120/90
o RR-16
o PR-86
o T-36.7
11:00pm
Received patient lying on bed with an IVF of D5LR 1l at 500cc level with
a urine output of 120cc level .vital sign was taken as follows:
o BP-130/90
o RR-19
o PR-83
o T-36.9
IFC was removed
DATE AND DOCTORS FOCUS DAR NURSES NOTES
TIME ORDER
January 22, 12:00am
2019 Result of ALT, Vital sign was taken:
AST and LDH Disturbed Sleeping Data:
result Pattern o BP-120/90
consume IVF + Total hours of sleep at o RR-18
meds night: 4-5hrs with o PR-81
Start interruptions o T-36.8
Presence of eye bags
FESO4 325mg Diclofenac 75mg IV given
OD Lack of concentration
Celecoxib Action:
1:00AM
200mg 1 cap Patient on bed with an intact IVF of D5LR 1L at 40cc.
Provide comfort measures
BID Followed by D5LR 1L with the same rate infusion.
such as proper positioning,
Ascorbic acid Patient was informed about the proper ways to lessen the
80mg1 tab OD deep breathing exercises,
susceptibility to infection and was instructed for daily wound
back rub.
Co amoxiclav care and to report any untoward signs and symptoms.
625mg 1tab Encourage to limit intake of 2:00am
caffeine and chocolate prior
BID for 7days Received patient on bed with an IVF of D5LR 1l at 875cc ital
to sleep.
Amlodipine sign was taken as follows:
10mg OD
Response:
Repeat CMC o BP-130/90
today
Understood o RR-17
Encourage o PR-84
early o T-36.9
ambulation Cefuroxime 1.5g IV given
and Tranexamic acid 2mg IV given
breastfeeding
Continue vital 3:00am
sign Vital sign was taken:
monitoring
o BP-120/90
o RR-20
o PR-81
o T-36.9
Tramadol 50mg IV given
DATA:
8:00AM
risk for delayed Verbalized discomfort Received patient on bed awake with an IVF of D5LR 1l at 125cc
recovery related to when moving level.verbalized discomfort in moving with a pain scale of 6/10,
post op pain facial grimacing and guarding behavior.
Pain scale of 6/10 She was encourage for early ambulation and eating foods rich
in vitamin and nutrient.vital sign was taken as follows:
Facial grimacing o BP-120/90mmHg,
o RR-16
Guarding behavior
o PR-86
Difficulty in moving/turning o T-36.7
on side Oral due meds given:
o Celecoxib 200mg 1 tab
Incision site is moist o Co amoxiclav 625mg 1 tab
o Amlodipine 10mg 1tab
ACTION: o Ascorbic acid 80mg 1 tab
o FESO4 325mg 1 tab
Encourage patient for
early ambulation to
promote circulation 9:00 AM
Encourage to eat fruits Patient was on bed with an IVF of D5LR 1l at 20cc
and adequate protein Followed by D5LR 1L with the same infusion rate
intake VS:
o BP-120/90mmHg,
Demonstrate the proper o RR-16
caring for the incision site o PR-86
o T-36.7
RESPONSE: 1:00pm
Received patient sitting on a chair with an IVF of D5LR 1l 500cc
Understand the level. vital sign taken and recorded as follows:
importance of early o BP-130/90mmHg,
ambulation o RR-17
o PR-89
o temp-36.5
5:00pm
Patient was on bed with an IVF of D5LR 1l at 20cc
Followed by D5LR 1L with the same infusion rate
6:00PM
2:00PM
Vital sign taken:
BP-130/90mmHg
o RR-17
o PR-89
o T-36.5
6:00PM
VS:
o BP-120/90mmHg,
o RR-19
o PR-85
o T-36.8
Co amoxiclav 625mg 1tab given
10:00pm
VS:
o BP-120/90mmHg, RR-15,PR-80,T-36.8
9:00AM
Discharge planning was conducted. Patient was
ordered to may go home which was ordered by
Dr. HB.
Patient was advised to take her home meds:
10:00am
The patient was discharged and instructed regarding
to her follow up checkup.
11:00am
patient was discharged in a good condition
COURSE IN THE WARD