Date April 09, 2012 9:25 AM

Order Pls. admit to Gyne ward under blue service Soft Diet

Rationale gastro/euro/infections

Remarks Done

A soft diet contains foods that are soft and easy to chew or swallow. n some situations, there are additional restrictions. For example, patients who need to avoid excessive reflux, VSq4 Monitoring VS is important in able to note, compare and report unusual ties. labs: see attached, Laboratory result would help identify and trace the imbalances of the client in terms of fluid and electrolytes level. Schedule for TAH or 04/11/12 Patient schedule for TAH due to myoma uteri or a benign tumor that grows within the muscle tissue of the uterus. Thus, TAH was ordered to removed the tumors. During a total abdominal hysterectomy, the doctor removes the uterus, including the cervix. The scar may be horizontal or vertical, depending on the reason the procedure is performed, and the size of the area being treated.

Done

Done

Done

Done

Date

Order Pap Smear consent

Rationale Pap smear is an invasive procedure wherein it microscopically examines the cell scraped from the cervix. Pap smear is a screening test for cervical cancer. Since there is a presence of benign tumor in the uterus, there is also a possibility that cervical cancer may be present or any other pathological disorder or infection. Thus, consent is needed prior to the procedure. FFP and RBC transfusion is indicated in patients with documented coagulation factor deficiencies and active bleeding, or who are about to undergo an invasive procedure. In order for the patient to be assess, evaluated and managed properly. Doctors would prescribe NPO in nighttime to prevent aspiration pneumonia especially those who will undergo a general anesthesia Monitoring VS is important in able to note, compare and report unusual ties. Lactated Ringers Solution with 5% Dextrose(D5LR).

Remarks Done

to secure 2 units of PRBC, 1 FFP of patient's blood types for stand by OR use

Done

Refer

Done

April 10, 2012 4:00 PM

May have soft diet, NPO midnight

Done

VSq4

Done

IVF D5LR 1L to run at 120cc/hr. in NPO

Done

Date

Order

Rationale D5LR is a hypertonic solution. It is non pyrogenic, electrolyte and nutrient replenisher. D5LR is a treatment use for persons needing extra calories but cannot tolerate fluid overload

Remarks

Sched for TAH tomorrow 2nd table

Total Abdominal Hesteretormy to remove the benign tumor cells in the uterus. Consent is an SPO prior to any invasive procedure in a hospital setting. It must be clear to the client what is the procedure, why is it necessary, and most importantly the patient must understand the significance of the procedure to her state. Abdominal perineal preparation is necessary prior to procedure; to remove the hair in the skin. Hair is known to lodge microorganism that would contaminate or enter the blood stream whenever the skin was cut. A client who will undergo surgery will be given Cefradine for susceptible infections

Done

Please secure consent

Done

AP Prep

Done

Please give Cefra 1 gram IVTT 1 hour prior to surgery then 8-9hours

Done

Date

Order for bond pyrg phos phosoda 4 PM and 7 PM Please follow up the availability of blood.

Rationale It is an over the counter laxatives in preparation for surgery. Blood loss is anticipated in every surgery. Thus a client must prepare blood to prevent CBL. To ensure that right blood type is administer to the patient. IV line is a route use to administer medications and blood transfusion. Patency of the line, ensures that the medication, solution or blood would enter the blood stream. Can help ward off illness. For the continuity of care, refer any unusual ties and progress.

Remarks Done

Done

Please cross match available blood Check patency of IV line

Done

Done

Gen/Oral Hygiene Refer

Done Done

April 10, 2012 11:40 PM

Pre-OP Anestheseology orders: Patient secure and examine Health reviewed To ensure patient's willingness to undergo the procedure. To ensure that the clients progress and need to undergo surgery Done

Done

Date

Order NPO p midnight except PO meds

Rationale Doctors would prescribe NPO in nighttime to prevent aspiration pneumonia especially those who will undergo a general anesthesia. Lactated Ringers Solution with 5%Dextrose(D5LR) Hypertonic solutions. A nutrient replenisher. D5LR is a treatment use for persons needing extra calories but cannot eat properly due to some considerations. TSh or Thyroid Stimulating Hormone and T4; they are lab test that would rule out goiter. Endocrinology is concerned with the study of the biosynthesis, storage, chemistry, and physiological function of hormones and with the cells of the endocrine glands and tissues that secrete them. Due to the clients palpitation, she was referred to the Endo to understanding the cause of her condition such as palpitations. Patient's palpitations can be a manifestation of underlying disease or illness.

Remarks Done

IVF: D5Lr 1L @ 120 cc/hr

Done

For stat TSH and FT4

Done

Refer patient to Internal Medicine for Endo

Done

Re: Health of palpitations and Goiter

Done

Date

Order Meds: 1.) Ranitidine 150 mg 1 tab 2 hours PTOR

Rationale

Remarks

Reversibly and competitively blocks histamine at H 2 receptors, particularly those in gastric parietal cells, leading to inhibition of gastric acid secretion. Tramadol is a man-made (synthetic) analgesic (pain reliever). Its exact mechanism of action is unknown but similar morphine. Like morphine, tramadol binds to receptors in the brain (opioid receptors) that are important for transmitting the sensation of pain from throughout the body to. Tramadol, like other narcotics used for the treatment of pain, may be abused. Celecoxib is licensed for use in osteoarthritis, rheumatoid arthritis, acute pain, painful menstruation and menstrual symptoms, ankylosing spondylitis and to reduce the number of colon and rectal polyps in patients with familial adenomatous polyposis. Due to the patients order of NPO. However meds must be taken due to surgery.

Done

2.) Tramadol 50 mg 1 tab 2 hours PTOR

Done

3.) Celecoxib 400 mg 1 tab 2 hours PTOR

Done

Side note: Take meds with 1-3 sips of water

Done

Date

Order Please follow up availability of blood for OR use

Rationale Blood preparation is must since surgery was scheduled. Other doctors would order autologous blood transfusion, wherein a client donates her own blood as a reserve. IV lines deliver liquids and medications to the body. They are made from small, flexible tubing that's attached on one end to a bag of fluid and to a small needle inserted into a vein on the other end. Because a dangerous bacterial infection could be released into the bloodstream and body organs, it is important that the IV line be properly cared for. If a person is due to go into hospital, sometimes that person becomes very aware of their hygiene. The thought of being vulnerable and exposed to strangers can cause the person to become very strict on their hygiene needs. Maintaining hygiene practices helps to reduce the risks of ill health, but equally important affects how we and others perceive ourselves and can influence our levels of

Remarks Done

Check for patency of IV line

Done

Gen/Oral hygiene

Done

Date

Order

Rationale confidence and self-esteem which can affect many aspects of our lives.

Remarks

Refer

In order for the patient to be assess, evaluated and managed properly This is to asses if the is ready for the surgery. Client received care through the assessment of the physician. The health profession is very particular in keeping a track or record about lab result because it will be a basis of a diagnosis. After the examination/assessment the doctor may advice to continue to surgery as plan. Further assessment is focused on identifying any underlying cause and assessment of cardiac function, however the physician still pursue the idea of surgery. P wave is the electrical vector directed to SA node to AV node. There is no any abnormalities found in the patients endocrine system.

Done

April 10, 2012 3:40 PM

Patient seen and examined Health received ad labs noted

Done

Done

May proceed with surgical plan

Done

(patient not cleared but 3/27/12 cardio pulse wave P wise

Done

Patient is cleared Endo is wise

Done

Date

Order Refer

Rationale In order for the patient to be assess, evaluated and managed properly A telephone order is sometimes made by the physician due to some factors: the physician is currently doing a surgery, physician is handling an emergency case, and other external factors. In terms of the rescheduling of the surgery, the physician did not state any reason why is there a postponement of such procedure. Surgical procedure can be postpone anytime, by the patient and by the doctor. Informing the staff and other department of the hospital especially the OR about the postponement of surgery is necessary. Thus they can accommodate other patient. When there is a postponement of a procedure, re scheduling is necessary ASAP since it is a major operation. Consent is important; because it is a signed document by the client that she understand what is the procedure, why it is necessary and the possible causes and effects.

Remarks Done

April 11, 2012

Telephone ordered by Dr. Tahera to nurse Mara Nieva: Pls re scheduled for OR schedule of Toralba, Juanita, today, still for rescheduling

Done

Please inform OR and AROD

Done

2:50 PM

rescheduled for TAH tomorrow, 1st table

Done

Secure consent Done

Date

Order AP Prep

Rationale Abdominal perineal care is a must before surgery. It removes microorganism that can enter the bloodstream and can be the cause of infection. Information must be disseminated to ensure the schedule. Soft diet is ordered by the doctor for the client can digest it quickly especially prior to surgery. NPO is an SOP to any patient will undergo surgery. Indicated in the treatment of infection due to cut in the skin for surgery. In order for the patient to be assess, evaluated and managed properly Anesthesiologist must see the client before the scheduled surgery to be able to asses what medication is appropriate for the condition of the patient. History taking is important. It is another form of knowing and understanding why the client in this particular institution must undergo major

Remarks Done

inform OR/AROD

Done

Soft diet then NPO P MN

Done

Cefazolin 1 gm IVTT 1 hr PTOR Refer

Done

Done

April 11, 2012

3:00 PM

Anesthesia Pre-Op order Patient seen and examined

Done

history of received

Done

Date

Order

Rationale surgery and factors that would contraindicate the procedure or any medication that would be given.

Remarks

NPO P MN

Doctors would prescribe NPO in nighttime to prevent aspiration pneumonia especially those who will undergo a general anesthesia. Hypertonic solution that is no pyrogenic and is areplenisher. D5LR is a treatment use for persons needing extra calories but cannot tolerate fluid overload. Celecoxib is licensed for use in osteoarthritis, rheumatoid arthritis, acute pain, painful menstruation and menstrual symptoms, ankylosing spondylitis and to reduce the number of colon and rectal polyps in patients with familial adenomatous polyposis. Reversibly and competitively blocks histamine at H 2 receptors, particularly those in gastric parietal cells, leading to inhibition of gastric acid secretion.

Done

Continue IVF with D5LR 2 120cc/hr

Done

Celecoxib 400mg 1 cap: 2 PTOR with sips of water

Done

Ranitidine 50 mg q IVTT once in NPO

Done

Date

Order Metoclopromide 10 mg IVTT PTOR

Rationale Stimulates upper GI tract motility, resulting in accelerated gastric emptying and intestinal transit, and increased resting tone of lower esophageal sphincter. Exerts antiemetic properties through antagonism of central and peripheral dopamine receptors. Vitals signs of the client must be stable prior to surgery. Any deviation or fluctuation could endanger the life of the client. In order for the patient to be assess, evaluated and managed properly OTC drug for laxatives. This is administer in preparation for surgery. Manufactured enema formula containing 16 g sodium biphosphate and 6 g sodium phosphate per 100 mL solution. It is available in disposable plastic pouches fitted with prelubricated rectal tubes. In order for the patient to be assess, evaluated and managed properly

Remarks Done

VS monitoring to OR

Done

Refer accordingly

Done

April 11, 2012 5:00 PM

Please give phos phoda at 7 pm today Fleet enema in am

Done

Done

Refer

Done

Date April 11, 2012 5:05

Order Hold Cefazolin give Cefradine 1 gm IVTT 1 hr Prior to Surgery

Rationale Cefazoline and Cefradine has same indication. They are antibacterial drug. However, Cefazolin is administered orally. In order for the patient to be assess, evaluated and managed properly s/p means status post about the epidural anesthesia administered. Only Anesthesiologist can removed the epidural catheter. PACCU is vital part of hospitals, ambulatory care centers, and other medical facilities. It is an area, normally attached to operating theater suites, designed to provide care for patients recovering from anesthesia. When sedated or under anesthesia, your body's normal protective airway reflexes, such as coughing, that prevent the aspiration of any regurgitated stomach contents is impaired. The aspiration of acidic or solid gastric contents can cause serious and even life threatening lung inflammation

Remarks

Refer

Done

April 12, 2012 11:30 AM

Anesthesia Post-Op Order: s/p TAH CSEA Cerebro Spinal Epidural Anesthisia To PACU until stable then to ward

Done

Done

NPO

Done

Date

Order

Rationale and infection. If stomach is full, the chances or regurgitating are greater, and the amount regurgitated will be greater which increases the likelihood of aspiration.

Remarks

monitor VSq15 stable then q hourly

VS monitoring after surgery is one of the indicator of patients recovery. IV solution used to supply water and electrolytes ( calcium, potassium, sodium, chloride), either with or without calories (dextrose), to the body. It is also used as a mixing solution (diluent) for other IV medications. Blood loss is the risk in every surgery, thus transfusion must be done during surgery and after surgery. Pain reliever may be taken to manage the post operative pain.

Done

Continue IVF with PLR @ 40CC/HR

Done

cont. blood transfusion 100 cc/hr

Done

meds: 1.) Tramadol 50 mg q6 IVTT x 3 doses to start at 6 pm PRN for pain

Done

Date

Order

Rationale

Remarks

2.) Dicofenal-sodium 75 mg in 10 ml PNSS q12 slow IVTT x3 doses to start @ 6 PM then shift to celecoxib 400 mg capsule 1 cap OD

Relief of mild to moderately severe somatic & neuritic pain; headache, migraine, traumatic pain, postpartum pain, post-op pain, & fever following various inflammatory conditions; dysmenorrhea; menorrhagia accompanied by spasm or hypogastric pain. Celecoxib is a pain drug, this will ensure the continuity of taking medications if the patient will no longer have an IV line or the patient can now have a DAT. Reversibly and competitively blocks histamine at H 2 receptors, particularly those in gastric parietal cells, leading to inhibition of gastric acid secretion. If other pain meds would not ease the pain experience by client. Epidural catheter should be removed; the use of such is only exclusive for anesthesia. The mechanisms and control

Done

3.) Ranitidine 50 mg q8 IVTT

Done

4.) Metoclomide 10 mg 6 IVTT PRN for pain For removal of Epidural Catheter, PT discharge for PACU. Thermoregulated patient

Done

Done

Done

Date

Order

Rationale

Remarks

systems used by the body to balance thermal inputs and thermal losses so as to maintain its core temperature nearly constant. O2 @ 4L/min with mask This to ensure the optimum level of oxygenation of cells gearing towards achieving balance in terms of oxygenation. This would also prevent in lung collapse. Monitoring of intake a gauge fluid balance and give valuable information about your patient's condition. A complete blood count. A test wherein it evaluates the composition and concentration of the blood. It consist of the WBC and RBC and other component present in the blood Diuretic drug use to treat edema or excess fluid in the body. This will help in maintaining the F&E in the body. In order for the patient to be assess, evaluated and managed properly Done

monitor I&O qh and record

Done

For CBC @ 8 pm tonight @ ward

Done

Feurosemide 40 mg IVTT 1 hr, pus+ BT with BP precaution Please include serum, Na+, K+, Ca+, determination pus+ BT Refer accordingly

Done

Done

Done

Date

Order Please transfuse 1 u FFP after 1 unit of PRBC on giving BT

Rationale Fresh frozen plasma is taken from whole blood. Administration of this indicates generally are limited to the treatment of deficiencies of coagulation proteins for which specific factor concentrates are unavailable or undesirable. In many clinical practices, fresh and frozen plasma contains proteins with two important coagulation factors in it. This is for the treatment of excessive bleeding resulting from systemic or local hyperfibrinolysis and prophylaxis in patients with coagulopathy undergoing surgical procedures. Prevention and treatment of hypoprothrombinemia, which may be associated with: Excessive doses of oral anticoagulants, Salicylates, Certain antiinfective agents, Nutritional deficiencies, Prolonged total parenteral nutrition.

Remarks Done

Tranecsamic acid 500 mg q8 IVTT, to start @ 8 pm

Done

Vit. K 10 mg IVTT to start @ 8 PM

Done

Date April 13, 2012 3:00 PM

Order May have general Liquid and crackers then soft diet once with flatus

Rationale Since after surgery, the body is still adjusting. Soft diet is ordered. Flatus is an indication of peristalsis. Hypertonic solution for patient that needs replenisher. Treatment for person who needs calories but cannot tolerate large amount of food due to some restrictions. It is used to treat bacterial infection in the skin. After negative skin test, this can be administer. Means that the patient has no allergy to such medication. It is a pain drug that minimizes the gastro intestinal acid production. For assisting in urination. Urethral muscle may not be able to contract. To relieve stress and anxiety after surgery. To know if the blood of the client is within normal range.

Remarks Done

IVF of D5LR @ 120cc/hr

Done

Meds: Cefazolin 1 gm IVTT then q8 (ANST)

Done

Celecoxib 20 mg cap BID

Done

retain Foley catheter

Done

Deep breathing exercise repeat CBC today

Done Done

Date

Order Transfer to Gyne Ward

Rationale Transfer patient to appropriate ward to continue care. Anti-inflammatory drug to treat pain. To facilitate urinating. DAT was ordered means that the client can now tolerate eating anything as long as it is not detrimental to her condition. For monitoring and comparison of previous CBD result. Cardinal signs is important thus must be monitored religiously and record. In order for the patient to be assess, evaluated and managed properly

Remarks Done

April 13, 2012 4:10 PM

Start: mefenamic acid 500 mg TID Retain FC may have DAT for dinner

Done

Done Done

repeat CBC

Done

VS monitoring

Done

Refer

Done