COURSE IN THE WARD

Date Doctors Order Rationale Nursing

Responsibilities
08-10- For red blood cell - These entire lab test are - Explained the lab
13 (RBC), prothrombin performed to screen for any test to the patient
11:35 time (PT), partial alteration and to serve as a
am prothrombin time baseline data for future
(PTT) and comparison
electrocardiogram - ECG to evaluate the
(ECG) functionality of the heart

Diagnosis seen
and examined - To ensure the patients - Assisted the
Health and progress and need to patient with the
Physical undergo surgery physician
examination
reviewed
ROS: (-) DOB
(-)chest pain
(+) weight loss
(-) hypertension
(-) asthma

Please determine - To know if the blood is - Instruct the

oxygen saturation carrying enough oxygen patient remove
prior to OR the nail polish
Refer result - For collaborative
management - Referred
accordingly
IVF:
PLRS 1 L x 8 hours - Plain Lactated Ringers - Regulated IVF
solution. Maintenance of correctly and
fluids and electrolytes labeled it

(-) Anesthesiologist
known Patient seen and - To ensure patients - Assist the patient
allergies examined willingness to undergo to the
the procedure and the anesthesiology
patient must be in normal and record the
body state results of
examination
Health reviewed; - To ensure the patients - Document the
Physical progress and need to results of patients
examination done undergo surgery health status

Anesthesia plans - For the patient to - Asked patient if

and risks understand the case and she understands
explained acceptance of medical the physicians
services to be rendered explanation
 Secure consent - For legal purposes and to - served as a witness
ensure that the patient - validated
understands the nature of understanding of the
the treatment patient & SO about
the importance of
signing consent.
Refer - Referral is done to correct - referred
unusualities as soon as accordingly
possible and to inform to the
attending physician of the
patients condition
s/p EL; - Status post to designate - Assessed the
Adhesiolysis; when someone has patient
TAHBSO/ significant procedure/
sabarachnoid events happen.
block- continuous
lumbar epidural
analgesia (SAB-
CLEA)
NPO until further - The patient is - Instruct the
orders unconscious; to avoid patient not to eat
aspiration especially or drink
those who will undergo a
general anesthesia

Monitor vital signs - Vitals signs of the patient - Monitor and

until stable must be stable prior to recorded vital
surgery. Any signs accurately.
deviation or fluctuation - Report for any
could endanger the life of deviation
the patient
IVF: - Lactated Ringers Solution - Regulated IVF
Right, D5LRS 1L + with 5% Dextrose(D5LR). A correctly and
1 amp nutrient replenisher. labeled it
Left, PLRS 1L x - Maintenance of fluids and - Check the
KVO electrolytes patency of the IV
line

Diclofenac 8 hours - Nonsteroidal anti- - Evaluate

for 3 cycles inflammatory drug. Used therapeutic
in severe postoperative response by
assessing pain,
pain
joint stiffness,
joint swelling and
mobility.
Meds:
1. Tidact 300mg IV - To slow the growth of - Administered
every 6 hours x sensitive bacteria medication using
3 doses; 1st the 10 Rs
dose given at - Check doctors
10 pm order
- Clean the IV port
prior to
administration of
drugs
- Monitor patient
for adverse
effects
2. Metoclopramide - Exerts - Check doctors
10mg IV every antiemetic properties order
8 hours PRN for through antagonism of - Clean the IV port
nausea and central and peripheral prior to
vomiting dopamine receptors. administration of
drugs
- Monitor patient
for adverse
effects
3. Ranitidine 50 - Short term treatment for - Check doctors
mg IV every 8 gastric ulcer order
hours x 3 - Clean the IV port
doses; 1st dose prior to
given at 10 pm administration of
drugs
- Monitor patient
for adverse
effects
4. Tramadol 50mg - Opioid analgesic for pain - Check doctors
SIVP every 2 management order
hours PRN for - Clean the IV port
severe pain prior to
administration of
drugs
- Monitor patient
for adverse
effects
- Assessed for pain
5. Paracetamol - To decrease fever - Check doctors
300mg IV every order
4 hours PRN for - Clean the IV port
T>38C prior to
administration of
drugs
- Monitor patient for
adverse effects
- Assessed patients
 fever or pain

6. Vitamin k - To restore potassium - Check doctors

order
- Instructed the
patient to take
the medications
with its proper
dosage and time

Keep - To balance thermal inputs - Secure the

thermoregulated and thermal losses so as thermometer in
to maintain its core place
temperature nearly
constant.
WOF:
Profuse bleeding at - To prevent further - Close monitoring
surgical site, complication and give - Referred any
hypotension and immediate medical complication
dyspnea management

Refer - For collaborative - referred

management accordingly
08-11- Repeat CBC today - To know if the blood of - obtained and filled
13 the patient is within a laboratory request
normal range. form and forwarded
it to the laboratory
- followed up the
result and attached
to the patients chart

Refer - For collaborative - referred

management accordingly
08-12- Soft diet then DAT - DAT was ordered means - Instruct the diet
13 with bowel that the patient can now properly
11:15 movement (BM) tolerate eating anything as
am long as it is not detrimental - Monitor if the
(+) to her condition patient complies
flatus with the given
diet

- Ensure patient to
take or eat food
she can tolerate
Start oral meds:
1. Mefenamic acid - Anti-inflammatory drug to - Administer drug
500mg/cap q 6 treat pain in 10Rs
x 7 days - Checked for
hypersensitivity
of the drug

2. Paracetamol - To relief fever, headache - Check doctors

500mg/tab q 4 and pain order
x 7 days - Monitor patient for
adverse effects
- Assessed patients
fever or pain

3. Clindamycim - To slow the growth of - Administered

150mg TID x 7 sensitive bacteria medication using
days the 10 Rs

4. Ferrous Sulfate - Prevent iron deficiency

1 tab 2x a day anemia - Explain to the
patient on how to
take the
medication

- Monitor
hemoglobin and
hematocrit levels
and reticulocyte
count during
therapy, as ordered

Insert dulcolax - It is stimulant laxative. It

suppository/ acts directly on the - Explain to the
rectum bowels, stimulating the patient the
procedure
bowel muscles to cause a
bowel movement. - Provide patients
privacy

- If the suppository
is prescribed as a
laxative, ensure a
toilet, commode
or bedpan is
available.
Transfuse 1 unit - Blood loss is the risk in - Check the lot,
pack red blood cell every surgery, thus serial numbers,
(PRBC) to now for transfusion must be done blood type, and
4 hours- their during surgery and expiration date of
donors will arrive after surgery blood to be
 from am. transfuse to the
patient
- Check also the
unit of blood
before
administering it
- Let the patient or
SO sign the
informed consent
for BT
- Check vital signs
according to
hospital protocol
May ambulate with - Promotes normalization - Assisted the
assistance of organ function by patient in
stimulating peristalsis ambulating to
and passing of flatus, prevent any
reducing abdominal aggravations
discomfort. of complications
of immobility such
as thrombus
formation
Refer - For collaborative - referred
management accordingly