Name: Danielle Orcales

Clinical Instructor: Mrs. April Love Oja,RN,MAN

Received patient named Jenelyn Jarabay 17 years old, female. Currently residing at Purok 2 Doongan,
Butuan City. A roman catholic, filipino citizen. Diagnosed with Urinary Tract Infection that may affect her
pregnancy.

History Prior to admission:

 UTI (lab results)

 For pregancy testing
 Transvaginal ultrasound
 Low hgb
 Low Hematocrit
 Low RBC

Admitted last December 8,2019 at around 5:30pm with a vital signs of:

T- 36.7°C

P- 123bpm

R- 23bpm

Bp: 100/60

Doctor’s order upon admission of ff:

 Transfuse 2 units of PRBC properly and crossmatched

 For TVS
 Ff Urinalysis

Medication order

 Ampicillin IVTT ANST

 Isoxsuprine Hcl tab TID

IVF consumed

#1 D5LR 1L

#2 D5LR 1L Received at the level of 800cc

Blood transfusion

12-08-19

#1 BT

12-09-19

#2 BT

Laboratory exam performed:

 Urinalysis
 CBC
 PRBC screening and crossmatching