Date Doctor’s Order Rationale

04/19/09 - Please admit under the service of - Admitting the patient in the

Dr. Borromeo agency provides a chance

- Consent to care for the medical personnel’s

- TPR every shift to monitor the health status

- For TAHUSO of the patient.

- Attach all labs

- CP clearance - SOP before any surgical

- Please inform procedures to anticipate/

surgeon/anaestheologist/ Dr. prevent possible

Luminarias/OR of this admission complications.

- Refer for any unusualities

- Refer accordingly

04/20/09 - NPO for midnight - Needed for surgery

- Full oral and body hygiene - Preparation for surgey

- Insert IVF with D5LR 1L at 30 - Acts as fluid replacement

gtts/min

- Ranitidine 1tab every 8 hours PO - To decrease gastric acid

secretions

- Pre Op meds given @ AM

- Secure one unit FWB for possible - For blood replacement

 OR use in properly typed and cross- during surgery

matched

04/21/09 Post-Op orders

11:30 AM -Flat in bed until 5:00pm then turn to - Safety precautions to

sides every 2 hours prevent falls, thrombus

formation and skin

-vital signs every 15 minutes until breakdown.

stable - For monitoring patient’s

status.

-MPD until further orders

-IVF @ 30gtts/min ; follow up with - IVF follow-up

D5 LR 3L at same rate

-Ampicillin 1gm IVTT every 6 hrs - Prophylaxis against GI

ANST (-) infections

-Metronidazole 500mg by IV drip for - Prophylaxis against

30 mins every 8 hours bacterial infections

-Tramadol 50 mgs IVTT every 6 - To decrease pain

hours

04/22/09 -Insert Bisacodyl 1 adult suppository -To soften stools

per rectum now

 -May have clear liquid diet once able -To monitor GI function

to pass flatus

-Encourage ambulation -To promote circulation

-Cont IVF and IVT meds

-I&O every shift -To monitor fluid balance

-no dressing till ordered

04/23/09 8:00 AM

(-) flatus - GI function has not restored

-Insert another Bisacodyl adult - To soften stool

suppository per rectum now

-may have clear liquid diet at lunch

time

-Continue IVF

-Pls. inform once with flatus

-for full ambulation

1:30 PM - GI functioning restored

(+) flatus - To have the stomach adjust

-may have clear liquid this lunch

Then general liquid tonight

(+) defecation
 -May have general liquid now then

soft diet tonight

Dr. Luminarias

04/24/09 8:00 AM

(+) BM

-May have DAT now

-IVF to consume

-Shift IVT meds to PO once IVF is

consumed

1) Amoxicillin 500mg QID #28 - For prophylaxis and/or

treatment of infection

2) Metronidazole 500mg TID PO - For prophylaxis and/or

p.c. #26 treatment of infection

3) Diclofenac Na 25 mg TID PO - For pain

p.c. #30

-Start: MV 1-0-0 #30 - To increase body’s

FeSO4 + FA 1-0-0 #30 PO immunity

p.c. - Acts as Iron

-For dressing today supplementation

- To promote wound healing

-Remove FBC now – refer if unable and prevent infection

to void 4 hrs. after - To prevent infection

-Please prepare above meds for

possible home meds - To continue prescribed

-For D/C tomorrow medications at home

- May continue recovery

outside hospital premises