S/P TAHBSO, S/P TAH or S/P SALPING-OOPHORECTOMY S: presence of flatus, ability to defecate, (-) flatus, (-)
BM
Diagnosis Example: G5P3 (3-0-2-3) Abnormal Uterine
Bleeding- Leiomyoma (INTRAMURAL) Urinary Retention O: Vital Signs: BP, CR, RR, T
Secondary S/P Total Abnormal Hysterectomy Bilateral
A: Ileus Secondary to Surgical Manipulation or
Salpingectomy under SAB-CEA S/P Blood Transfusion
Secondary Anesthesia Effect, S/P LSCS, # of days (1st
Subproblem #1: Ileus Post-op day), OB Score
S: presence of flatus, ability to defecate, (-) flatus, (-) P: diet
BM
Subproblem #2: Respiratory Splinting
O: Vital Signs: BP, CR, RR, T
S: dyspnea, cough
Abdomen:
O: chest and lung findings
A: Ileus Secondary to Surgical Manipulation or
A: Respiratory Splinting Secondary to Incisional Pain,
Secondary Anesthesia Effect, S/P TAHBSO, # of days
S/P LSCS, # of days, OB Score
(1st Post-op day), OB Score
P: deep breathing exercises 15 mins 3x a day
P: diet
Steam inhalation 15 mins BID
Subproblem #2: Respiratory Splinting
Side to side movement every few hours
S: dyspnea, cough
Subproblem #3: Abdominal wound pain and healing
O: chest and lung findings
S: degree of pain (mild, moderate, severe) (rate)
A: Respiratory Splinting Secondary to Incisional Pain,
S/P TAHBSO, # of days, OB Score O: Vital signs: BP; CR; RR; T
P: deep breathing exercises 15 mins 3x a day Abdomen
Steam inhalation 15 mins BID A: Abdominal Wound Healing in Progress, S/P LSCS, #
of days, OB Score
Side to side movement every few hours
P: antibiotics, pain relievers
Subproblem #3: Abdominal wound pain and bleeding
Subproblem #4: Uterine Wound Pain and Healing
S: degree of pain (mild, moderate, severe) (rate)
S: degree of pain (mild, moderate, severe) (rate)
O: Vital signs: BP; CR; RR; T
O: Vital Signs: BP, CR, RR, T
Abdomen:
Abdomen
A: Abdominal Wound Healing in Progress, S/P
TAHBSO, # of days, OB Score A: Uterine Involution in Progress, S/P LSCS, # of days,
OB Score
P: antibiotics, pain relievers
P: Antibiotics, pain relievers
S/P LSCS
S/P NSD
Diagnosis example: G1P1 (1-0-0-1) Pregnancy Uterine
38 2/7 weeks age of gestation, cephalic, delivered via Diagnosis Sample: G1P1 (1-0-0-1) Term, cephalic,
Primary LSCS under SAB due to failure of descent (st – delivered spontaneously to a live full term baby boy in
1x2 hours) to a Live full term baby boy in Occiput Right occiput anterior, BW: 3.36 kg: BL: 47 cm, AS: 9,9
Posterior BW: 3.3 kg; BL: 47 cm; AS: 9,9 BS: 38 weeks BS: 38 weeks, AGA (2/18/18, 9:15 am) s/p median
episiotomy with repair
Subproblem #1: Ileus
Subproblem #1 Uterine Wound Pain and Bleeding Please admit to OB Ward under the service of
Dr. Marcial
S: degree of pain, (mild, moderate, severe) (rate)
Secure Consent for admission and management
O: Vital signs: BP, CR, RR, T TPR every shift and record
DIET: NPO post-midnight
Abdomen:
Double-prep abdomen and perineum
A: Uterine Involution in Progress, S/P NSD. # of days, Dr. Marcial cognizant of admission
OB Score
#1 Previously Scarred Uterus
P: antibiotics, pain relievers
Dx: CBC
Subproblem # 2: PMLE/LMLE/ Median Episiotomy
Blood Typing
wound pain and healing
UA
S: degree of pain (mild, moderate, severe) (rate)
Monitor VS and FHT every 4 hours and
O: Vital Signs: BP. CR, RR, T
record
A: RMLE/LMLE/ Median Episiotomy Wound Healing in
Tx: IVF c/o Anesthesia
Progress, S/P NSD, # of Days, OB Score
Schedule for repeat LSCS 07/17/2018
P: antibiotics, pain relievers
07:00 AM
S/P Diagnostic Curettage:
Secure Consent
MVS q 15x1, q 30 then hourly thereafter until
Inform Dr. Gregorio for AA
stable
Back to ward once stable Refer to PCOD for Neonatal Care
DAT when fully awake
Antibiotics: Cefuroxime (Zegen) 1.5 mg
Subproblem #1: Uterine Pain and Bleeding ANST one hour prior to OR
Present IVF FO 200 cc to consume if with undue Secure 1 unit PRBC properly typed and
bleeding and if spontaneously voiding cross-matched as standby
Antibiotic
#2 Financial Difficulty
Pain reliever
Send specimen for histopath Refer to MSS
Refer
Secure previous chart
Physicians Admitting Order Template for LSCS - Service
or Charity Patient
