JMJ Marist Brothers

Notre Dame of Marbel University

College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

Patient’s Name: GERONIMO, ZEBEDEE LU

Age: 63/Male
Hospital No.: 00000-1C
Attending Physician: Dr. Lorenzo
Chief Complain: Epigastric pain, vomiting

CASE 3: Gastric and Duodenal Disorders

DAY 0 in the MEDICAL WARD: After treatment in the Emergency Room, the patient was endorsed in
the ward. The attending physician reviewed the admitting orders and the laboratory results.
During rounds, the patient still complains of epigastric pain decreased to 6/10 from 10/10. He claimed
that he is still nauseated with dizziness. Suddenly, the patient vomited fresh blood with an estimated
amount of 20cc. The AP asked the nurse to take the vital signs with reply: BP= 90/70mmHg;
PR=115bpm; RR=25cpm; T=35.60C
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

DOCTOR’S ORDER
Date Time Progress Notes Order C A R E D
02/11/21 0700H (+) epigastric pain 5/10 Give Tranexamic Acid 500mg IV now then Q8o RTC ✓ ✓ ✓
(+) nausea Continue present other meds. ✓ ✓ ✓
(+) dizziness NPO Temporarily. ✓ ✓
(+) hemoptysis Present IVF#1 PNSS IL increase to 30gtts/min. ✓ ✓
For CT Scan Whole Abdomen ✓ ✓ ✓
Refer for persistent symptoms. ✓ ✓
Dr. Lorenzo
Samantha Jane F. De la Cruz,SN/JanMaverick S. Rabino, RN

Legend: C – Carried Out A – Administered R – Requested E – Endorsed D - Discontinued

Patient’s Name: GERONIMO, ZEBEDEE LU Age/Sex: 63/Male Hospital No: 00000-1C

Attending Physician: Dr. Lorenzo Room No.: 103-C

 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

MEDICATION SHEET

Date MEDICINES Date Date

Ordered Discontinued
Shift Time Initial Time Initial Time Initial Time Initial
02/11/21 Give Tranexamic Acid 6A-2P
500mg IV Q8o RTC 2P-10P
10P-6A
6A-2P
2P-10P
10P-6A
6A-2P
2P-10P
10P-6A
6A-2P
2P-10P
10P-6A
6A-2P
2P-10P
10P-6A

PRN
Date MEDICINES Date Date
Ordered Discontinued
Shift Time Initial Time Initial Time Initial Time Initial
6A-2P
2P-10P
10P-6A
6A-2P
2P-10P
10P-6A

STAT ORDERS
Date MEDICINES Date Date
Ordered Discontinued
Shift Time Initial Time Initial Time Initial Time Initial
02/11/21 Give Tranexamic Acid 6A-2P 7am
500mg IV now 2P-10P
10P-6A
6A-2P
2P-10P
10P-6A

MEDICATION NURSE
Shift Full Name & Full Name & Initial Full Name & Initial Full Name &
Initial Initial
6A-2PM Samantha Jane F.
De la Cruz
2P-10P
10P-6A
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

Patient’s Name: GERONIMO, ZEBEDEE LU Age/Sex: 63/Male Hospital No: 00000-1C

Attending Physician: Dr. Lorenzo Room No.: 103-C

 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

NURSES NOTES AND TREATMENT RECORD

DATE SHIFT
TIME
FOCUS DOCUMENTATION SIGNATURE
02/11/2
1
6A-
2PM
Received patient awake, sitting on bed with #1 PNSS 1L x 30
7am gtts/min @ 1L cc level. Hooked @ Right metacarpal vein,
infusing
well.                                                                                                
  
F> Fluid Volume Deficit
D> “Nanghihina ako dahil sumusuka ako nurse.” As verbalized
by the patient.
>Nausea noted
>Vomiting noted
> (+) Hematemesis
> On NPO
> BP:90/70mmHg
A >Monitored Vital signs especially BP and HR.
>Monitored Input and output.
> Assisted in most comfortable position.
> Regulated prescribed IV as ordered.
> Administered Tranexamic Acid 500mg IV now, as ordered.
> Encouraged enough rest.
> Instructed not to eat for 8 hours.
2:00p
> Assisted for CT Scan whole Abdomen.
m > Encouraged to do breathing exercises.
> Instructed to damp limps with cotton soaked in water.
R > “mas naging mabuti napo pakiramdam ko nurse, hindi napo
ako nasusuka.” As stated by the patient.
>BP:110/70mmHg
>Endorsed patient to NOD - SAMANTHA JANE F. DE LA CRUZ
02/11/21

Patient’s Name: GERONIMO, ZEBEDEE LU Age/Sex: 63/Male Hospital No: 00000-1C

Attending Physician: Dr. Lorenzo Room No.:103-C

 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

DAY 3: After 3 days of being admitted, the patient manifested stable vital signs with no other complains. During

rounds, the AP made the discharge orders.

DOCTOR’S ORDER
Date Time Progress Notes Order C A R E D
02/14/21 0830H May Go Home today. D/C IV ✓ ✓
Meds:
1. Tranexamic Acid 500mg 1cap TID pc for 3 ✓
more days.
2. Omeprazole 40mg 1 cap OD for 2 weeks ✓
Refer to Dr. De Dios for GI evaluation as outpatient. ✓ ✓
Follow-up after 1 week at clinic. ✓ ✓
Advised. ✓

Dr. Lorenzo
Samantha Jane F. De la Cruz,SN/Jan Maverick S. Rabino, RN

Legend: C – Carried Out A – Administered R – Requested E – Endorsed D - Discontinued

Patient’s Name: GERONIMO, ZEBEDEE LU Age/Sex: 63/Male Hospital No: 00000-1C

Attending Physician: Dr. Lorenzo Room No.: 103-C

HOME INSTRUCTIONS
Patient’s Name: Geronimo, Zebedee Lu Age: 63 Sex: Male Rm No.: 103-C
Attending Physician: Dr. Lorenzo
Final Diagnosis: Bleeding Peptic Ulcer Disease

Home Medications:
TIME
MORNIN NOON EVENIN BEDTIME
MEDICINE DOSAGE
G G
Tranexamic Acid 500mg 1cap 3x a 500 mg 1 cap 7am 1pm 7pm
day after meal for 3 more days
Omeprazole 40mg 1 cap Once a 40 mg 6am
day for 2 weeks
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

Follow-up Schedule:
DOCTOR’S NAME DATE & TIME CLINIC ADDRESS CONTACT NUMBER
Dr. Lorenzo 02/21/2021;8:30am Alunan Avenue, 09123456789
Koronadal City,
South Cotabato

Other Instructions:
1.Instruct to follow the prescribed medication regimen and attend follow up checkup after 1 week at Dr.
Lorenzo’s clinic.
2.Take Tranexamic acid after meal to prevent GI irritation. Take Omeprazole before meal for optimal control of
daytime gastric acidity.
3. Instructed not to take aspirin and other non-steroidal anti-inflammatory drug to prevent ulcer development
and prevent complication during healing phase.
4. Contact physician immediately for signs of complications.
5. Advised to ask assistance when moving or standing since both drugs has side effect of dizziness and
blurred vision.

I certify that I understand the information presented to me.

( / ) Patient ( ) Parent/Relative ( ) Legal Guardian
Geronimo, Zebedee Lu
Signature Over Printed Name
Date: 02/14/21

Prepared & Explained by:

Samantha Jane F. De la Cruz, SN

Signature over Printed Name
Date: 02/14/21