Date: 4/23/2021

Patient’s Data
Name: Martha de Jesus
Chief complaint: Baby in breech position
History of present illness: On the 6th month of pregnancy, the baby’s presentation was in
breech. The patient was informed that the baby will rotate naturally if not, she will need to
undergo CS. On 4/22/21, she was scheduled for IE and found to be 3 cm dilated. She was
scheduled to undergo CS delivery on the same day. Her expected date of delivery was 4/29/2021.
Diagnosis: G2P1 (1001) PU 38 3/7 weeks AOG by LMP, breech in the latent phase of labor.
General Impression of Client: Patient received in semi-Fowler’s position lying diagonally on
the bed, applying cold compress over the hypogastric area. Facial grimacing and abdominal
guarding observed. The patient appears conscious, coherent, and responsive when interviewed.

Doctor’s Orders
Doctor’s Order Rationale/ Explanation
Diet As Tolerated (DAT) once with After surgery, the patient might not tolerate food right away due to
bowel movement (BM) bowel manipulation as well as anesthesia thus resulting into
nausea, vomiting, and possibly aspiration.
Shift IVTT meds to PO (once on soft After first day post-op, the pt’s digestive system must have worked
diet) already as evidenced by bowel movement. Thus, IVTT is no
longer necessary because she can tolerate oral medications.
Medications:
Cefuroxime 500 mg tab BID x 7 days Cefuroxime: Given as an antibiotic to prevent infection since
surgery, indwelling catheter, and insertion of IV fluids are a break
in the skin or mucus membranes.
MV + Iron tab BID x 1 month MV + iron: Provide nutrients lost during pregnancy and birth, and
for breastfeeding. Iron is needed to replenish blood loss and
prevent anemia.

Mefenamic Acid 500 mg 1 tab q 8H x 3 Mefenamic acid: NSAID for pain relief from labor and delivery,

days then PRN for pain and surgical incision

Remove FBC catheter 6 AM tomorrow, Removal of catheter decreases risk for UTI, urethral pain, and
to void 4-6H after difficulty in voiding.
TPR q 4H
Labs: repeat CBC, HBsAg, Urine
Analysis, APTT
Discontinue Blood line but keep the
D5LR 1L to run for 8 hours
Refer accordingly
To monitor signs and symptoms of infection, hemorrhage, and
shock.
Repeat CBC: to detect anemia and determine the need for blood
replacement
HBsAg: detect hepatitis B from the mother
Urine analysis: to assess bladder or kidney infections, diabetes,
dehydration, and preeclampsia by screening for high levels of
sugars, proteins, ketones, and bacteria.
APTT: to detect early postpartum hemorrhage which prevent
progression to uncontrollable blood loss.
During the surgery, the pt may not have lost a large amount of
blood hence the blood line is to be discontinued. Since she is still
not able to eat or drink fluids from the surgery, D5LR is a
temporary means for fluid and electrolyte replenishment and
caloric supply.
Refer pt to specialists in cases of complications.