Patient VT, 42 years of age and born on May 2, 1980, married with one child and currently

residing at Tumauini, Isabela. She is a filipino citizen and her religious affiliation is Roman Catholic. She
can speak and understand Tagalog and Ybanag. She is a graduate of Bachelor of Science in Commerce.
On June 5, 2022 at 2:00 PM, she experienced vaginal bleeding and feeling of dizziness, hence she was
rushed to the Emergency Department of Cagayan Valley Medical Center via Ambulance. She was
admitted with the diagnosis: G3P1 (1021) Hydatidiform Mole 27 1/7 Week AOG, Anemia Secondary,
Advance maternal age.

History of present Illness

One month PTA, she experienced intermittent vaginal spotting for a period of 1 week but no
consultation was made, no medications taken and no pregnancy test taken. One week PTA, the patient
still experienced vaginal bleeding with 2 pads moderately soaked per day. Few hours PTA, the patient
had massive vaginal bleeding with vesicular tissue and it was accompanied by dizziness which prompted
her husband to bring her to the hospital, hence, the admission.

Patient has no known allergies and previous hospitalizations are because of childbirth. She has
no recollection of her childhood vaccinations.

DOCTOR’S ORDER

June 5, 2022 Please admit to LR-OR

2:30 PM Secure consent for management
On NPO
Diagnostics: CBC, UA, BT, FT4, TSH serum, BhCG titer, SE, Chest Xray
IVF: PLRS 1 L x 8 hours
PNSS 1L x KVO
Meds:
Start Ampicillin Sulbactam 1.5 g IV ANST

For total abdominal hysterectomy

Secure consent for the procedure
Inform OR
Secure 2 units of PRBC properly typed and crossmatched
Watch out for BT reactions
Give Furosemide after 2 units of PRBC
Hook 02 inhalation via NC at 2-3 LPM
VS q1

5:30 PM Secure another 1 unit of PRBC

Please facilitate transfusion with a goal of hemoglobin >10g/dl
Please facilitate CxR-PA
Provide adequate 02
Adequate hydration but watchout for volume overload
POST-OP order
June 6, 2022 To PACU
9 AM NPO
VS q15 minutes until stable then q20 minutes
 O2 inhalation at 4L/min via facemask
IVF: Regulate present IVF PLRS 1L x 8hours then T/F D5LRS 1L x 12 hours
Line 2- PNSS 1L x KVO + 2nd unit of PRBC x 4hours then T/F 3rd unit PRBC x
4hours
Give furosemide 40 mg IV after 2nd unit of PRBC
Give Ketorolac 30 mg IV every 6 hours x 6 doses
Nalbuphine 10 mg IV every 4 hours x 4 doses then prn for moderate to severe
pain
Tranexamic acid 500 mg IV every 6 hours x 4 doses
Ranitidine 50 mg IV every 8 hours while on NPO
Metochlopromide 10 mg IV every 8 hours prn
Keep patient thermoregulated
Monitor intake and output every 1 hour
Position on moderate high back rest

11:00 AM May transfer to ward

VS q2 hours
Intake and output q 4hours
Refer
7PM May have soft diet
IVF:
Discontinue PLRS 1 L x 8 hours
Maintain PNSS 1 L x KVO
Start oral meds:
Ampicillin Sulbactam 750 mg tab, 1 tab evry 8 hours x 7 days
Fe Fumerate + Vit B complex 500 mg/ tab 1 tab BID
Ascorbic Acid 500 mg/ tab OD
Celecoxib 200 mg/ tab 1 tab q 12 hours
Amlodipine 10 mg/tab 1 tab OD
May do bladder training then pull IFC
For repeat CBC with PC
Encourage early ambulation
VS q1
Refer

The following are the significant findings during your physical assessment:

 Patient is awake, conscious and coherent. She is oriented to time and place and responds to
questions accurately.
 Patient appears weak and with facial grimace on movements. She is observed to have guarded
behavior.
 With ongoing IVF of PLRS 1 L x KVO hooked on the right arm and PNSS 1L x KVO hooked on the
left arm
 With IFC connected to urine bag
 Weight: 60 Kg Ht: 5’6 feet
 VS: 120/80 mmHg, 37.1 c, 80 BPM, 19 CPM
 Skin color is pale, nail beds also appear pale and capillary time is at 3 seconds
 Presence of incision on the abdomen with bandage and appears clean and dry
 Patient verbalized, “Mahina ang pakiramdam ko at mejo nahihilo ako”
 Upon verifying, the patient said, “ Masakit ang sugat ko at hirap akong makagalaw dahil sa sakit”

Tasks:
1. Make a case study using the following format:
1.1. Introduction
1.2. Pathophysiology
1.3. NCP (3)
1.4. Drug Study
1.5. Discharge Care Plan
2. Accomplish the Kardex. Carry out the latest orders given by the Doctor.
3. Using FDAR, make a Nurse charting for your shift.
4. Endorse at the end of your shift