F – Hypothermia Precaution

D- Received pt. On bed with mother, awake, responsive to stimuli, with skin warm to touch. On
breastfeeding per demand. S/F Enbs and hearing screening test prior to discharge.

A - Visit pt and assessed for any complications.

-Bathing done; swaddled.

- kept thermoregulated; Provided droplight @ bedside.

-Continue BF per demand

-Advised mother to burp after feeding.

-All needs attended.

-MGH with mother; Home instructions given.

-Cord clamp removed.

-Hearing test passed.

R- Discharged.

F – RISK FOR INFECTION

D - S/P REPEAT CS. ON BED. WITH SKIN WARM TO TOUCH. ON DAT ; VOIDING FREELY. FOR MGH
TODAY.

D > RECEIVED ON BED, LYING AWAKE AND ORIENTED. NIRD. WITH ONGOING PLR 530CC LEVEL @
120CC/HR, PATENT AND INTACT. ON SD. WITH JP DRAIN. VOIDING FREELY. POST-OP SITE, DRY AND
INTACT.

A- VISITED AND ASSESSED FOR ANY COMPLIATIONS.

-NEEDS ATTENDED TO.

-ENCOURAGED TO INCREASE OFI.

-ADVISED TO REPORT UNUSUALITIES

-HOME INSTRUCTIONS GIVEN.

- CHANGE OF DRESSING DONE.

D - S/P CS. ON BED, AWAKE AND ORIENTED. NIRD.WITH ONGOING PLR 880CC LEVEL@
120CC/HR,PATENT AND INTACT. WITH FC ATTACHED TO UROBAG.

A- VISITED AND ASSESSED FOR ANY COMPLIATIONS.

- POST-OP SITE, DRY AND INTACT.

-REGULATED IVF.

-REMOVED FC AS ORDERED. MUST VOID 4-6HRS POST REMOVAL.

- INSTRUCTED TO DRINK PLENTY OF WATER.

- INSERTED DULCOLAX SUPP PER RECTUM AS ORDERED.

-ROUNDS WITH AP, SEEN AND EXAMINED.

- DECREASE IVF TO KVO.

-NEEDS ATTENDED.

R > ENDORSED.

R – DISCHARGED.

RISK FOR INFECTION R/T POST-OP DELIVERY CS.

F – INFECTION R/T VAC APPLICATION.

D > ON BED, AWAKE AND ORIENTED. POSITIONED COMFORTABLY. NIRD. WITH ONGOING PNSS 360CC
LEVEL AT KVO RATE, PATENT AND INTACT. VOIDING FREELY.

A >ASSESSED POST-OP SITE, DRY AND INTACT DRESSING.

> ENCOURAGED VERBALIZATION OF DISCOMFORT OF PAIN.

>KEPT RESTED AND MONITORED.

> ENCOURAGED TO INCREASE OFI.

>PROVIDED SAFETY MEASURES.

>KEPT RESTED AND MONITORED.

> ENCOURAGED TO INCREASE OFI.

>CHECKED IVF PATENCY PRIOR TO OR.

>VS ENROUTE TO OR.

> CONTINUE TREATMENT REGIMEN.

>TRANSPORTED TO OR PER STRETCHER.> CONTINUE TREATMENT REGIMEN.

R > ENDORSED.

F – CONTINUITY OF CARE

D > ON BED, AWAKE AND ORIENTED. NIRD.WITH ONGOING PLR 370CC LEVEL @ KVO RATE, PATENT. ON
DAT, DM DIET. VOIDING FREELY. WITH CBG MONITORING Q6H.

A > VISITED PT AND ASSESSED FOR ANY COMPLICATIONS.

>ENCURAGED TO INCREASE OFI.

>KEPT MONITORED; WELL-RESTED.

>PROVIDED COMFORT MEASURES.

R > ENDORSED.

F >LEFT SIDED WEAKNESS.

D >S/P CS. ON BED, AWAKE AND ORIENTED. NIRD. WITH ONGOING PNSS 1L @ 120CC/HR,PATENT AND
INTACT. ON LSLF DIET. "MURAG LUYA PAJUD AKONG WALA NA KAMOT, MOKALIT RAG KAWALAY
UMOY," AS VERBALIZED.

A >VISITED AND ASSESSED FOR ANY COMPLIATIONS.

>KEPT MONITORED.

>ROUNDS WITH AP, SEEN AND EXAMINED.

>REGULATED IVF TO KVO AS ORDERED.

>ENCOURAGED TO DO ROM ON AFFECTED AREA.

>NEEDS ATTENDED TO.

R>ENDORSED.

D > POTASSIUM LEVEL : 3.05MMOL/L.ON BED, AWAKE AND ORIENTED. POSITIONED COMFORTABLY.
NIRD. WITH ONGOING PNSS 680CC LEVEL AT 80CC/HR, PATENT AND INTACT. ON DM DIET. VOIDING
FREELY.

A > VISITED PT AND ASSESSED FOR ANY COMPLICATIONS.

>ROUNDS WITH AP, SEEN AND EXAMINED.

>DECREASE CBG MONITORING TO BID.

>STARTED PREGABALIN AND ATORVASTATIN 20MG 1TAB OD.

>NEEDS ATTENDED TO.

R >ENDORSED.

***************************************************************************

F > POST TRANSFER ASSESSMENT DONE

D > RECEIVED FROM ER PER WHEELCHAIR, AWAKE AND ORIENTED. NIRD. WITHOUT IVF. ON DAT.
SCHEDULED FOR FISTULECTOMY ON 12/22/23 @ TO FOLLOW 1ST CASE.

SCHEDULED FOR TAHBSO ON 1/5/23 @ 12NN.

SCHEDULED FOR LAP HERNIORRHAPHY ON 1/5/23 @ 8AM.

A > PLACED COMFORTABLY ON BED.

>ANESTHESIA CONSENT SIGNED.

>FLEET ENEMA GIVEN.

>NEEDS ATTENDED TO.

>PRE-OP INSTRUCTIONS GIVEN.

> PLACED COMFORTABLY AND SAFELY ON BED.

>ORIENTED TO PLACE AND HOSPITAL POLICIES.

>HUMULIN 70/30 10 UNITS SC GIVEN.

> INSTRUCTED PT ON DAT FOR NOW THEN NPO POST MIDNIGHT.

>WOF ANY UNUSUALITIES.

>KEPT MONITORED; ANESTHESIA CONSENT SIGNED.

>NEEDS ATTENDED TO; PRE-OP INSTRUCTIONS GIVEN.

F > JAUNDICE

D > ON BED, AWAKE AND RESPONSIVE TO STIMULI. NIRD. WITH ONGOING D5IMB 200CC LEVEL @
17.5CC/HR VIA INFUSION PUMP, PATENT AND INTACT. ON BF PER DEMAND. ON CONTINUOUS
PHOTOTHERAPY. VOIDING FREELY; WITH DIAPER.

> VISITED AND ASSESSED FOR ANY COMPLICATIONS.

>MAINTAINED ON PHOTOTHERAPY WITH SHIELD ON EYES AND GENITALS.

>KEPT MONITORED AND THERMOREGULATED.

>SAFETY MEASURES PROVIDED.

>FACILITATED TB, IB, DB TEST; TSR.

>NEEDS ATTENDED TO.