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Patient came in due to her scheduled cesarean section under Dr. Pamittan. Past medical history includes: Had previous hospital admissions due to appendectomy (1998), and dehydration due to gastroenteritis for several occasions with latest admission last 2001. Family history reveals: Mother side: (+) HPN, (+) DM Father side: (+) TB, (+) gastric cancer, grandmother Patient had no hypogastric pain, no vaginal bleeding, no vomiting, BOW not ruptured yet and 90% effaced when she arrived at the OR. This is her second pregnancy with first pregnancy also under CS (2005) due to cephalic disproportion. Patient had regular prenatal care and is being treated for Gestational diabetes and had been taking insulin injections with titrated dose 2x a day from 4th month of pregnancy until present. Pre-op assessments are all normal including HGT. The patient tolerated the epidural anesthesia and the procedure well last July 3, 2012. The patient’s chart indicates this final diagnosis: PUFT Cephalic in Labor with alive Baby Boy G2P2 (2-0-0-2) ; GDM. Post Cesarean Section Orders are as follows; A. Transfer to post partum ward when stable. B. Vital signs monitoring q4h x 24 hours, I and O. C. Bed rest x 6-8 hours, then ambulate; keep patient flat on back x 8 hours Incentive spirometer q1h while awake. D. Diet: NPO x 8h, then sips of water. Advance to clear liquids, then DAT once w/ flatus. E.IV Fluids: IV D5 LR or D5 ½ NS at 125 cc/h. Foley to gravity; discontinue after 12 hours. I and O catheterize prn. F.Medications 1. Cefazolin (Ancef) 500 mg IV q 8 hrs x 2 days. 2. Nalbuphine (Nubain) 5 to 10 mg SC or IV q2-3h 4. Hydroxyzine (Vistaril) 25-50 mg IM q3-4h prn nausea. G.Labs: CBC in AM -done Postoperative Management for Day 1 post-op A. Assess pain, lungs, cardiac status, fundal height, lochia, passing Of flatus, bowel movement, distension, tenderness, bowel sounds, incision. B. Discontinue IV when taking adequate PO fluids Change meds to
Discontinue Foley. incentive spirometer q1h while awake Six hours post-partum assessment reveals normal physical examination except for the post-operative wound in the lower abdomen and light vaginal bleeding. C. . and I and O catheterize prn. lowest is 6.PO once on DAT. D. Ambulate TID with assistance. highest is 9. Other assessment reveals the following: Weight: 71 kgs Height: 5 feet and 6 inches BP: 130/90 mmHg PR: 87 RR 19 HGT: 146 mg/dl Post-op pain scale: In the last six hours. Current is 8.
0 1.35 – 7.14 0.30 5 – 10 0.010 – 1.36 .04 0.0 0.02 .22 .0.04 320 120 – 140 g/dL 0.01 .66 0.45 1.35 8.60 0.010 Moderate 7. CBC Hemoglobin Hematocrit WBC Segmenters Lymphocytes Eosinophils Stab Cells Platelets Actual Findings Normal Findings 116 0. Urinalysis: Microscopic Exam Color Transparency pH Specific gravity Epithelial cells Chemical Exam Albumin Sugar Yellow Hazel 6.LABORATORY / DIAGNOSTICS Procedure / Date 1.40 0.05 150 – 400x9/L 2.02 0.0.025 Negative Negative .0.0.