NCM 107

Clinical Case Scenario

October 26, 2021
 Clinical Case in
Gynecologic Nursing
Case Description
Case Description
• Ms. M.B., a 21 y.o.
primigravid, was admitted
to LMMC last October 18,
2021 for elective C-section.
• She was admitted to the
OB-GYN Unit under the
service of Dr. JAV
• Accompanying her is Mr.
K.A.
 ER Notes
• Case No: 2021-67602
• Patient Name: Ms. M.B.
• Age: 21 y.o.
• Date of Birth: 6-27-2000
• Civil Status: Single
• Religion: RC
• Nationality: Filipino
• Occupation: Nurse
 ER Notes
• Triage Classification: Non-urgent
• Covid-19 Screening: (-) Symptoms, (-) Exposure
(-) PCR, May admit to Non-COVID unit (Green
Zone)
• Room Classification: Private
• Hospitalization Plan: PhilHealth and HMO
(Maxicare)
 ER Notes
• Family History of Illness: Ms. MB’s father is a
known HYPERTENSIVE patient, and has been
taking maintenance medication for the past 5
years. Ms. MB’s mother has Asthma, but has
not had attacks over the past 2 years. Both of
the patient’s grandparents died of cancer, and
were known diabetics.
 ER Notes
• Past Medical History: Ms.
MB has had no medical
illnesses for the past 1 year.
She used to have Asthma
like her mother, but the last
episode was when she’s 14
y.o. She has no remarkable
cardio-pulmonary conditions
at the present time. She has
no known allergies.
ER Notes
• Obstetrical History:
Menarche: 13 y.o
LMP: January 14, 2021
EDD: October 21, 2021
EGA: 39 weeks and 5 days
Status: Primigravida
Score: G1P0
Comorbidity: None
 ER Notes

Date of Admission:
October 18, 2021
Time of Admission: 9am
Attending Physician:
Dr. JAV
Admitting Diagnosis:
Twin Pregnancy G1P0 39
5/7 weeks AOG, NIL
Physical Assessment
 Physical Assessment
Height: 150cm, Weight: 60kg

Vital Sx: 120/80 mmhg, 36.5c, 20 cpm, 86bpm, FHT: 140bpm

No constitutional findings on review of systems, clear breath

sounds, no signs of beginning labor, BOW intact

(+) Chloasma on face, (+) Striae Gravidarum on right thigh,

(+) Linea Negra on the Abdomen
Laboratory and
Diagnostic
Examinations
LAB/DIAGNOSTIC RESULTS

PLT: 200, 000/mcL WBC: 9, 000/ mcL

RBC: 4.50m /mcL HCT: 40.1 %
HGB: 14 g/dl

SEGMENTER: 60 LYMPHOCYTE: 30
MONOCYTE: 5 EOSINOPHIL: 5
LAB/DIAGNOSTIC RESULTS

ABO TYPING: O+
LAB/DIAGNOSTIC RESULTS

HbSAg: Non- Reactive

LAB/DIAGNOSTIC RESULTS

COLOR: Amber TRANSPARENCY: Slightly

Turbid
PH: 6.1 SPECIFIC GRAVITY: 1.020
WBC: 1-2 /hpf RBC: 5-10 /hpf
Pus Cells: 2-3/hpf Epithelial Cells: plenty
Glucose: None Albumin: None
LAB/DIAGNOSTIC RESULTS
ULTRASONOGRAPHY

IMPRESSION: Twin Male Intrauterine Pregnancy in

transverse lie, dichorionic-diamniotic, 39 weeks AOG,
both 3.2 kg by sonography, appropriate for gestational
age, Adequate amniotic fluid, Placentas located
posteriorly, Noted active fetal movements with FHT 146
and 148 respectively, No nuchal cord at the time of
examination.
LAB/DIAGNOSTIC RESULTS
Physicians’ Orders
 PRE-OPERATIVE ORDERS
October Please admit px to our OB-GYN Unit, under my
18, 2021
9am service
Secure consent for admission, operation, and
management
For Elective Cesarean Section today 5pm
Instruct NPO
Hook IVF: D5 LR 1L x 20gtts/min on the right arm
Attach all lab results done as OPD
Refer to Dr. EC for Anesthesiology service
Refer to Dr. DSM for Pediatric service
Administer Cefuroxime (Zegen) 1.5g IV as loading
dose ANST
 PRE-OPERATIVE ORDERS
October Inform OR and confirm schedule
18, 2021
9am Follow up business clearance
Monitor maternal VS q4 and record
Monitor FHT q2 and record
Quantitative I and O please, and record
Refer Accordingly
 POST-OPERATIVE ORDERS
October Transfer patient to PACU
18, 2021
8:45pm Hook to cardiac monitor for close monitoring
Maintain on NPO
Regulate present IVF at 120cc/h
IVF to follow:
• PO1 D5L5 1L + 10 units oxytocin x 120cc/h
• PO2 D5 LR 1l x 120 cc/h
• PO3 D5 LR 1L x 120cc/h to consume
Flat on bed for 8 hours until 4:45am
Quantitative I and O q1 and record
Monitor VS q15 until stable, then q1 there after
until ward transfer
 POST-OPERATIVE ORDERS
October Administer:
18, 2021
8:45pm • Metoclopramide (Plasil) 10mg IV q8 PRN for
Nausea/Vomiting
• Tramadol (Tramal) 50mg SIVP q8 PRN for pain
• Diphenhydramine (Soniphen) 50mg deep IM
prn for pruritus
Watch out for profuse vaginal bleeding
Refer Accordingly
 WARD ORDERS
October Noted (+) flatus, (-) profuse bleeding
19, 2021
6am May have soft diet
IVF to consume
IV meds to consume
May remove foley catheter at 10am
May ambulate with care
Start Oral Medications:
• Cefuroxime (Zegen) 500mg/tab, 1 tab po BID-PC
• Mefenamic Acid (Revalan) 500mg/tab, 1 tab po
TID-PC
• Ferrous Sulate with Vit.B + Folic acid (Hemarate
FA) tab, 1 tab po OD-AC
 WARD ORDERS
October May have DAT if with (+) BM
19, 2021
6am
May apply abdominal binder
For change of dressing tomorrow, please prepare
dressing kit with transparent dressing
Refer accordingly
 MGH ORDERS
October MGH Today
20, 2021
6am
Continue oral medications at home until check up
Increase oral fluid intake
Full body bath daily
Perineal hygeine TID using FEMCARE wash
Daily wound care with hydrogen peroxide and
betadine
Follow up check up on October 26, 2021- Tuesday,
at Our Lady of Peña Francia Medical Clinic, 9am
Nurses’ Notes
 NURSES’ NOTES
10-19-21 6am-6pm
6am: Received px on bed with on-going IVF of PO2 D5LR 1Lx
120cc/h on the right hand, at 900ml level , infusing well
• Awake
• Afebrile
Px verbalized: “masakit ang tahi ko”, NPS 6/10
• (+) facial grimace
• (+) guarding behavoir
With post-op site dressing noted as dry, clean, and intact
VS noted as :
• BP: 120/70 mmhg
• HR: 90 bpm
• RR: 20cpm
• T: 37 c
 NURSES’ NOTES
10-19-21 6am-6pm
On soft diet instructed
7am: Administered Mefenamic Acid (Revalan) 500mg/tab, 1 tab
po
• Positioned the patient on semi-fowlers
• Provided resting periods for comfort and relaxation
• Encouraged deep breathing excercises
9am:patient verbalized decreased in post-op site pain
• Administered Cefurozime (Zegen) 500mg/tab, 1 tab po
10am: patient reported relief of pain
FC removed aseptically, (+) spontaneous voiding
11am: Administered FeSO4+Vit.B+FA (Hemarate FA) tab, 1 tab
po AC
1pm: seen and examined by Dr. JAV with COD done aseptically
 NURSES’ NOTES
10-19-21 6am-6pm
4pm: IVF consumed and IV line removed aseptically
I and O taken and recorded
All needs attended
AP updated accordingly
6pm: Endorsed px to next NOD

Mark Ryan Pimentel, RN

Lic. No: 0955751
Discharge Details
 DISCHARGE DETAILS

Date of Discharge: 10-20-21 Time: 10AM

Physicians: DR. JAV (OB-PERINAT)
DR. EC (ANESTH)
Final Diagnosis: G1P2 (2002) Twin Dichorionic-
Diamniotic Pregnancy, 39 weeks AOG delivered via
Low Segment Cesarean Section to live term baby
boys, BW 3.2kg and 3.1kg respectively, AS 8,9 and
8,9 .
 

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