DATE DOCTOR’S ORDER RATIONALE

NOVEMBER  Please admit to > Admitting patient

09,2017 surgical ward will ensure continuity
of care

> for legality of care

 Secure consent to
and ethical right an
care
individual has to
decide what is done to
his or her body

> to monitor any

 TPR every 4 hours
changes in vital signs
that may be related to
patient’s conditions

> Doctors were not

sure whether the
 Low Fat Diet gallstones are either
cholesterol or pigment
stones. Thus, this is
done to prevent any
further damage to the
gallbladder.

51
 Start venoclysis >to replace insensible
with PLR iiL at loss of fluids in the
20gtts per minute body and to prevent
electrolyte imbalance

>to be able to keep

 Labs: Please
record of the status of
attach all labs
the patient Jaun.
from outside

>Cefuroxime is an
 Medications:
antibacterial that is
1. Cefuroxime ordered by the doctor
750mg IVTT every 8 because patient’s pus
hours ANST cells in urinalysis
result is 3-6, and may
be used as a
prophylaxis for
further infection.

>Treating short-term
spasms of the gall
bladder and
abdominal spasm.
Since patient is have
2. Hyosine 10mg an inflamed gall
IVTT every 8 hours bladder it is important
PRN for abdominal to decrease the pain to
pain prevent discomfort

52
 >to monitor if patient
is properly hydrated
 Intake and Output
or not since patient
every shift
has a condition it is
important to keep him
hydrated

>They determine
which treatment
 Vital signs every 4 protocols to follow,
hours provide critical
information needed to
make life-saving
decisions, and confirm
feedback on
treatments performed

 Dr. Perez inform

>informing the
of this admission,
Physician assigned for
please refer SOC
a specific patient will
on daily
be essential to
medications
continuity of care

> In order for the

 Refer accordingly patient to be assessed
and evaluated
properly and be

53
 managed accordingly.

Helps to managed
accordingly.

November 10,  Continue > For the patient to

2017 medications complete the
medication regimen
and for continuity of
care

> patient is still for

 IVF to follow PLR
surgery so it is
iL at 20gtts/min
important to keep him
hydrated.

 Advised patient >for further

instructions and for
understandings of
what to be done
during the span of
care

 Refer
>for continuity of care

54
 NPO

>patient vomited once

during that day, to
decrease risk for
aspiration patient is
placed on NPO

>For the liver to

 Vitamin K i amp
activate clotting
every 8 hours
factors such as
prothrombin,
proconvertin,
thromboplasstin, and
stuart factor. Vitamin
K deficiency is very
common on patients
who have a condition
that causes the body
to not absorb fat
properly.

>Cardiopulmonary
clearance prior to
performing surgeryis
 TCU CP clearance
important to avoid
complications during
surgery as a result of
an

Underlying
cardiopulmonary

55
 condition.

November 11,  Follow up all labs >results are needed

2017 and CT scan and it was not yet
endorsed to the
nurses

November 12,  Ranitidine 1amp >patient was

2017 IVTT every 8 hours temporarily placed in
NPO diet which
causes an increase
secretions of gastric
acids, and may lead to
ulcerations, and
Ranitidine is an anti
ulcerant that helps on
prevention of ulcer

>Normal Saline is a
 IVFTF: PNSS iL at sterile, nonpyrogenic
10 gtts/min solution for fluid and
electrolyte
replenishment Used
because it has little to
no effect on the
tissues and Make the
person feel hydrated
preventing
hypovolemic shock or
hypotension

56
 > this imaging study is
very essential to
diagnosing and
treating patient’s
condition

 Still for CT scan of

upper abdomen > for continuity of care
with plain and
contrast

 refer

November  Still for CT scan of >this imaging study is

13,2017 upper abdomen very essential to
with contrast diagnosing and
treating patient

>an order of continue

 Continue
medications was
medications
written with no orders
of any

 IVFTF: PNSS iL at >Normal Saline is a

same rate sterile, non pyrogenic
solution for fluid and
electrolyte

57
 replenishment Used
because it has little to
no effect on the
tissues and Make the
person feel hydrated
preventing
hypovolemic shock or
hypotension

>For continuity of care

 Refer

>Vitamin K is shifted
 Shift Vitamin K to
every 12 hours since
every 12 hours
patient has a
significant
improvement towards
his hemoglobin and
hematocrit level.

>A serum albumin

 For serum test can tell your

albumin test doctor how well your

liver is working.

>along with its derived

measures of

 Repeat protime prothrombin ratio (PR)

and international
normalized ratio

58
 (INR)—are assays
evaluating the
extrinsic pathway of
coagulation. This test
is also called "ProTime
INR" and "PT/INR".
They are used to
determine the clotting
tendency of blood, in
the measure of
warfarin dosage, liver
damage, and vitamin
K status. PT measures
factors I (Fibrinogen),
II (Prothrombin), V
(Proaccelerin), VII
(Proconvertin), and X
(Stuart–Prower
Factor). It is used in
conjunction with the
activated partial
thromboplastin time
(aPTT) which
measures the intrinsic
pathway and common
pathway.

 Medically cleared >Medical clearance is

may go ahead very important to
with planned ensure that patient is
surgical procedure capable on going unto
surgery to prevent any

59
 complications

November 14,  Continue >For the patient to

2017 medications complete the
medication regimen
and for continuity of
care

>Normal Saline is a
sterile, nonpyrogenic
solution for fluid and
electrolyte
 IVFTF PNSS iL at
replenishment Used
same rate
because it has little to
no effect on the
tissues and Make the
person feel hydrated
preventing
hypovolemic shock or
hypotension

> this imaging study is

 Waiting for official very essential to
CT Scan result diagnosing and
treating patient’s
condition

>alkaline phosphatase
level test (ALP test)

 For serum measures the amount

alkaline of alkaline
phosphatase enzyme

60
 phosphate test in your bloodstream.
Abnormal levels of
ALP in your blood
most often indicate a
problem with your
liver, gallbladder, or
bones.

 For open > was to surgically

cholecystectomy remove the
on Friday gallbladder with a
November 17, larger incision
2017 8 am

 Secure signed
>Patient has the right
consent
to be consented in all
procedures to be done,
and for legal
purposes. Anesthesia
clearance is for the
patient to be
evaluated whether
he/she is fit to
undergo the operation

>For the OR to know

that such case will be
 Identify OR performed and to
prepare the necessary

61
 instruments and
room. This is also to
coordinate availability
of staff and surgeon

>For the liver to

activate clotting
factors such as
 Vitamin K I prothrombin,
ampule IV every 8 proconvertin,
hours X3 doses thromboplasstin, and
stuart factor. Vitamin
K deficiency is very
common on patients
who have a condition
that causes the body
to not absorb fat
properly.

November 15,  Continue >For the patient to

2017 medications complete the
medication regimen
and for continuity of
care

>including date of
 For OR on Friday
surgery on the doctors
order is very essential
on identifying on when

62
 to start the
preparation.

>Normal Saline is a
 IVFTF: PNSS iL at
sterile, nonpyrogenic
same rate for 2
solution for fluid and
cycles
electrolyte
replenishment Used
because it has little to
no effect on the
tissues and Make the
person feel hydrated
preventing
hypovolemic shock or
hypotension

>the physician must

 Follow up labs
review all test results
for more additional
treatment.

>In order for the

patient to be assessed
 refer and evaluated
properly and be
managed accordingly.

November 16,  NPO Post- >NPO is to prevent

2017 midnight peristalsis, aspiration
and injury during

63
 surgery

>an order of continue

 Continue
medications was
medications
written with no orders
of any

 Dr J. Molina >For the OR to know

informed that such case will be
performed and to
prepare the necessary
instruments and
room. This is also to
coordinate availability
of staff and surgeon

 For Ex Lap if >to open the abdomen

possible FNAB of by a surgical
pancreas procedure and the
abdominal organs of
the patient will be
examined for injury or
disease.

 Dr. Rachel Alegata > to coordinate

Informed availability of the

surgeon

64
  Please prepare the >It is used to help
following: drain the blood or
fluid
- Thoracostomy
tube Fr. 16 #1

 - Jackson > to use as a post-

Pratt Drain #1 operative drain for
collecting bodily fluids
from surgical sites.

 Pls. prepare the ff.

>proper screening and
- 10 cc syringe crossmatching is
with G. 25 important before
needle. administering blood to
prevent any negative
reactions.

 Secure ii units
>proper screening
of whole blood
and crossmatching is
properly
important before
screened and
administering blood to
cross matched
prevent any negative
of patient
reactions.
specific blood
type for possible
OR use

November 17,  For PACU >for recovery. To let

2017 the vital signs, such
as blood pressure,

65
 heart rate, or
respiratory rate on
stable state.

>to let the patient in

 Moderate high comfortable position
back rest position and to prevent
aspiration because
.
there is increase in
secretions.

November 18,  Run 200cc to >to prevent electrolyte

2017 current IVF, then imbalances
report
>to determine the
 BP after effects of the
intervention.

> This particular diet

 DAT
is only giver when
 Remove FBC client can now
tolerate any food she
desires that is
nutritious

 Hold nalbuphene > may cause very bad

and sometimes deadly
breathing problems.
 Start Tramadol
>this will help the
drip as ordered x
client to reduce the
2 cycles then shift
pain he felt especially
to TDL plus 1 tab

66
 TID at the surgical area.

 D/c Tranexamic >shifted to Vitamin K

acid and shift to because patient with
Vit. K Vit. K deficiency is
very common on
patients who have a
condition that causes
the body to not absorb
fat properly.

 IVF to follow with

>to replace insensible
D5LR ii at 20
loss of fluids in the
gtts/min
body and to prevent
electrolyte imbalance

 Refer to IM on call >proper screening

per evaluation and and crossmatching is
management important before
administering blood to
 Please transfuse i
prevent any negative
unit of blood of
reactions.
patient blood type
properly screened
and crossmatched

 TCU ECG 12
leads ,

November 19,  Please follow up >to get the results

2017 result

 Continue
>an order of continue
medications
medications was

67
 written with no orders
of any

 IVFTF D5LR i L
with SR >Hypertonic
Nonpyrogen ic,
 Pharmine 1
parenteral fluid,
bottle to run in 12
electrolyte and
hours OD
nutrient replenisher.
 Refer

November 20,  Continue >an order of continue

2017 medications medications was
written with no orders

of any
 Dr. Molina
updated of
patients status

>Hypertonic
Nonpyrogen ic,
 IVFTF: D5LR IL at
parenteral fluid,
SR
electrolyte and
nutrient replenisher.

 For repeat CBC >used to evaluate your

with PC, SGPT, Alk overall health and
Phos and B1/ B2 detect a wide range of
on Wednesday disorders

68
 Revise pain >also used for
medications : management of pain

- TDL plus 1 tab >also used as an

TID analgesic for severe
pain
- Ketorolac 1
> is used to treat pain
amp Q&H PRN
or inflammation
for severe pain
- Celecoxib 200 >Piptaz has has
mg tab 1 tab antibiotic activity
BID against an extremely
 To give 2 broad spectrum of
more doses gram-positive
of Piptaz
Cefixime is used to
and shift to
treat many different
Cefixime
types of infections
200mg cap,
caused by bacteria.
1 cap BID if
okay with IM

 Liverprime >contains a silybin-

tab, 1 tab phosphatidylcholine
OD if okay complex which helps
with IM protect the liver by
conserving
glutathione in the
cells (silybin) while
helping in the repair
and replacement of
cell membranes

69
 (phosphatidylcholine.

 Heraclene > is quite a popular

Forte tab , 1 supplement which is
tab OD used in the treatment
of variety of health
issues.
 Appebon
>for proper
with Iron
interventions
tab, 1 ab
BID

 Dr. Molina >to have a proper

gave done evaluation and to be
orders ordered for a more
 Refer to IM
> In order for the
to include in
patient to be assessed
doing
and evaluated
rounds
properly and be
 Refer
managed accordingly.
accordingly

 Metronidazole 500 >it is an antibiotic

mg IV q 8 hours used to kill bacteria.

 May give > is the superior

Liverprime BID option to help get rid
of fatty liver
 Anti HCV
determination > is used to find out if
someone has ever

70
 been infected
with Hepatitis C.

> used to treat a wide

 Last day, Piptazo
variety of bacterial
today,
infections
 Start Cefixime
tomorrow a.m.
>anti-hypertensive
 Losartan 50 mg, ii
drug used to lower
tab OD
down the blood
pressure.

November 21,  For repeat CBC > used to evaluate

2017 today your overall health
and detect a wide
range of disorders

 Change wound
>to prevent the wound
dressing
from having
microorganisms and
infections

 To strengthen the
 Encourage to sit
abdomen and
up on bed
prevent from blood
 Update Dr. Molina clots

 Continue >to let the surgeon

71
 Medications aware about the
progress of the
patient’s condition.

 Advise with
present >for continuation of

management pharmacological
management.

-increased
Sylimarin > is the superior

(Liverprime) 1 cap option to help get rid

TID of fatty liver

November 22,  IVFTF with D5LR >to prevent electrolyte

2017 IL at KVO imbalances

 Continue >for continuation of

medications pharmacological
management.

> to remove and

 D/c IVF
terminate the IVF
 MGH asceptically

 Patient advised >patient may go home

 For referral for >patient will be

surgical reffered to CUMC to
endoscopy at have a surgical
CUMC procedure endoscopy

 For follow up with >to determine the

72
 Dr. J. Molina at progress of the
her clinic in Bethel patients health
Hospital status.

 Meds:

- Cefixime > used to treat many

200mg cap BID different types of
x 5 doses infections caused by
bacteria.

> used as an analgesic

- TDL plus 1 tab
for severe pain
TID PO PRN
for pain

73