DOCTOR’S ORDER

DATE/TIME DOCTOR’S ORDERS RATIONALE

November 16, 2019
4:10 AM Please admit patient to labor room To be able to provide the
patient with the specific
care needed

Secure consent to care It is the right of the

patient to be consented
in all procedures to be
done

DAT, NPO once in active labor DAT- to prevent sudden

adjustment of the body
because of sudden
change of food. In a
way, to maintain the
nutritional status of the
patient.

Once in active labor the

Start venoclysis with D5LR iL @ 30
gtts/min
client cervical dilatation
ranges from 3-7 cm and
contraction will become
stronger closer together
and regular and last 45-
60 seconds. NPO was
ordered then to prevent
aspiration.
This is to avoid
dehydration since D5LR
is for fluid and electrolyte
replenishment

CBC determines the

quantity of each blood
Labs: cell, including the
CBC amount of hemoglobin,
hematocrit and the
proportions of WBC and
RBC, and thus to know
any deviations or
abnormalities in the
blood.
Blood typing
This is to know the
compatible blood for
blood transfusion if client
is needed for blood
transfusion
HBsAG
To test if the client is
nonreactive with

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 Hepatitis B, thus
ensuring compatibility for
blood transfusion
Monitor FHT and uterine contraction
q hourly To know the rate and
rhythm of fetus’
heartbeats; to monitor
the duration, interval,
frequency and intensity
of every contraction.

Vital sign monitoring q 4h

To monitor if there is
abnormal fluctuation in
the normal range of the
patient’s vital signs.
Monitor I & O q shift
Intake is the act of
consuming or taking
foods, fluids or
substances in the body.
Output is the process of
waste exiting in the
body. Monitoring intake
and output will
determine if the intake is
equal to substance
excreted by the patient’s
body, thus giving
valuable information on
the patient’s condition.
Monitoring for progress of labor
This is necessary to be
able to provide
necessary healthcare
and this will give
sufficient information to
the client’s labor
progress.
Refer accordingly
This will create
collaboration among
healthcare provider in
order to arrive
appropriate treatment.
November 17, 2019
5: 48 AM Post-partal watch To maintain continuity of
care during postpartum
period, thus optimizing
postpartum care and
establishing a patient-
centered outcomes.

IVF D5LR iL + 10 “u” oxytocin 30 This is to avoid

gtts/min x 2 cycle to change dehydration since D5LR
is for fluid and electrolyte
replenishment and

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 oxytocin to avoid
bleeding and for uterine
contraction.

DAT DAT- to prevent sudden

adjustment of the body
because of sudden
change of food. In a
way, to maintain the
nutritional status of the
patient.

Meds: This is used to treat

Cefuroxime 120 mg, 1 cap BID bacterial infections from
episiotomy causing
death of bacteria.

Mefenamic Acid 500 mg, 1 cap This is given to manage

TID postpartum pain
especially pain from
episiotomy.

FeSO4 1 cap Iron supplement to aid

iron deficiency and to
increase hemoglobin
level.

Refer accordingly This will create

6:12 AM
HgB- 8.8 g/dL To secure one unit WB patient blood
type properly screen and crossmatch
for blood transfusion
collaboration among
healthcare providers in
order to arrive
appropriate care and
treatment.
It is necessary to test for
blood type in order to
select a donor’s blood
that is compatible before
doing the crossmatch.
Crossmatching is way
for healthcare provider
to test the patient’s
blood against a donor’s
blood to make sure they
are compatible.

Pre-BT meds: This is given to aid the

Paracetamol 300 mg IVTT pyretic effects of
introducing blood to
client.

Diphenhydramine 500 mg IVTT This is primarily given

before BT to decrease
the patient’s body
response to allergens;
this medication is also
given to facilitate

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 incisions healing.

Post-BT meds: This medication is given

Furosemide 40 mg IVTT
after BT to reduce the
vascular overload that
may be imposed by the
additional volume blood
volume delivered during
blood transfusion.

Repeat CBC of 6ᵒ Post-BT (1st BT) CBC determines the

quantity of each blood
cell, including the
amount of hemoglobin,
hematocrit and the
proportions of WBC and
RBC, and thus to know
any deviations or
abnormalities in the
blood that is subject for
further evaluation.

Refer This will create

collaboration among
healthcare providers in
order to arrive
appropriate care and
treatment.
11:25 AM
140/90 mmHg Start Amlodipine 5 mg 1 tab po now Used to prevent certain
then OD types of chest pain. It
works by relaxing blood
vessels so blood can
flow more easily.
November 18, 2019 Continue on going blood transfusion Since client has low
9:40 AM hemoglobin level, the
unit of packed red blood
cells is expected to raise
circulating hemoglobin.
This will also replenish
the blood loss.

Continue medications Compliance with the

medications will avert
any complications.

IVFTF D5LR @ same rate This is to avoid

dehydration since D5LR
is for fluid and electrolyte
replenishment.

Refer This will create

collaboration among
healthcare providers in
order to arrive
appropriate care and

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 treatment.
November 19, 2019 Awaiting UA results To know if there are any
HgB-9.3 g/dL abnormalities that will be
subject for further
examinations

Continue meds Compliance with the

medications will avert
any complications

Iron supplement to aid

Increase FeSO4 1 cap BID iron deficiency and this
was increased since BT
was already ordered to
stop, increasing intake
per day will increase
hemoglobin level as
well.
November 20, 2019 MGH No longer need to
receive inpatient care.
May go home for easily
recovery.

Home meds: This is used to treat

Cefuroxime 500 mg x 5 days, 1 cap bacterial infections from
BID episiotomy causing
death of bacteria.

This is given to manage

Mefenamic Acid 500 mg x 5 days, 1 postpartum pain
tab especially pain from
TID episiotomy.

Iron supplement to aid

FeSO4 x 1 day, 1 tab BID iron deficiency and to
increase hemoglobin
level.

Used to prevent certain

Amlodipine 5 mg, 1 tab OD types of chest pain. It
works by relaxing blood
vessels so blood can
flow more easily.

To check and identify for

Follow up care after 1 week any changes in health
condition after 1 week of
being discharged in the
hospital.

Instructions given To provide critical

information for patient to
manage their own care

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