DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.

COLLEGE OF NURSING

CASE LOAD – HEAD NURSING

Clinical Area: Surgical Ward Date: July 31 – August 1, 2022 Clinical Instructor: Mrs. Evelyn U. Rances, MHS, RN
Student Head Nurse: Jamie John Q. Esplanada

Room Laboratory &

Name of Patient & Admitting Date Attending Parenteral Special
Age Diet IVF Oral Medications Diagnostic
No. Chief Complaint Diagnosis Admitted Physician Medications Endorsement
Exams

516 RAAGAS, BENJAMIN Jr. —-- DAT —-- —--- ● Cefoxotin 1g

12 NN - 12 MN

● Omeprazole
40mg OD ORIF

516 ORNIDO, VIRGIE —-- 37 7/30/2022 Dr. Ampuan DAT —-- —-- —--- ● 1 unit OR
VSE
CC: anterior neck mass

520 Renal Cell

Secure 6U PRBC
Carcinoma PLR @ 30
MAITIM, GERALD 44 7/28/2022 DAT - - standby
Left gtts/min

520 SAMILLANO, JUGO LSLF PLR @ ● KCl tab 2 tabs TID x ● Paracetamol NPO post lunch
80cc/hr 4 doses - verify if 600mg IVTT
completed na q6H PRN for
fever

● Tramadol
50mg IVTT q8H
PRN for pain

521 GOMEZ, DIA MAE Cholelithiasis 15 6/22/2022 Dr. Ilagan NPO D5NSSx30 ● UCDA 250 mg PO ● Paracetamol ● Maintain high
BID (Patient 600 mg IV q 6H back rest
Stock); 8 AM - 6 x 6 doses (4/6):
● O2 inhalation at 5
PM 12 NN - 6 PM
LPM via FM
● Ketorolac 300
● Cont. IVF PLR at
mg IV q 6H x 6
 DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.
COLLEGE OF NURSING

doses (4/6): 12 30 gtts/min.

NN - 6 PM
● Cont. BT

521 GABIETA, NILDA Obstructive 54 7/22/2022 Dr. Vilches LSLF HL ● Lactulose 30cc OD ● Ceftriaxone 1g ● Low fat diet +
Jaundice HS 8PM q12H 12AM - … 6 scoops in
Secondary to 12NN ½ glass water
● Cetirizine 10mg 1
Klatskin QID
tab OD HS 8PM ● Metronidazole
Tumor
500mg IVTT ● Heplock
q8H 8AM -
● For review of
4PM - 12MN
CT scan image

● Monitor V/S q
shift

523 LUCENDA, JARED OBSTRUCTIVE 27 7/23/22 Dr. Vilches NPO HL ● Lactulose 30cc OD ● Ceftriaxone 1g ● For OR schedule
JAUNDICE HS 8PM q12H 12AM -
PLRx30 ● Secure 3U FFP,
FROM 12PM
1U PRBC for OR
CHOLEDOCHO
● Metronidazole use
LELITHIASIS
500mg IVq8H
● Mark abdominal
8AM - 4PM -
status
8PM - 4AM
● Monitor VS and
● Paracetamol
I&O.
PRN

523 LAUZON, BONIFACIO Obstructive 76 Dr. Dacuro LSLF PNSS 30 ● Lactulose 30cc OD ● Ceftriaxone 1g ● Secure 3U -
Jaundice from gtts/min HS 8PM IV q12H x 5 PRBC for OR use
Choledocholet doses
● NAC 600mg half ● LSLF diet
hiasis, R/O
glass BID x 60 ● Metronidazole
Pancreatic ● IVF:PNSS 30
doses 6PM
Mass, Hydrops ● Paracetamol gtts/min
of Gallbladder
● Tramadol ● Still for CT scan
50mg IV q8H
● Monitor V/S,
RTC 2pm-
I&O
10pm-
 DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.
COLLEGE OF NURSING

6am ● Repeat
Creatinine, CBC
● Furosemide
BUN NaCL
40mg IV post-
tomorrow 12
BT
noon

523 LERIOS, MILLROSE Obstructive 18 7/27/2022 Dr. Vilches/Dr. Low fat Diet PLR @ ● Ceftriaxone 1g S/P Open
Jaundice from Kangleon/Dr. 100cc/hr IV q12H 6AM - Cholecystectom
Choledocholit Apilado 6PM y
hiasis in Mild
● Metronidazole
Acute
50mg IV q8H
Cholangitis
10AM - 6PM -
2AM

● Paracetamol
30mg IV q6H
12PM - 6PM

● Ketorolac
30mg IV q8H
10AM - 6PM -
2AM

524 MAGALSO, NORIE Staghorn 51 7/17/2022 Dr. Blas/Dr. DAT HL @ L ● Omeprazole FBC
Calculi, Left Medina 40mg IV once
with NPO 6PM
Ureteropelvic
● Cefazolin 1g IV
Ectasia, Right
q12H 12AM -
12PM

● Gentamycin
240mg IV OD
4PM

524 LINGGAN, EDMOND AKI probably 21 Dr. Dacuro DAT PNSSx30 ● Meropenem 1g —-
from Severe IVTT q12H
Bilateral
● Ceftriaxone 1g
Hydronephrosi
IVTT q12H
s from
 DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.
COLLEGE OF NURSING

Bilateral (shifted, pls

Obstructive verify)

* ceftriaxone
shifted to
meropenem (pls
verify also)

524 CANDAZA, AIDA Hurthle cell 35 7/24/2022 Dr. Ampuan DAT HL ● Ascorbic acide ● Paracetamol Repeat ● FBC, PENROSE
carcinoma 8AM 600mg IVTT ionized
● possible
q6H - calcium
● Ferrous sulfate discharge
completed
8AM
● Daily wound
● Tramadol
● Vit. D + Calcium - care and
50mg IVTT q8H
NA mobilize
PRN for pain
● For possible RAI
● Ondansetron
therapy once
4mg IVTT q12H
confirmed on
PRN for pain
histopath result
● Tranexamic
acid 500mg IV
q8H 10am-
6pm-2am

● Cefazolin 1gm
IVTT q8H
10am-6pm-
2am

Lobby- GACILLOS, FEDERICO Incarcerated 59 7/27/2022 Dr. Ramas DAT HL —---- ● Cefoxitin 1g IV S/F OR
in Inguinal 30min
(East) Hernia
● Paracetamol
60g IV q 6 hrs
PRN for pain

Lobby- DE PAZ, AILEEN Acute 28 7/28/22 NPO D5LRx30 ● Cefoxitin 1 gm S/F “E” AP
in Appendicitis IV q 8H ANST
(East) (-): 10 AM - 6
 DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.
COLLEGE OF NURSING

PM

● Metronidazole
500 g IV q 8H
ANST (-): 10 AM
- 6 PM

● Paracetamol
300 mg IV q 4H
PRN for T: >38
degrees celcius

Lobby- CALIPAYAN, RODOLFO Indirect 67 7/01/22 DR. Espania NPO post- D5LR 1L @ ● Transulosin 1tab ● Cefazolin - -Still NPO
in Inguenal MN 30gtts/min OD 8PM 1gm IVTT
For OR
(West) Hernia ®, 30 mind
Incarcerated, PTOR CBG TID while on
t/c testicular NPO
● OMEPRAZ
mass
OLE g 30
mins prior
to OR

Lobby- CERBO, PERLITH Obstructive 53 7/19/2022 Dr. Vilches LSLF DM HL ● Vit. K 8am- ● For CT Scan ● Secure 3U PRBC
in Jaundice 4pm-12am WAB 3C for OR use
(West) Probably from done 7/26
● Iron Sucrose ● CBG BID
Periampullary
2 amp 12 nn ● S/F HbAC
Mass ● LSLF Computed
diabetic diet

ON HOLD ● Heplock

● Pls carry out IM-

endo order

● May sit-up on
bed

● Monitor V/S
 DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.
COLLEGE OF NURSING

Lobby- DAMAYO, CRISTITA Acute 69 7/12/22 DR. Pontica DAT with IJ: HL HOME MEDS: May go home cardio
in abdominal SAP wise
Clopidogrel 75 mg 1 Nebulazation:
(West) pain from
tab OD 8 am - for 2decho
performed 1. Salbutam
as OPD
peptic ulcer Trimitazidine 35 mg 1 ol +
disease type tab Bid 8am - 6pm Ipatriptan
III; q8hrs
Pneumoperito Atorvastatin 40g 1 tab (Mayda ine orange
4pm -
neum from OD na paper antibiotic
12mm -
ruptured restriction Iya chart
ISDN 5g SL as needed 8am
abscess Kay lampas na 7
for chest pain
days it Iya piptaz)

Lobby- VENTURA, CRISTITA HL ● Paracetamol ● progress diet

out 600mg IVTT to soft diet
q6H x 8 doses
● follow-up
8AM - 8PM
official biopsy
● Omeprazole result
40mg IVTT OD
● to consume
6PM
cefuroxime for
● Ketorolac 10 days
30mg IVTT q8H
● daily wound
x 3 doses
dressing
10AM - 6PM -
2PM ● IFC removed
(07/31/2022)

Lobby- GINAY, CONCHITA Choledocholit 70 NPO PLR 1L at 100 ● Beneprotein 2 ● Omeprazole ● rpt CDC, plt ● CBG q6H
out hiasis cc/hr scoops ½ glass OD 40mg IV OD STAT
● JP
6AM
● Lactulose 30 cc ● Na, K, Cl,
● Inserted NGT
now then OD HS ● Cefoxolin 1g Crea STAT
q8H 8AM - ● start Lactulose
● ABG
4PM - 12AM 30cc OD HS
● CXr AP view
● Diphenhydrami ● Paracetamol
ne 8PM
 DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.
COLLEGE OF NURSING

● Ceftriaxone STAT 300 mg IV q 4H

q12H 8AM - PRN for temp
● For UTZ of
8PM >38C
HBT STAT
● Human (Note for ● monitor V/S
Albumin 2% x 4 dilated and I&O q
doses q12H intrahepatic) 2hours
4PM - 4 AM
● for close watch
● Paracetamol
30mg IV q4H
PRN for
T=>38C

Lobby- TORRE, CLARO Indirect 37 7/25/2022 NPO post- HL ● Cefuroxime FBC

out Inguinal lunch (v/o 750 mg IV
Hernia, Right resume q8hrs
Incarcerated diet)
● Metronidazol
e 500mg IV
8hrs

12PM-8PM-4AM

● Tramadol
50mg q8
8PM-4AM-
12NN