IX.

Medical and Surgical Management

DATE AND TIME DOCTOR’S ORDER RATIONALE
Please admit Provides timely and comprehensive
medical evaluation and intervention,
maximizing recovery chances and
minimizing complications.
Secure Consent Ensures patient autonomy and
understanding of medical procedures,
promoting ethical healthcare delivery.
TPR q shift Monitors patient's temperature, pulse,
and respiration regularly to detect any
changes in their physiological status.
NPO Prevents aspiration of gastric contents
04/26/2024 during labor, reducing the risk of
7:50 AM complications such as aspiration
pneumonia.
IVF D5LR 1L + 10units Provides intravenous fluid support to
Oxytocin at 30gtts/min maintain hydration and electrolyte
balance during labor and delivery and to
keep the uterus well contracted.
FHT every hour To assess fetal well-being and detect any
signs of distress.
Refer accordingly Ensures appropriate specialist
consultation or transfer to a higher level
of care as needed for optimal
management of the patient's condition.
POSTPARTUM ORDERS
To ward Indicates the location where the patient
will be admitted for ongoing monitoring
and care.
V/S q15 until stable Monitors vital signs every 15 minutes
until the patient's condition stabilizes to
detect any changes promptly.
DAT Indicating the patient can resume oral
12:04 PM intake based on their tolerance and
clinical status.
IVF + 10units Oxytocin at To prevent postpartum hemorrhage and
30gtts/min then to consume promote uterine contractions, followed
by oral intake.
Cefuroxime 500mg BID To prevent postpartum infection and
ensure maternal health and recovery.
Mefenamic Acid 500mg Given for pain management and relief of
TID postpartum discomfort.
 Ferglobin cap OD To replenish iron stores and prevent
postpartum anemia.
Morelac BID Provided for continued nutritional
support and lactation assistance in the
postpartum period.
Senokot OD at HS Facilitates bowel movement and prevents
constipation following labor.
Lactomin Plus 1 sachet BID Supports postpartum recovery and
overall well-being, aiding in lactation and
hormonal balance.
Perineal hygiene with Maintains cleanliness and reduces the
betadine feminine wash risk of infection in the perineal area
following delivery.
Keep uterus well contracted Prevents postpartum hemorrhage by
promoting uterine contraction and
reducing the risk of excessive bleeding.
WOF signs of profuse Instructs monitoring for signs of
vaginal bleeding excessive vaginal bleeding, facilitating
early detection and intervention if
needed.
Refer accordingly Ensures appropriate follow-up care and
referral to specialists as needed,
promoting comprehensive management
and optimal postpartum recovery.
MGH Indicates that the patient's condition is
stable and meets discharge criteria,
allowing for continuation of recovery and
postpartum care in a comfortable home
environment.
Home Medications: Specifies medications for the patient to
Cefuroxime 500mg continue taking at home for ongoing
04/27/2024
Mefenamic Acid 500mg management and recovery following
12 NN
TID discharge from the hospital.
Ferglobin OD (1week)
Morelac BID
Follow-up after 2 weeks Continuous monitoring of treatment
effectiveness, medication tolerance, and
patient progress allows for timely
adjustments and continuity of care.