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Patient M.Y., 35/F, was admitted to Female Maternity Ward with a diagnosis of G2P1 (1001) PU 14 weeks AOG, Hyperemesis Gravidarum. Nurse Ria was assigned
Patient M.Y., 35/F, was admitted to Female Maternity Ward with a diagnosis of G2P1 (1001) PU 14 weeks AOG, Hyperemesis Gravidarum. Nurse Ria was assigned to be the morning shift nurse (6am-2pm). When she made her rounds, she received an ongoing IVF of D5 LR 1L x 8 hours. She was put on NPO because of active vomiting at 7:45am with 100ml vomitus. Metoclopramide 10 mg TIV Now then q8 was ordered and started at 8am (Stock Dose: 10 mg/2ml). At 12pm, no further vomiting was noted, and the patient was ordered to have clear liquids. She immediately took water of about 50ml and another 50 ml of water 1:30pm. Patient urinated twice: 9am=250ml, 11am= 250ml, and 1pm= 200 ml. The patient had no BM in the morning. Nurse Marie was the afternoon shift nurse (2pm-10pm). The attending physician made rounds and IVF rate was decreased to 12 hours at 2pm. The diet was shifted to soft diet at 3pm and the patient had 200 ml of Sports Drink. The patient complained of mild nausea. Metoclopramide was given as previously ordered. For dinner, she was given a 350 ml mineral water but consumed only half of it. She was also served clear soup of about 5 oz and consumed it. Vitamin B Complex tablet, 1 tablet OD was started and she took it with 1 oz. mango juice. She urinated 3x: 250ml at 4:30pm, 300ml at 8pm, and 250ml at 10pm. Patient had one- time, solid BM after dinner. Nurse Anne was the night-shift nurse (10pm-6am). IVF rate was decreased to 16hours at the start of the shift. Metoclopramide was given as previously ordered. She took 4oz of juice at 11pm. She had 3x urination: 200ml at 12am, 250ml at 2:30am, 300 ml at 6am. She woke up early and requested for a milk. She was given Soz. but consumed only % of it. She had no BM, nor vomiting episode the entire night shift.
Complete the table below. | ||||||||||
SHIFT | INTAKE | OUTPUT | ||||||||
Oral | IVF | IVmeds | Others | Total | Urine | Stool | Vomitus | Othen | Total | |
6-2pm | ||||||||||
2-10 pm | ||||||||||
10-6 am | ||||||||||
TOTAL |
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