FOCUS CHARTING

DATE TIME FOCUS NURSE’S REMARKS

D>She is is Gravid 2, Para
11/30/2020 8 AM Labor Pain 1.

-She presented with uterine

contractions coming every
4 minutes apart and
increasing intensity

-39 weeks gestation as per

ultrasound

- On vaginal examination,
cervix is 90% effaced and
8cm dilated.

“Pain started an hour ago

with feeble intensity
contractions. which have
increased in frequency and
intensity in last half an
hour” as verbalized by the
patient.

A> ongoing IVF of D5LR to

run @20gtts/min hooked at
right metacarpal vein.

Evaluated degree of
discomfort through verbal
and non-verbal cue

-Provided use of comfort

measures such as back
and leg rubs, sacral
pressure, and hot
compress to perineum.

-Coached use of
appropriate breathing
relaxation technique.
-Recommended client to
void every 1-2hours

-Provided a quiet
environment that is
adequately ventilated,
dimly lit, and free of
unnecessary personnel.

-Offered encouragement,
provide positive
reinforcement for client
effort.

-Recorded time and the

frequency intensity, and
duration of uterine
contractile pattern

-Provided safety measure

and raise side rails.

-Administered medication
as ordered Mefenamic Acid
500mg 1 cap TID and
Cefalexin 500mg 1 cap TID

-Monitored maternal vital

sign and fetal heart rate.

-Assisted client in
assuming optimal position
for bearing down.
- comfort measures
provided
-All needs attended

R> Normal labor and

delivered a healthy single
baby boy with Apgar score
of 8 at birth and 9 Apgar
score at 5 minutes
 SOAPIE CHARTING
DATE/TIME DIET/TREATMENT NURSE’S REMARK’S
11/30/2020 Admitted this female patient 32 yr.
8 AM old under the service of Dr. Jacobs.
She is Gravid 2, Para 1 and her
previous pregnancy was
uncomplicated.

Received patient lying on bed awake

with ongoing ivf of D5LR to run
@20gtts/min hooked at right
metacarpal vein; Infusing well.

S- “Pain started an hour ago with

feeble intensity contractions which
have increased in frequency and
intensity in last half an hour” as
verbalized by the patient.

O- Vaginal examination, cervix is

90% effaced and 8cm dilated

A- Labor pain related to uterine

contraction as manifested by facial
grimaced.

P- At the end of my shift, the patient

will have a normal labor and will
deliver a healthy baby boy the pain
reduced.

I- Evaluated degree of discomfort

through verbal and non-verbal cues
NPO
-Provided use of comfort measures
D5LR 1L such as back and leg rubs, sacral
pressure, and hot compress to
perineum.

-Coached use of appropriate

breathing relaxation technique.
 -Recommended client to void every
1-2hours

-Provided a quiet environment that is

adequately ventilated, dimly lit, and
free of unnecessary personnel.

-Offered encouragement, provide

positive reinforcement for client
effort.

-Recorded time and the frequency

intensity, and duration of uterine
contractile pattern

-Provided safety measure and raise

side rails.

-Administered medication as
ordered

-Monitored maternal vital sign and

fetal heart rate.

-Assisted client in assuming optimal

position for bearing down.
- comfort measures provided
-All needs attended

E – Goal met, normal labor,

delivered a healthy baby boy.

Endorsing

Received patient from ER

11/30/2020 with an IVF of D5LR infusing well at
9 am the right metacarpal
B.
What are your nursing responsibilities if you are assigned to this postpartum
patient?
• Providing support and information to the woman regarding episiotomy repair and
related pain-relief and self care measures.
• Applying an ice pack to the perineum to promote comfort and reduce swelling..
• Assisting with hygiene and perineal care; teaching the woman how to use the perineal
bottle after each pad change and voiding; helping the woman into a new gown.
• Monitoring for return of sensation and ability to void (if regional anesthesia was used).
• Encouraging the woman to void by ambulating to bath room, listening to running
water, or pouring warm water over the perineal area with the peribottle .
• Monitoring vital signs and fundal and lochia status every 15 minutes and documenting
them.
• Promoting comfort by offering analgesia for afterpains and warm blankets to reduce
chilling .
• Offering fluids and nourishment if desired .
• Encouraging parent–infant attachment by providing privacy for the family.
• Being knowledgeable and sensitive to typical cultural practices after birth.
• Assisting the mother to nurse, if she chooses, during the recovery period to promote
uterine firmness due to the release of oxytocin from the posterior pituitary gland, which
stimulates uterine contractions .
• Teaching the woman how to assess her fundus for firm ness periodically and to
massage it if it is boggy.
• Describing the lochia flow and normal parameters to observe for postpartum.
• Teaching safety techniques to prevent newborn abduction.
• Demonstrating the use of the portable sitz bath as a com fort measure for her
perineum if she had a laceration or an episiotomy repair .
• Explain comfort/hygiene measures and when to use them.
• Assisting with ambulation when getting out of bed for the first time.
• Providing information about the routine on the mother–baby unit or nursery for her
stay .
• Observing for signs of early parent–infant attachment: fingertip touch to palm touch to
enfolding of the infant.