Republic of the Philippines

Department of Health
COTABATO REGIONAL AND MEDICAL CENTER

LAST NAME FIRST NAME SUFFIIX,IF ANY MIDDLE NAME HEALTH RECORD

Mrs. X
AGE/ SEX DATE OF BIRTH(mm/dd/yy) WARD ROOM
29 years old/ Female Delivery Room

NURSES NOTES
DATE FOCUS DATA/ACTION/RESPONSE
TIME/SHIFT

05/03/2021 Active Labor Pain Received patient lying on bed with an IVF of Plain LR 1
7-3PM Liter run at 30gtts/min., hooked at the left basilic vein,
infusing well.

Data

Subjective Data
CC of labor pain associated with muscle weakness, easy
fatigability, and depression.

Objective Data
Initial BP taken was 90/ 60 mmHg, PR=73 bpm, RR= 23
bpm, O2 sat=94%, Temp.=36.1C. FHR= 148 bpm.

Action
- Changed client’s clothes to patient’s gown.
- Vital signs taken and recorded.
- Monitored MIO q hour.
- Perineal care done.
- Encouraged to ambulate.
- Taught and demonstrated to the patient the deep
breathing, proper positioning and pushing. Encouraged to
do these.
- Encouraged verbalization of feelings and concerns.
Response
Goal achieved; after 8 hours of nursing intervention, the
patient verbalized, “Ma’am nabawasan po ang sakit na
nararamdaman ko.” Pain scale rated 6/10.

Chua, Marielle P./Prof. Evelyn Siong

NDU BSN 2 NDU CI
05/03/2021 11:00PM