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 Post-Partum Care Received patient lying on bed with an IVF of Plain LR 1
7AM Liter run at 20gtts/min., hooked at the right basilic vein,
infusing well.

Data

Subjective Data
The patient verbalized, “Sumasakit po ang private part ko
ma’am." Pain scale was 9 out of 10.

Objective Data
- Facial grimace and teary eyed were observed.

Action
- Vital signs taken and recorded.
- Perineal care done.
- Assisted client into a comfortable position.
- Encouraged to ambulate.
- Administered Mefenamic Acid as per doctor’s order.
- Assessed the patient’s general appearance.
3PM Response
Goal achieved; after 8 hours of nursing intervention, the
patient verbalized, “Medyo di na po ganun kasakit ma’am
kumpara kanina.” Pain scale was 7/10.

Chua, Marielle P./Prof. Evelyn Siong

NDU BSN 2 NDU CI
05/04/2021 1:00PM