DELIVERY

Date/Time Focus Data, Action, and Response

09-20-2021 From OB ward to LR D- Into DR, a 33-year-old, G2P0 from ER per wheelchair accompanied
by IVF of D5LRS at 500 cc level, oxytocin at 10 units/mL level
8:46 PM infusing at metacarpal, basilic, cephalic vein.

D- Scheduled NSD by Dr. Soriano, placed at DR table in supine

Pre-labor Preparation position
A-Assisted in repositioning into lithotomy position; draped properly;
A-IFC inserted aseptically; initial count of sponges, needles, and
instruments done

D- With full cervical dilation and continues uterine to contractions

occurring every two to three minutes and a duration of 60-90 seconds
A-Effective breathing pattern
9:11 PM Delivery of the baby
A-Provide praise and encouragement

D- Betadine swabbed; brought to PACU per stretcher via stretcher with

D5LRS at 500 cc level
A-Monitor vital signs; check the level of consciousness; check if there
Delivery ended are any bleedings
10:01 PM

D- “Sumasakit yung tahi paminsan-minsan” as verbalized by the

patient; with pain scale of 7/10; BP of 120/70, pulse 82 b/min., T-
09-21-2021 37.30C; restless, guarding behavior over incision site, facial grimace,
1:03 PM Pain related to postpartum profuse sweating, pale looking
NSD
A-Incision site checked with no foul smell and no discharges; wound
dressing intact and dry; repositioned to semi-Fowlers position;
encouraged and demonstrated relaxation techniques such as deep
breathing; encouraged to sleep and rest

1:15 PM R: Expressed alleviation of pain from scale of 7 to 3; comfortably fell

asleep as verbalized by the patient; BP of 120/80, pulse 78 bpm, T of
37C.

4:00 PM

Evangelista, Queenie Ellise D.

UC-CON BSN IIB- GROUP B