NURSES NOTES

Name: Rhiza Noel Age: _23_______________ Attending Physician: Dr. Seboa

Sex: F _Civil Status: Single Room No. /Bed No. ______________________ Hospital No. ______________________
Date Shift Focus Time D = Date / A = Action / R = Response
2/22/2020 Receiving assessment 12:53am D: Received patient lying on bed from delivery room, awake,
conscious with facial grimace; patient was on active labor, thus
as ordered on NPO with ongoing IVF: D5LR 1L @30 gtts/min.
infused well @ left arm, with receiving V/S of: BP-
110/70mmHg, HR: 85 bpm, RR: 19 cpm, Temp: 36.8 O2Sat: 98%,
Weight: 117 lbs.
A: Established rapport, monitored patient’s progress of labor
and UC and FHT q15, V/S q hourly. Labs taken as follows: CBC,
U/A, HGT and Anti SARS COV 2 test
R: Referred Accordingly
4:30 am D: V/S taken as follows: BP: 110/60 mmHg, HR: 87 bpm, RR: 21
cpm, O2Sat: 99%
A: incorporated 6 units’ oxytocin @remaining IVF then regulated
@ 10 gtts/min. titrated accordingly.
6:45 am A: Infused Hyoscine-n-butyl bromide 1 amp 2cc sterile water,
STAT
R: referred accordingly
Post-operative care/ follow-up 9:30 am D: Patient was on DAT and flat on bed for 2 hours awake with
restlessness, worry evident on the face and started to voice
concern. “I am very much concern of the well-being of my baby”
as verbalized by the patient.
A: Established a trusting relationship with patient using touch
(with permission), presence and demeanor. Provided patient
with reassurance and comfort measures. Encouraged patient to
relax by doing relaxation techniques, such as deep breathing.
R: Patient was able to relax and feel comfortable verbalizing
understanding. “I can now rest knowing my baby is in good
hands” as stated by the patient.
9:45 am A: infused 14 units of oxytocin to present IVF, run 200 cc MFD,
then regulated @ 30 gtts/min. Du meds were given as
prescribed
Breastfeeding Education A: Encouraged patient breastfeeding, demonstrated the process
of it and informed patient healthy effects of breastfeeding of
both client and baby.
R: Patient was able to understand importance of breast feeding.
“I will breastfeed my baby, so that she can have all the nutrients
she can get and I can be closer to her” as verbalized by the
patient.
Pre-transfer assessment 10:45 D: Patient vital signs are stable, taken as follows: BP: 122/70
am mmHg, HR: 72 bpm, RR: 20 cpm, )02Sat: 99%. Patient is
scheduled transfer for ward. 2 hrs. post-NSVD
A: Informed patient about transfer, as ordered. Instructed to
take meds on time as prescribed and educated effects of
medications to know when to refer immediately to physician.
Advised patient to relax and get enough sleep.
R: Patient expressed enough knowledge and understanding from
education discussed. Patient was able to relax and got enough
sleep before transfer.
End of shift 11:00am Endorsed patient to the next nurse in duty, with ongoing IVF:
D5LR 1L @30 gtts/min. plus 14 units oxytocin to run, 200 cc
MFD @30 gtts/min.
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