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Nurses Notes Case 10

Rheena Velasquez, a 32-year-old married woman, was admitted to the hospital for labor and delivery. Upon receiving the patient, the nurse noted she was awake, conscious, and in active labor. Vital signs and intravenous fluids were administered and the patient's progress was monitored. To manage the patient's pain rated at 9/10, pain medication was given and relaxation techniques were used. The patient's pain reduced to an 8/10 but was manageable. The nurse also provided breastfeeding education to the patient, who understood the importance and benefits of breastfeeding her baby. At the end of the shift the patient's vitals were taken and she was endorsed to the next

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JERRYMAE RIVERA
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632 views4 pages

Nurses Notes Case 10

Rheena Velasquez, a 32-year-old married woman, was admitted to the hospital for labor and delivery. Upon receiving the patient, the nurse noted she was awake, conscious, and in active labor. Vital signs and intravenous fluids were administered and the patient's progress was monitored. To manage the patient's pain rated at 9/10, pain medication was given and relaxation techniques were used. The patient's pain reduced to an 8/10 but was manageable. The nurse also provided breastfeeding education to the patient, who understood the importance and benefits of breastfeeding her baby. At the end of the shift the patient's vitals were taken and she was endorsed to the next

Uploaded by

JERRYMAE RIVERA
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd

NURSES NOTES

Name: Rheena Velasquez Age: _32______________ Attending Physician: Dr. Rosales


Sex: F _Civil Status: Married Room No. /Bed No. ______________________ Hospital No. ______________________
Date Shift Focus Time D = Date / A = Action / R = Response
7/10/2020 Receiving assessment 5:00am 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- 90/60mmHg,
HR: 96 bpm, RR: 18 cpm, Temp: 36.7 O2Sat: 98%, Weight: 60kg.
A: Established rapport, and admitted patient under service with
Admission secured consent for care. Administered Ampicillin 2 grams IVTT,
TPR q4h, I&O monitored and charted. Monitored patient’s
progress of labor, UC and FHT q15. Informed Dr. Rosales of
admission.
R: Patient was referred accordingly
Labor Pain D: Patient lying on bed with grimace of pain evident in the face,
restlessness. “I am in so much pain!” as verbalized by the patient
with a pain scale of 9/10( where 10 is the highest and 1 is the
lowest)
A: Administered Mefenamic acid 500mg/tab PO, as ordered.
Assisted patient in relaxing techniques to ease pain, such as
deep breathing. Allowed patient do comfortable position and
used therapeutic touch like massage to ease pain.
R: Patient appear relaxed/resting between contraction with a
pain score of 8/10 but manageable. “There is still pain but it is
now bearable” as verbalized by the patient.
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.
End of shift 10:00 Endorsed patient to the next nurse on duty, with ongoing IVF:
pm D5LR 1L @30 gtts/min. infused well @ left arm, with V/S taken
as follows: BP- 100/60mmHg, HR: 75bpm, RR: 20 cpm, Temp:
36.2, O2Sat: 98%
DOH-SWUMed-NSD-F-004 Rev. 1

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