Allena, Camille Marie A.

NCM 33 – B1

Perineal Care, Hot Sitz Bath, Heat Lamp Treatment Documentation

Date and Time Focus Progress Note

08/30/2021 Increased odorless vaginal D: Patient is 36 weeks
discharge pregnant, primigravidarum
15:00 and complained of increased
odorless vaginal discharge
that is clear and milky in
color,.

A: Performed Perineal Care

to remove perineal
secretions.
15:15
R: Patient verbalized “I am
comfortable now.” -------------
----------------------- C.Allena,SN

08/30/2021 Difficulty in defecating due to D: Patient is 36 weeks

hemorrhoids pregnant, primigravidarum.
15:00 Complained of difficulty in
defecating due to
hemorrhoids, defecated once
brownish formed stool about
10 mg,

A: Performed Hot Sitz Bath to

encourage normal voiding
and Heat Lamp Treatment to
reduce swelling due to
hemorrhoids.
15:45
R: Patient stated that the
swelling has minimized and
verbalized “I feel so
relieved.” . ------------------------
---------------------C. Allena, SN
 Cord Care Documentation

Date and TIme Focus Progress Note

08/30/2021 Newborn Cord Care D: Full-term newborn
weighing 3,500 gm at birth.
16:00 Umbilical stump is dry and no
presence of foul odor.

A: Performed cord care with

70% solution alcohol to
facilitate the healing and
prevent infection of the cord
stump.

16:15 R: Baby exhibit no signs of

discomfort. -----------------------
---------------------C.Allena, SN