Date / Time Focus Progress Notes

08/08/20 Ineffective Breathing Data:

10:00 AM Pattern related to  Rapid and shallow respiration
bronchospasm decrease  RR: 20 bpm – Tachypnea
lung expansion as Action:
evidenced by tachypnea  Provide emotional care
 Placed in high fowler’s position to facilitate
breathing and lung expansion.
Response:
11:00 AM Patient manifested decreasing respiratory
rate (RR: 17) and appeared less strained
and distressed upon breathing.
08/08/20 Pain related to labor Data:
11:30 am contractions as  Uterine contraction intensity: 2 to 3 minutes
evidenced by strong lasting 60 seconds
palpations  Strong palpations
Action:
 Provide comfort measures: Back rub and
helping position of comfort.
 Encouraged to breathing exercises,
specifically the patterned breathing.
Response:
2:43 PM Patient’s pain was lessen and controlled.
08/08/20 Risk for Maternal Injury Data:
3:00 PM related to pre-existing  Diagnosed with Gestational Diabetes
Endocrine Disorder of  Vital Signs taken as follows:
mother: Gestational BP: 110/70 mmhg
Diabetes PR: 69 bpm
RR: 20 bpm
Temp: 36.8 C
 Action:
 Record accurate intake and output
 Assess dependent areas for edema
 Monitor the laboratory test results focusing
on the blood glucose level.
 Plan oral fluid replacement within multiple
restrictions, as ordered.
Response:
4:04 PM Patient has acquired and maintain normal
blood glucose level.
08/08/20 Fatigue related to Data:
7:38 PM prolonged efforts and  “I am so tired, I can’t push anymore!”, as
pain as evidenced by verbalized by the patient.
verbal reports  The mother had been pushing 2 ½ hours
Action:
 Administer IVF of PLR 1 liter, as ordered by
the physician.
 Administer 10units oxytocin (1ampule), as
ordered by the physician.
 Keep the patient informed to the status of
labor.
Response:
8:00 PM Patient had a sense of control of the
laboring process.
08/08/20 Risk for Infection related Data:
10:03 PM to episiotomy  Presence of episiotomy wound
Action:
 Maintain aseptic technique when changing
dressing or caring wound.
 Emphasize the significance of proper
hygiene.
 Response:
08/09/20 Patient was free from any signs and
12:56 AM symptoms of infection.
08/09/20 Acute Pain related to Data:
7:00 AM surgical incision  Pain scale of 8 out of 10
secondary to episiotomy  Guarded movement
Action:
 Administer analgesics, as ordered by the
physician.
 Assist in different position like sitting,
standing, or walking.
Response:
10:50 AM Patient’s pain was lessen and verbalize,
“hindi na masyadong masakit”.
08/09/20 Activity Intolerance Data:
3:00 PM related to surgical  Facial grimace
procedure  Limited mobility
Action:
 Encourage adequate rest periods
 Maintain comfortable and quiet environment
Response:
5:23 PM Patient was able to decrease physiological
signs of intolerance.
08/09/20 Risk for Fall related to Data:
3:30 PM body weakness as  Activity level: Level III
manifested by  Fatigue
restlessness Action:
 Move items used by the patient within easy
reach.
 Ask the family member to stay with the
patient, to not leave alone.
  Assist the patient in walking and standing.
Response:
6:00 PM Patient have not sustain fall.