Good morning ma'am, may i come in po?

ako diay si shajarah imohang nurse karon sugod sa

ala 7 sa buntag hantod alas 3 sa hapon and for patient identification maan pwede ba nako
matan aw imong wristband og palihog kog ingon saimong full name og birthdate, okay thank
you ma'am and by the way maam makasabot raba ta og bisaya maam mo? So i’ll be the one na
mag perform sa assessment nimo maam og mag monitor saimohang progress sa imong labor
until manganak, and mag hatag pud ko og medication na order sa imong physician na si dr
chua. Unya mangutana lang ko maam ha kung kumusta naman atong pakiramdam ron? Ask
lang pud ko maam kung okay raba ang temperature sa aircon aron ma adjust nato? Okay
maam mang hangyo lang pud ko saimong cooperation ron maam aron sunod2 atong
assessment og magka sinabot tang duha maam ha

So Sige po maam icheck nako imohang dextrose ha.og palihog ko patan aw saimong kamot
Okay mam wala man pud naghubag imong kamot, naga flow man gihapon ang fluid

NGANONG MAG SIGE MAN MOG BALIK2 KUHA OG VS NURSE? Maam kailangan ni sya
maam para ma monitor gihapon namo ang imong vital signs kung normal ba gihapon

VITAL SIGNS: unya magkuha nakog vital signs nimo maam ha (priority O2 sat, temp, PR, RR,
general assessment, then BP)

SPO2: unahon nato imong SPO2, so normal man hinuon. Since ang normal range ani kay
95-100% ang imoha kay naa sa 98%. Which means naay good oxygenation ang imong lawas.

TEMP: og Magkuha napud kog temperature nimo mam ha. So while gakuha ko og temperature
magkuha pud ko saimong pulse rate og respiratory rate. Okay so Ang imohang temperature kay
36.3’C, normal man hinuon mam wala kay kalintura. Since ang normal man ani kay 36 to
37.5’C.

PR & RR: imong pulso pud maam or pulse rate kay normal sad which is 81, ang normal nato
60-100. Tapos 20 cpm man nuon imong respiration, normal ra ni siya kay atong normal range
man ani mam kay 12-20 cpm.

And lastly sa VS kay BP: so relax lang ta maam ha, okay Mam so imong BP kay 120/80
mmHg, normal rani mam.
(-) Vomiting: no signs of vomiting
(+) GI distress: Habang gadako si baby sa imong sulod sa tiyan mam, ang imohang lawas
mag-adjust pud maong in distress ka karon.
(+) Abdominal Pain: Kaning abdominal pain mam normal jud ni sya sa mga buntis, naga
stretch man gud imong tiyan para masuportaan ang pagdako sa imong baby.

If mag ask ang patient nganong sakit iyang tiyan? We dont have to be worry and scared
about it maam since its a normal symptom in pregnancy while your baby is growing your cervix
will soften and it will begin to dilate or open but we are doing everything we can to help elicit the
pain okay?
If mag ask ngano nagka GI distress? Maam while your baby is growing your cervix will also
expand? So might be some changes in your body that is why you are in distress

TT-2 doses is already given Feb 15, 2022 & July 18, 2022: Kailangan ning tetanus toxoid mam
para ma protektahan ka ug si baby sa posible na tetanus.

Patient History: na check pud nako imong medical history so Uncomplicated ang imong patient
history unya nagka experience kag (Hives at 14 weeks AOG). tungod ni sya sa pag change
saimong body maam ga stretch ang imong panit maam so naay mga katol2 na imo ma feel. So
Prenatal labs are negative. Tapos sa imong Specific IgE test, negative man hinuon kas food
allergens mam (Class 0: Absence of IgE)

DIAGNOSIS: 25 years old naman ka maam no? primi-para on her 39th weeks AOG
Discuss Diagnosis/Labs: According sa imong….

Okay so proceed nata saimong test result

CBC: normal man hinuon tanan ang results tapos no signs of anemia which is good mam.
UA: no result
Chest X-ray: normal chest findings, walay complications which is also good

Blood typing: Type O imohang blood tapos Rh positive, ang pasabot ani naay Rh factor
imohang blood, naa ang specific protein sa imohang red blood cells

Covid-19 Test (RAT): Negative man hinuon ka sa Covid mam so mas maayo ni.

Hook EFM monitoring; monitor labor in progress- Please monitor FHT

- Ang meaning aning efm maam kay electronic fetal monitoring ang purpose ani maam
kay para ma monitor namo ang imohang contractions pati ang heart rate ni baby.

Progress notes:
Primipara at 39 weeks AOG:
➢ Singleton pregnancy in vertex presentation
- Isa lang ka baby imong gina conceive mam tapos iyang position kay nag una ang
iyahang ulo mam.
Aug. 15, 2022 @ 8 AM (+)- on active labor:
- ibig sabihin ani mam imohang cervix kay dilated na sya sa 6 centimeters. Tapos mam
mag e expect lang na habang kagawason si baby mag ka andam2 jud og ka kusog ang
contractions sa imong tiyan, mas mutaas tapos mas musakit. Ayaw lang kaayu kabalaka mam
kay naa man mi para tabangan ka.
Now ma’am, i'm gonna brief you on what is going to happen during your labor and delivery.
Since you are already in your 39 weeks, you are in full term. That means contractions will
reach the peak of intensity every 2 to 3 minutes that will last about 60 to 70 seconds.

So ang kasakit na imong ma feel sa panahon sa pagpanganak tungod ni sya sa effacement or

stretching and dilation of the cervix, kini maam adunay posibilidad nga hinayhinay nga
pagbukas agig pagpangandam sa pagpanganak nimo sa imong bata. So during sa
pagpanganak, i position in lithotomy alang sa maayong pag-access sa bata sa panahon sa
pagpanganak.So, you will be instructed to push in your abdomen aron dali nga makagawas ang
fetus. Sa higayon nga mapagawas na ang bata, the baby will be placed in you for skin-to-skin
contact o Unang Yakap aron ma-regulate ang temperatura sa bata ug preparasyon sa
pagpasuso

After the procedure you, and your newborn, will be transferred to the ward and will be
advised to rest first and avoid getting up. So do we have questions or clarification
maam?

PHASE 4: PIKAS SCRIPT so im now going to administer the medication this drug is ordered by
dr chua

HEALTH EDUCATION

So proceeding now to your health education ma'am chantal, since it was your 1st time of having
a baby I encourage you ma'am to take a Rest and avoid such a stressful environment you also
need to have a healthy diet, you need to eat a healthy foods like fruits and vegetables for
energy source and as much as possible drink plenty of water because if you were breastfeeding
your baby you are prone to be thirsty while breastfeeding the baby so this is to avoid
dehydration and practice some breathing techniques maam katon mag inhale ka through your
nose and exhale through your mouth

PHASE 5: ENDING SHIFT

Alright, ma'am, thank you for your time and cooperation maam. I’ll just recommend you to the
next student nurse on duty to assist and monitor you. If you have any concerns or needs, just
press the button next to your bed to notify us. Thank you, ma'am. I'll go ahead now.
ENDORSEMENT:
Good morning, endorsing patient room 457, location at Emergency Room-IPD Pt dimagueba,
adelaine chantal, 25y/o, female. Came in due to Gi distress and Abdominal Pain under the
service of Dr. Chua. diagnosis: Primipara on her 39th weeks AOG
(-) vomiting
(+) GI distress
(+) Abdominal pain
Vital signs:
Temperature is 36.3
Bp is 120/80
Respiratory rate is 20
PR is 81
SPO2- 98%
TT- 2 doses already given
1st dose on feb 15, 2022
2nd dose on july 18, 2022
IVF: D5LR 1L @120cc/hr
Remaining after 8 hours @ 3pm 40cc
Labs
- CBC. CXR, blood typing, Covid-19 test Done na
– Done na ang oxytoxin drip pati na ang PLR 500 cc fast drip while on side lying position
– On hold ang levocitirizine temporarily
– Enoxaparin 40 mg SQ q24
– Nalbuphine 5 mg IV q2 PRN moderate pain or Acetaminophen 650 mg PO q4 PRN
– Aluminum and Magnesium hydroxide 30 ml PO q2 PRN indigestion
– Metoclopromide 10mg IV q4 PRN for nausea and vomiting
– Pitocin 6mUnits/min; decrease dose to 4mUnits when contraction progressed to 5-6 dilation

Refer and facilitate lab works Watch out for any unusualties.

End of endorsement, thank you!