Shaira C. Palarion BSN 2B Miss. Aileen C.

Abadingo

UNIVERSITY OF CEBU LAPU-LAPU AND MANDAUE COLLEGE OF

NURSING
ASSESSMENT (NARRATIVE)

My first duty was in the OB ward at Eversley Childs Sanitarium and General
Hospital on November 13, 2022. I had 1 patient. She was a new mom Gravida 1
Para 0, delivered (vaginally) on November 13, 2022. She was doing well with her
baby, but she has a little pain due to his stitches. She and her child were doing
well, although she was experiencing some discomfort from his stitches. I started
my work by focusing on my vital signs. I walked in to check on the patient at about
11:30. BP was 120/70, PR was 76, RR was 16, and the temperature was 36.4. The
patient's pain score was 6/10, which I also evaluated. I immediately go to the
mother's infant after examining the mother. Vital signs were: RR 60, Temp 37.0,
and PR 120, all within normal limits.

On November 14, 2022, at 3:30 in the morning, I returned to recheck the mother's
and the infant's vital signs. Mother's vital signs were as follows: BP is 110/70, PR
is 70, RR is 17, and the temperature is 36.5. The pain rating has dropped to 5/10.
The infant's vital signs, which were all within normal ranges, were RR 47, Temp
36.6, and PR 116. After checking their vital signs, I asked the mother how much
fluid she had consumed between 11:00 p.m. and 4:00 a.m., and she said 4 glasses,
or 880 ml in total. Urine output and stool: The patient said that she peed twice but
did not poop throughout that period. Four diapers were used for the baby's poop,
and one diaper was used for the urine.

After making sure everything was in order, I went to our CI, Miss Abadingo, to
report my findings. Overall, both the mother and the child are doing well with no
complications.