DILATATION AND CURRETAGE Date and Time FOCUS DATA, ACTION, RESPONSE Time ‘Safe Operation D> Into/received labor room a __y/o, G_P_ mother from OB ward/ER per wheelchairfstretcher/ambulatory accompanied by IWOD/RNSE/SNOD on duty with ongoing IVF of _1L+___*u" oxytocin at __mi level infusing well BE the Teftiright metacarpalbasilicalcephalic vein, conscious and coherent; with moderate/minimal bleeding noted, weak and pale in appearance with intial vital signs as follows: BP___mmig. Pr_bpm, RR__cpm,Temp_¢ D> Into delivery room, ambulatory accompanied by NODANSE,SNOD on duty with ongoing IVF of 1L+_"u" oxytocin at _ml level infusing well Consent “A> Ushered to bed, secured consent for D&C signed J consent for D&C attached to chart Positioning and ‘A> Assisted to DR table and positioned to lithotomy, comfort | administered oxygen inhalation per nasal cannula at 23lpm, shaved perineal area and draped asepticall Startof | A> Nubain 1 amp given IV by NOD/RNSE as per anesthesia | verbal order of Dr. sedation Wincorporation ‘A> Additional 10 "u" oxytocin incorporated to above IVF as per verbal order of Dr. Dand ‘A> Completion’ Evacustion/ Dilstation curettage done by Dr. specimen saved then given to ‘watcher for histopathology. Medication ‘Ae Methylergometrine 1 amp given VAM at right/left deltoid as per verbal order of Dr. Post: op care Health teaching Z> Perineal care done and adult diaper placed snugly. “Transferred to stretcher and brought to labor room ‘A> instructed on proper breathing technique and proper personal hygiene _and to report excessivebleeding and other concerns to NOD Unit Wanster ‘A> Brought to ward per stretcher/wheslchair with above IVF of _1L +__“u" oxytocin infusing well with the latest vital signs of BP___mmrig, Pr_bpm, RR__cpm, Temp_CDateand Time. Focus LABOR ROOM Tats, Action, Response TIME WE TIME TIME Tabor pain Patient care Postioning and comfort Fluid and administration or meaication D> Intojreceived labor roam a —_yio, 6 P_from OB vward/ER accompanied by WOD/RNSE/SNOD on duty; With ongoing WFof __1L+_"u” oxytocin 2 _milevel infusing well ‘metacarpal/cephalic/basilica vein. D=grimaces, means occasionally, iritable at times, ‘guarding lumbosacral area noted: with vital signs of BP__mmHo, Pr_opm, RR_cpm, Temp _C “A> Assessed level of pain, Assessed progress of labor; Monitored vital signs and recorded: Assisted ‘on ambulation; Nassaged lumbosacral area, ‘Ax Assisted to DR table and postioned to lithotory for IE done by. revealing _em carvical ilatation: Perineal shaving done: Ushered to LR for further monitoring, ‘A> WF of ___1L+__"U owytocininserted by __at the LR metacarpallcephaiic/oasilis ven and Teguateato _gttsimin ‘As First dese OF HNBB 1 amp given NV push By INOD/RNSE. ‘AS Blood specimen extracted by medtech on duty for CBC, ABO typng and HB sag, TIME Health teaching ‘A> Instructed on proper deep breathing techniques: ‘squatting to raciitate descent; Maintainec on NPO. 5 ordered and encouraged to verbalize feelings ‘and concema ‘Ro Increased intensity of pain with pain scale of ‘and uterine contractions eccurring every 2-3 ‘minutes: With duration of 60-90 seconds. TIME Unit Transtar “A> Brought te DR ambulatory with same WF accompanied by TOE INCLUDED IF IT WAS DONE A> Bag of water ruptured artifcially/spontaneously by A> Seen and exemines by Dr. Ordered for "E” caesarean section due to arrest of cervical llatation/arrest of descent: ‘Scheduled for "E” CS; informed OR NOD, ‘paediatrician ang Anesthesioiogst TIME Consent ‘Secured consent for the procedure/operation signed by the patientiparent/husbandirelative.