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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.
