Name: Aubrey Dynise C. Torralba Clinical Instructor: Prof.

Nassefah Ali

NURSESNOTES
Name of the patient: Marites Corazon Age: 29 yrs. Old Sex: Female

Date/Time/Shift FOCUS DAR

06-21-21 Deficit fluid volume D> Received awake on bed,

7-3pm primigravida, 39 week pregnant, has
abdominal pain and headache, deficit
8:00 AM fluid volume.
>T : 98.8 F, P: 102 bpm, BP:
116/72mmHg, RR: 18 bpm, Spo2: 98

A> Assess and record the amount and

10: AM site of bleeding
 Assess location of the uterus
and degree of contractibility.
 Massaged uterus using one had
and place 2nd hand above
symphysis pubis
11:00 AM  Monitor vital signs every 10
minutes and check for
ocipillary refill
R> Body fluid volume improved and
no dysfunctioned bleeding observed.
Name: Aubrey Dynise C. Torralba Clinical Instructor: Prof. Nassefah Ali

NURSESNOTES
Name of the patient: Marites Corazon Age: 29 yrs. Old Sex: Female

Date/Time/Shift FOCUS DAR

06-21-21 Abdominal and head D> Received awake on bed, has

7-3pm pain abdominal pain and headache
>T : 36.30, P: 102 bpm, BP:
12:00 NN 165/110mmHg, RR: 20 bpm, Spo2:
99%, FHR is 130bpm, SFH 36cm.

A> Investigate verbal reports of pain,

noting specific location and intensity
1:15 PM  Assess location of the uterus
and degree of contractibility.
 Maintain bed rest during acute
attack and provide quiet restful
environment
 Administer medication as
indicated such as IV analgesics.
R> Pt is relieved from pain and has
stable hemodynamics and free from
complications.
Name: Aubrey Dynise C. Torralba Clinical Instructor: Prof. Nassefah Ali

NURSESNOTES
Name of the patient: Marites Corazon Age: 29 yrs. Old Sex: Female

Date/Time/Shift FOCUS DAR

06-21-21 Impaired skin and D> Primigravida, 39 week pregnant,

7-3pm tissue integrity r/t right mediolateral episiotomy
incision made in the >T : 98.8 F, P: 102 bpm, BP:
2:10 PM perineum 116/72mmHg, RR: 18 bpm, Spo2: 98

A> Inform pt that episiotomy is

necessary
 Advice pt to push only during
contractions
 Perform episiotomy
 Perform all procedures
following strict aseptic
technique.
R> Performed proper bearing down
technique which helps in the
expulsion of the baby and tearing of
perineum.