DATE AND FOCUS DATA ACTION RESPONSE

TIME
/ / From LR to DR D> Brought to delivery room ambulatory accompanied by
Time: RNSE/SNOD/IWOD on duty, with an ongoing IVF of ________ 1L +
__________ ______ “u” oxytocin at ______ ml level infusing well at the R/L
metacarpal/cephalic/basilic vein.
From Ward to LR D> Into Delivery room a _____ year-old G_P_ from ER/OB ward per
wheelchair/stretcher/ambulatory accompanied by RNSE/SNOD/IWOD
on duty, with an ongoing IVF of ________ 1L + ______oxytocin “u” at
______ ml level infusing well at the R/L metacarpal/cephalic/basilic
vein.
For Direct DR D> With full cervical dilatation and continuous uterine contractions
occurring 2-3 minutes and duration of 30-60 seconds, bloody mucoid
and bulging perineum noted.

Time: Positioning and Comfort A> Assisted to DR table and positioned to dorsal lithotomy; IE done by
__________ _______revealing full cervical dilatation; informed Dr._______;
administered oxygen inhalation per nasal cannula at 2-3 LPM; coached
on proper bearing down.
A> RMLE done by Dr. ________/ Perineal support done by
Dr._________.

Time: Safe Delivery of the Baby A> Delivered an alive baby girl/boy via NSD in cephalic presentation
__________ with a birth weight of __________kgs and a birth length of _______cm
attended by DR. ________; with ________ tight/loose nuchal cord loop
noted.
Time: Start of Anesthesia and A> Nubain 1 amp given intravenously by NOD/RNSE as per verbal order
__________ Sedation of Dr. __________.
A> Midazolam ¼ amp. Given intravenously by NOD/RNSE as per verbal
order by Dr. __________.

Time: Medication A> Oxytocin 1 amp. administered IM/IV at R/L deltoid by NOD/RNSE as
__________ ordered.

Time: Safe Delivery of Placenta A> Placenta out completely in Schultz/Duncan presentation, with
__________ BP=_________ mmHg, PR=_____bpm, RR=_____cpm, T=_____oC.

Time: Medication A> Methylergometrine 1 amp. administered IM/IV at R/L deltoid by

__________ NOD/RNSE as ordered.

Time: IV Incorporation A> Additional 10 “u” oxytocin to present IVF as per verbal order of DR.
__________ ________.

Time: Episiorrhaphy A> Evacuation of blood clots and placental fragments done by Dr.
__________ / _______ using curette/manually. Episiorrhaphy done by Dr.
Blood Clots Evacuation __________; massaged uterus until firm and contracted.

Time: Nutrition and Bonding A> Breastfeeding initiated, bonding monitored/vital signs monitored
__________ and recorded, breastfeeding per demand and proper burping
encouraged.
Time: Post-partum Care/Health A> Transferred to stretcher then brought to LR; Advised mother to
__________ Teaching massage uterus until firm and contracted; to wash perineal area with
tap water and report excessive bleeding to NOD.

Time: Unit transfer A> Brought to OB ward per stretcher/wheelchair accompanied by

__________ _________ and with ongoing IVF of ______ 1L + _______ "u" oxytocin.
Date and Time of Birth: __________________________________________________________

Name/Sex of the Baby: __________________________________________________________

DATE AND FOCUS DATA ACTION RESPONSE

TIME
/ / Immediate D> Born an alive baby girl/boy via NSD with weak/loud cry, _____
Time: newborn tight/loose cord loop, meconium stain, pinkish/acrocyanotic in color,
__________ care with thin/thick vernix caseosa, with moderate lanugo at the back; with
____ flexion and extension of extremities; APGAR score of ____ at 1 and
5 minutes respectively, with initial vital signs of T=_____ oC, CR= _____
bpm, RR=_____ cpm.

Promoting bonding, A> Rendered immediate newborn care, placed on mother’s abdomen,
airway, and immediate drying of oronasal secretions and blood stains done, initiated
cord care bonding with mother through skin-to-skin contact; cord cut aseptically
when pulsation stopped, put on bonnet, (oronasal secretions suctioned;
administered oxygen inhalation via _________.)
Nutrition and A> Cleansed breast of mother, latching done with ________ sucking
bonding reflex noted.

Data and A> Anthropometric measurement taken as follows:

identification Wt= _____ kgss, Ht= _____ cm, CC= _____ cm, Abd= _____ cm, Arm=
_____ cm, clothed and placed nametag on the left foot, credes
prophylaxis applied on both eyes. Vitamin K 0.1ml given at left vastus
lateralis
Time: Immunization A> Hepatitis B vaccine 0.5ml given at right vastus lateralis.
__________

R> Pinkish, with good sucking reflex, with latest vital signs of
T=_____ oC, CR=_____ bpm, RR=_____ cpm
Time: Unit transfer R> Brought to OB ward beside mother per
__________ stretcher accompanied by _______. Endorsed.
Date and Time of Birth: __________________________________________________________

Name/Sex of the Baby: __________________________________________________________

DATE AND FOCUS DATA ACTION RESPONSE

TIME
/ / Immediate D> Into DR from OR an alive baby ______ cuddled by
Time: newborn care Dr. _______, with initial vital signs of T=____ oC, CR=___ bpm, RR= ____
__________ cpm.
Promoting bonding, A> Rendered immediate newborn care, immediate drying of oronasal
airway, and secretions and blood stains done, initiated bonding with mother
cord care through skin-to-skin contact; cord cut aseptically when pulsation
stopped, put on bonnet.
Nutrition and A> Cleansed breast of mother, latching done with ________ sucking
bonding reflex noted.

Data and A> Anthropometric measurement taken as follows:

identification Wt= ____ kgs, Ht=___ cm, HC= ____ cm, CC= ____ cm,
Abd= ____ cm, Arm= ____ cm, clothed and placed nametag on the left
foot, credes prophylaxis applied on both eyes. Vitamin K 0.1ml given at
left vastus lateralis.

Time: Immunization A> Hepatitis B vaccine 0.5ml given at right vastus lateralis.
__________

R> Pinkish with good sucking reflex, with latest vital signs of T= ____ oC,
CR= ____ bpm, RR= ____ cpm.
Time: Unit transfer R> Brought to OB ward per stretcher cuddled by_______.
__________

Besitan, Jazzy Mae L. Brutas, Mary Grace G.

Calama, Erika Diane J. Caymo, Aubrey L.
Codiaman, Gladys D. Cogoy, Matt Anthony C.
Colas, Darriette Kaye D.
GROUP 414(C) BATCH 2022 BENGUET STATE UNIVERSITY
COLLEGE OF NURSING
Mhyrlynejee M. Salis-Camdas
CLINICAL FACILITATOR
DATE AND FOCUS DATA ACTION RESPONSE
TIME
Immediate D> Received an alive baby boy/girl under radiant warmer with an
newborn care ongoing oxygen inhalation per nasal cannula at ____ lpm, with
loud/weak cry, pinkish/acrocyanotic in color, with nasal
flaring/grunting/clubfoot; with initial vital signs of T= ____ oC, CR= ____
bpm, RR= ____ cpm.
A> Promoted safety by putting pillows at the side, monitored vital signs
and recorded.
Nutrition and A> Latching done to mother at PACU with good/fair sucking reflex.
bonding
Time: Unit Transfer A> Roomed in mother at OB ward cuddled by RNSE on duty
__________ with latest vital signs as follows; T= ___ oC, CR=____ bpm, RR=____cpm.

DATE AND FOCUS DATA ACTION RESPONSE

TIME
Immediate D> Received an alive baby boy/girl under radiant warmer with an
newborn care ongoing oxygen inhalation per nasal cannula at ____ lpm, with
loud/weak cry, pinkish/acrocyanotic in color, with nasal
flaring/grunting/clubfoot; with initial vital signs of T= ____ oC, CR= ____
bpm, RR= ____ cpm.
A> Promoted safety by putting pillows at the side, monitored vital signs
and recorded.
Nutrition and A> Latching done to mother at PACU with good/fair sucking reflex.
bonding
Time: Unit Transfer A> Roomed in mother at OB ward cuddled by RNSE on duty
__________ with latest vital signs as follows; T= ___ oC, CR=____ bpm, RR=____cpm.

DATE AND FOCUS DATA ACTION RESPONSE

TIME
Immediate D> Received an alive baby boy/girl under radiant warmer with an
newborn care ongoing oxygen inhalation per nasal cannula at ____ lpm, with
loud/weak cry, pinkish/acrocyanotic in color, with nasal
flaring/grunting/clubfoot; with initial vital signs of T= ____ oC, CR= ____
bpm, RR= ____ cpm.
A> Promoted safety by putting pillows at the side, monitored vital signs
and recorded.
Nutrition and A> Latching done to mother at PACU with good/fair sucking reflex.
bonding
Time: Unit Transfer A> Roomed in mother at OB ward cuddled by RNSE on duty
__________ with latest vital signs as follows; T= ___ oC, CR=____ bpm, RR=____cpm.
 DATE AND FOCUS DATA ACTION RESPONSE
TIME
/ / Labor Pain D> Into labor room a ______ year old G_P_ from ER/OB ward
Time: accompanied by IWOD/RNSE/SNOD/ on duty, with ongoing IVF of
__________ _______ 1L + ___ “u” oxytocin at ____ mL level infusing well at the R/L
metacarpal/cephalic/basilic vein.
D>Grimaces, moans occasionally, irritable at times, guarding lumbosacral
area noted; with vital signs of: BP=______mm/Hg, PR=___bpm, RR=___
cpm, Temp._____ oC.
Time: Patient Care A> Ushered to bed; assessed level of pain; assessed progress of labor,
__________ monitored vital signs and recorded; assisted on ambulation; massaged
lumbosacral area.
Time: Positioning and A>Assisted to DR table and positioned to lithotomy for IE done by
__________ Comfort _________________ revealing ____cm cervical dilatation; informed Dr.
_____________; perineal shaving done; ushered to LR for further
monitoring.
Time: Fluid and A>IVF of _______ 1L ____ “u” oxytocin inserted by _____ at the L/R
__________ Administration of metacarpal/cephalic/basilica vein and regulated to ___ gtts/min.
medication
A> First dose HNBB 1 amp, given IV push by NOD/RNSE.
A>Blood specimen extracted by Medtech on duty for CBC, ABO typing and
HB sag.
Time: Health Teaching A>Instructed on proper deep breathing techniques; Squatting to facilitate
__________ descent; Maintained on NPO as ordered and encouraged to verbalize
feelings and concerns.
R>Increased intensity of pain with pain scale of ____ and uterine
contractions occurring every 2-3 minutes; with duration of 60-90 seconds.
Time: From LR to DR A>Brought to DR ambulatory with same IVF accompanied by _______.
__________

Besitan, Jazzy Mae L. Brutas, Mary Grace G.

Calama, Erika Diane J. Caymo, Aubrey L.
Codiaman, Gladys D. Cogoy, Matt Anthony C.
Colas, Darriette Kaye D.
GROUP 414(C) BATCH 2022 BENGUET STATE UNIVERSITY
COLLEGE OF NURSING
Mhyrlynejee M. Salis-Camdas
CLINICAL FACILITATOR
 DATE AND FOCUS DATA ACTION RESPONSE
TIME
/ / Safe Operation D> Into labor room a ______ y/o G_P_female from ER/OB ward per
Time: wheelchair/stretcher/ambulatory accompanied by RNSE/SNOD/IWOD on
__________ duty. Received with an ongoing IVF of ______1L+______ “u” oxytocin at
_____ mL level infusing well at the L/R metacarpal/cephalic/basilic vein;
conscious and coherent, with moderate/minimal bleeding noted; weak
and pale in appearance; with initial vital signs of BP= ____ mmHg,
PR= ______ bpm, RR= ______ cpm, T= ______ oC.
D> Brought to DR ambulatory accompanied by
Time: IWOD/RNSE/RMSE/NOD/SNOD with an ongoing IVF of _______ 1L+
__________ _______ "oxytocin at _______ mL level infusing well at the L/R
metacarpal/cephalic/basilic vein.
Consent A > Ushered to bed, consent for ____________ signed by ____________
and attached to chart, /Consent for ____________ checked and attached
to chart.
Positioning and A > Assisted to DR table and positioned to lithotomy; administered
Comfort oxygen inhalation per nasal cannula at 2-3 lpm; shaved perineal area and
draped aseptically.
Time: Anesthesia A > IV sedation done by Dr. _____________.
__________ Sedation
Time: IV Incorporation A > Additional 10 “u” oxytocin to present IVF as per verbal order of Dr.
__________ _____________.
Time: D and C A > Completion/evacuation/dilation curettage done by
__________ Dr._____________ specimen saved then given to watcher for
hispathology.
Time: Medication A > Methylergometrine 1 amp. administered IM/IV at R/L deltoidby
__________ NOD/RNSE as ordered as per verbal order of Dr._____________.
Time: Post-op Care A > Perineal care done and adult diaper placed snugly; transferred to
__________ stretcher and brought to labor room.
Time: Health Teaching D > Conscious and coherent
__________ A > Assessed level of consciousness; instructed on proper breathing
technique, proper personal hygiene and to report excessive bleeding to
NOD.
Time: Unit Transfer A > Brought to OB ward per stretcher accompanied by _____________
__________ with above IVF of ___ 1L+ ___"u" oxytocin infusing well; with the latest
vital signs of BP= ____ mmHg, PR=____ bpm, RR= ____ cpm, T=____ oC.

Besitan, Jazzy Mae L. Brutas, Mary Grace G.

Calama, Erika Diane J. Caymo, Aubrey L.
Codiaman, Gladys D. Cogoy, Matt Anthony C.
Colas, Darriette Kaye D.
GROUP 414(C) BATCH 2022 BENGUET STATE UNIVERSITY
COLLEGE OF NURSING
Mhyrlynejee M. Salis-Camdas
CLINICAL FACILITATOR
 DATE AND FOCUS DATA ACTION RESPONSE
TIME
/ / Pre- operative D> Into O.R per _________ accompanied by ________ with an ongoing IVF
8:00 AM preparation of _______ at______ cc level infusing well on the R/L arm, Consent for
surgery signed and attached to chart, confirmed identity, site, procedure
and consent.
A> Ushered to _________ O.R. ambulatory and positioned comfortably,
monitors attached; initial vital signs taken as follows: BP=_____,
CR=______, RR=_____, SPO2=______.
A> Assisted to L/R lateral and on knee chest position, lumbar skin care
preparation done by ___________.
8:10 AM Anesthesia D> (sub arachnoid block/ combined spinal epidural) anesthesia induced by
Induction Dr. _____________.
A> Repositioned to supine with arms extended on arm boards, electro
surgical placed under buttocks/legs.
IFC Insertion A> IFC inserted aseptically by _______.
Skin Prep A> Abdominal skin care preparation done by _________________.
8:15 AM Draping D> Draped aseptically by Dr.______.
A> Initial sponge, instruments and needles count done; time out
completed.
8:30 AM Operation started D> ________ incision initiated by Dr._______, assisted by Dr._______.
8:35 AM Venoclysis A> Above IVF of ________ consumed and replaced with same solution.
8:49 AM Specimen out D> (Name of specimen) ____________extracted.
Drainage/Tube D> JP/Penrose inserted aseptically by Surgeons.
Attachment A> Final sponge, instrument, needle count done and verified by (Nurse on
Duty) _____________________, sign out completed.
9:15 AM End of Operation D> (Name of procedure) _________________done, antiseptic solution
and top dressing applied and secured by Surgeons.
A> Immediate post op. care done, kept warm with blankets.
9:20 AM Unit Transfer A> Transferred to RR bed, ensured safety, brought to recovery room with
an IVF of ______ infusing well on the R/L arm, with intact IFC/JP/Penrose,
Latest BP= _____, CR=______, RR=_____ SPO2=_______, surgical checklist,
OR tech, and anesthesia record attached to chart, specimen labelled given
to watcher with histopathology request, endorsed to RR nurse.
 DATE AND FOCUS DATA ACTION RESPONSE
TIME
/ / Pre-operative D> Into O.R per_____ accompanied by _____ with an ongoing IVF of
8:00am preparation _____ at _____ cc level infusing well on the R/L arm, consent for surgery
signed and attached to chart, confirmed identity, site, procedure and
consent.
A> Ushered to _____ O.R. ambulatory and positioned comfortably,
monitors attached; initial vital signs taken as follows: BP= _____,
CR=_____, RR=_____, SPO2 =_____.
A> Assisted to L/R lateral and on knee chest position, lumber skin care
preparation done by_____.
8:10am Anesthesia D> (sub arachnoid block/ combined spinal epidural) anesthesia induced
induction by Dr. __________________.
A> Repositioned to supine with arms extended on arm boards.
IFC insertion A> IFC inserted aseptically.
Skin prep A> Abdomino-perineal skin care preparation done by _____.
8:15am Draping D> Draped aseptically by Dr._______________.
A> Initial sponge, instruments and needle count done; time out
completed.
8:30am Operation started D> _____ incision initiated by Dr. _____________, assisted by
Dr._________.
8:32am Venoclysis A> Above IVF of _____ consumed and replaced with same solution.
8:35am Baby out D> Born an alive baby boy/girl, cord clamped and cut by Dr.________,
secretions wiped, received by Dr. _________.
8:37am Placenta out D> Placenta out in _____ presentation, uterine incision sutured.
A> Final sponge, instrument, needle count done and verified by (Nurse
on Duty) _________________, sign out completed.
9:15am End of operation D> (Name of procedure) ____________________done, antiseptic
solution and top dressing applied and secured by Surgeons.
A> Immediate post op. care done, kept warm with blankets.
9:20am Unit transfer A> Transferred to RR bed, ensured safety, brought to recovery room with
an IVF of _____ infusing well on the R/L arm, with intact IFC connected to
urine bag, latest BP _____, CR _____, RR _____, SPO 2 _____, surgical
checklist, OR tech and anesthesia record attached to chart, endorsed to
RR nurse.

Besitan, Jazzy Mae L. Brutas, Mary Grace G.

Calama, Erika Diane J. Caymo, Aubrey L.
Codiaman, Gladys D. Cogoy, Matt Anthony C.
Colas, Darriette Kaye D.
GROUP 414(C) BATCH 2022 BENGUET STATE UNIVERSITY
COLLEGE OF NURSING
Mhyrlynejee M. Salis-Camdas
CLINICAL FACILITATOR