NAME: GENDER:

CIVIL STATUS: AGE:

RELIGION: OCCUPATION:
ADDRESS: DATE OF ADMISSION:
NURSING ASSESSMENT SPECIAL END
appears drowsy, weak and pale looking, positive face tans out to Ob ward
appears dehydrated , warm to touch, moans in pain, with ne TPR Q 4H and record
new born baby girl beside her VS Q 2H till stable
BP 120/90 Keep uterus contracted
BT 38.8 WOF profuse vaginal bleeding and refer
RR 20cpm WOF hypotension and refer
PR 90 bpm refer accordingly
CHIEF COMPLAINT secure blood

Labor pains

DIET MEDIC
DAT once fully awake
oxytocin 1 amp IM NOW
PHYSICIAN cefuroxime 500mg/tab Q 8H

Dr. Alvin Uy

DIAGNOSIS

NSD G2P2 to alive baby girl

 BED #:
ALLERGIES:
BIRTHDAY:
CLASSIFICATION:
SPECIAL ENDORSEMENT LABORATORY DIAGNOSTIC PROCEDURES

rpt CBC and refer results

rpt UA and SB

eding and refer

fer

MEDICATION ONGOING IVF

REMARKS
3/322 7:36PM MCA D5 LR 1L x 8H plus 10 units oxytocin
8H 3/3/228PM MCA

IVF TO FOLLOW
STIC PROCEDURES

OING IVF

cin

FOLLOW
PATIENT'S NAME: Maria AGE:
DATE/TIME: BLOOD PRESSURE TEMPERATURE PULSE RATE
3/3/22 3-11 7;19 pm 120/90 38.8
 GENDER: CS: BED#:
PULSE RATE RESPIRATORY RATE
20 cpm
#NAME?
PATIENT'S NAME: AGE:
DATE AND TIME: PROGRESS NOTES DOCTOR'S
DONE transfer to
ADVISED DAT once fu
DONE TPR Q 4H an
GIVEN VS Q 2H ti
GIVEN give oxytcin 1
DONE Incorporate 10U oxytocin to o
awaiting results IVF to follow D5L
awaiting results rpt CBC and r
advised with SB rpt U
start on cefuroxime
Mefenamic acid 500m
given Ascorbic acid
lactulose 30
may give paracetamol 500 mg/t
done keep uterus c
done WOF profuse vaginal
done WOF hypotensi
refer acco
SIGNED:DR.
SIGNED: SNOD M
 GENDER: CS: BED#:
DOCTOR'S ORDER
transfer to Ob ward
DAT once fully awake
TPR Q 4H and record
VS Q 2H till stable
give oxytcin 1 amp IM now
orporate 10U oxytocin to ongoing IVF of D5LR 1Lx8H
IVF to follow D5LRX8H TB TC
rpt CBC and refer results
rpt UA
start on cefuroxime 500mg, 1tab Q 8H
Mefenamic acid 500mg/tab Q 8H for pain
Ascorbic acid 1 tab OD
lactulose 30 cc ODHS
give paracetamol 500 mg/tab, for T38.5 and above Q 4H
keep uterus contracted
WOF profuse vaginal bleeding and refer
WOF hypotension amd refer
refer accordingly
SIGNED:DR. ALVIN UY
SIGNED: SNOD MCA (NAME MO)
 MEDICATION ADMINISTRATION RECORD

DATE OF ORDER MEDICATION DOSAGE ROUTE FREQUENCY

PRN AND STAT MEDICATIONS

DATE OF ORDER MEDICATION DOSAGE ROUTE FREQUENCY
DMINISTRATION RECORD

DATE OF ADMINISTRATION TIME OF ADMINISTRATION INITIALS

MEDICATIONS
DATE/TIME ADMINISTERED INITIALS
 INTAKE AND OUTPUT SHEET
INTAKE OUTPUT
DATE/SHIFT ORAL TUBE FEED OTHERS TOTAL URINE EMESIS NG
OUTPUT
DRAINS OTHERS TOTAL
PATIENT'S NAME:
AGE:
GENDER:
C/S:
BED #:
DATE/SHIFT/TIME FOCUS NOTES (DATA
3/3/22 3-11 7;19 pm pain D in from Dr per stretcheraccompanied by NOD
pale,and weak looking, moans in pain, appea
ongoing IVF of D5 LR 1Lx 8H at 900cc level
A admission care rendered
initial vs checked taken and recorded
placed comfortably in bed
assessed presence of pain noting site, durati
DBE encouraged when pt appeard awake, di
pt's attention through good NPR
PRN medication for pain administered as pre
R AP, VS rechecked and appears within nomal
D BT 39, warm to touch, flushy appearance
A light blanket provided, TSB rendered , window
Paracetamol 500mg/tab administered for feve
R BT subsided to 38
 NOTES (DATA, ACTION, RESPONSE)
heraccompanied by NOD, appears drowsy,
ng, moans in pain, appears dehydrated, with baby girl beside her, with
R 1Lx 8H at 900cc level
ered
en and recorded
n bed
of pain noting site, duration and severity , allowed patient to rest
en pt appeard awake, diverted
h good NPR
pain administered as prescribed by
nd appears within nomal limits
h, flushy appearance
d, TSB rendered , windows opened fan provided
/tab administered for fever
SIGNED: NOD MCA