DATE TIME FOCUS DATA, ACTION, RESPONSE

12/1/2020 9:30 AM Perineal pain D> Pt. 20 yrs. old; G1P1T1P0A0L1M0; with 1L
D5LR infused with 10 IU oxytocin at 30 gtts/min
hooked @ right arm infusing well with 200 ml
remaining; pt. was conscious and responsive;
afebrile, no foul-smelling lochia, no visual changes,
no calf pain with dorsiflexion of foot, no swelling,
redness and discharges at episiotomy site;
emptying of bladder is good; no difficulty in
breathing; no mood swings; Pt. reported perineal
10:30 AM pain score of
7/10.--------------------------------------------------------
A> Asses vital sign; Applied ice packs to the
perineal area. Educate pt. of the importance of
11:00 AM ambulation for perineal healing, emphasized eating
more protein foods for wound healing.
administered analgesics as prescribed by doctor.
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R> Pt. verbalized “Medjo nawala na ang sakit
nurse, salamat.” Pt. also reported pain score of
2/10. -------