FDAR

Name of Patient: Yan, Mahani Age: 28 Birth Date: 6/19/92

Date of Admission: August 22, 2021 Sex: F Room: 3002

DATE AND
FOCUS DATA ACTION RESPONSE
TIME

August 22, Pain due to suture Subjective: ● Assessed At the end of my

2021 of perineal patient’s vital eight (8) hours of
@ 11:00 AM laceration Objective: signs shift:
- Patient ● Evaluated
sustained a patient’s pain ● Patient’s vital
second-degree through a a signs were
laceration which scale of 1-10 stabilized
was repaired with 10 being compared to her
and sutures the highest admission
were applied ● Asked client ● The patient still
- Cervical about the experiences
Dilation: comfort and pain due to her
5 cm upon provided a suture as
admission; 8 calm evidence by her
cm upon environment grimacing face
assessment of ● Educated the rated the pain
physician after client and her as 9 out of 10
a few minutes watcher about ● Patient also
perineal care understood the
and wound importance of
dressing monitoring and
cleaning her
@ 1:00 PM Stress related to Subjective: ● Encouraged suture
the difficult labor - Patient also had client to share ● Client also
process uncomfortable her verbalized her
strong experience experience
contractions and and feelings during labor and
palpations during labor compared it to
during labor and delivery, her previous
- Patient and compare experience with
complained it to her her first child.
about nausea previous She stated that
and had an experience she did not have
uncontrollable with her first any lacerations
urge to push child before as
- Back pain was ● Provided evidenced by
noted especially physical care her past medical
during uterine such as bath, history in which
contractions back rub, and she did not have
nourishment, any past
Objective: allowing the medical or
- Patient is on patient to surgical history.
her second participate at ● Patient also
gravid their own showed signs of
- Patient was pace. relaxation and
 trembling while ● Also taught was able to
on labor some apply
- Labor non-pharmac non-pharmacolo
Contractions: ological gic interventions
4-5 min apart interventions during after
lasting for 40 for delivery.
sec. distressing
such as
breathing
techniques
and adequate
rest

Goal Met

Angelica Claire B. Barecuatro, SN Goal Partially Met

Name of Student
Goal Unmet