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  • Time Subjective Objective Assessment Planning

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    The document contains medical records for a patient in labor. It records her vital signs, assessments, and care plan over a period of active labor from 23:30 to 04:40. Key details include: - The patient is a 37 week pregnant G4P3A0H3 woman in the active first stage of labor with a head-down fetus and a history of chronic hypertension. - Her vitals and assessments are monitored regularly as her dilation progresses from 6 cm to full dilation between 23:30 and 03:30. - At 04:25 a baby boy is born weighing 3.1 kg with good vital signs. The placenta is delivered at 04:40 weighing 500g with

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    The document contains medical records for a patient in labor. It records her vital signs, assessments, and care plan over a period of active labor from 23:30 to 04:40. Key details include: - The patient is a 37 week pregnant G4P3A0H3 woman in the active first stage of labor with a head-down fetus and a history of chronic hypertension. - Her vitals and assessments are monitored regularly as her dilation progresses from 6 cm to full dilation between 23:30 and 03:30. - At 04:25 a baby boy is born weighing 3.1 kg with good vital signs. The placenta is delivered at 04:40 weighing 500g with

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    Download as pptx, pdf, or txt
    6 views2 pages

    Time Subjective Objective Assessment Planning

    Uploaded by

    elmy
    The document contains medical records for a patient in labor. It records her vital signs, assessments, and care plan over a period of active labor from 23:30 to 04:40. Key details include: - The patient is a 37 week pregnant G4P3A0H3 woman in the active first stage of labor with a head-down fetus and a history of chronic hypertension. - Her vitals and assessments are monitored regularly as her dilation progresses from 6 cm to full dilation between 23:30 and 03:30. - At 04:25 a baby boy is born weighing 3.1 kg with good vital signs. The placenta is delivered at 04:40 weighing 500g with

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 2

    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

    23.30 Abdominal pain (+) BP: 140/70 mmHg G4P3A0H3 S/L/IU Obs. Mother and fetal well
    FM (+) P: 90 x/mnt 37 weeks head being
    RR: 20 x/mnt presentation with Observation VT/4 Hours
    T: 36,8 C active phase 1st
    HIS: 3x10-35 stage of labor +
    DJJ: 12-13-13 Chronic
    (152x/mnt) Hipertension
    VT: : 6 cm, eff 50%,
    amnion (+) , head
    persentation, denom
    unclear, HI, small
    parts and umbilical not
    palpable

    02.30 Abdominal pain (+) BP: 140/70 mmHg G4P3A0H3 S/L/IU Obs. Mother and fetal well
    FM (+) P: 86 x/mnt 37 weeks head being
    RR: 20 x/mnt presentation with Observation VT/4 Hours
    T: 36,7 C active phase 1st
    HIS: 3x10-40 stage of labor +
    DJJ: 12-11-12 Chronic
    (140x/mnt) Hipertension
    TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

    03.30 Abdominal pain (+) BP: 140/70 mmHg G4P3A0H3 S/L/IU Obs. Mother and fetal well
    FM (+) P: 90 x/mnt 37 weeks head being
    RR: 20 x/mnt presentation with Observation VT/4 Hours
    T: 36,8 C active phase 2nd Management active 2nd Phase
    HIS: 3x10-35 stage of labor +
    DJJ: 12-13-13 Chronic
    (152x/mnt) Hipertension
    VT: : full dilatation,
    eff 100%, amnion (+) ,
    head persentation,
    denom unclear, HI,
    small parts and
    umbilical not palpable

    04.25 - Baby was born male/ BW 3,1


    Kg/ length 51cm/ HC 34cm

    04.40 - Placenta born 500 gram


    Bleeding 300cc

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