A 23 y.

o female patient along with her

husband came to ER with complaints of
lumbosacral pain 4 to 5 hours before going
to Emergency Room. The patient is G3P2
with OB Score of 3002, you observed that
she keeps on touching her back with
grimace on her face. The first day of her
Last Menstrual Period is on 06/13/2018,
EDD is 03/20/2019 AOG is 40 weeks.
DATE /SHIFT/TIME FOCUS DATA, ACTION, RESPONSE

03/20/2019
7AM – 7PM

D> a G3P2 with cc as lumbosacral pain.

9:30am
> guarding behavior and facial grimace
noted.
> LMP 06/13/2018 EDD 03/20/2019 AOG 40
Weeks
DATE /SHIFT/TIME FOCUS DATA, ACTION, RESPONSE

9:45am A > Put safely on bed.

> Vital Signs taken as follows:
BP 120/80mmHg
Temp 36.7
PR 70 bpm
RR 20 cpm
9:55am > Placed in Lithotomy position, data
gathered by Midwife on Duty:
IE 7cm
FH 25 cm
FHT 140 LLQ
(+) BOW
10:05am > referred to ROD with orders
made,carried out.
DATE/SHIFT/TIME FOCUS DATA,ACTION,RESPONSE

R > on active phase of labor

> For admission

10:10am Admission D > IE of 7cm

> with regular uterine contractions
noted
> for admission as per ROD
10;13am > For CBC with typing
A > Consent to care explained and
made to sign.
> Oriented to Ward Set Up and
hospital policy.
> Lab request made and STL
10;17am R > For POL and FHT Monitoring.
> wheeled to ward
> endorsed
You have this Male Adult Patient admitted in Ward 1.
You received him in Semi-Fowler’s Position. His V/S
upon assessment ; BP 160/110mmHg PR 80 Temp
36.8 RR 20 cpm.
You asked him if he knows where he is, he opens his
eyes, stares at you and answers you with his slurred
speech and inappropriate words.
Upon telling him to raise his legs he didn’t do
anything but after pinching his Right Leg he
immediately raise it.
DATE/SHIFT/TIME FOCUS DATA,ACTION.RESPONSE

03/20/2019
7PM – 7AM
8pm ELEVATED BLOOD PRESSURE D> with BP of 160/110mmHg
> nuchal pain, blurring of
vision not claimed
> with an IVF of PNSS 1L and
Hydralazine drip as side drip.
A > V/S taken and recorded
8:05pm > Hydralazine Drip titrated
to _______________.
> Low Salt Low Fat diet
advised.
8:30pm R > with Latest BP of
140/90mmHg.