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FDAR

This document contains 3 nursing notes documenting the care of a patient in labor and postpartum. The first note describes the patient's labor pain and contractions. The second note addresses risks of dehydration as the patient has not urinated in 4 hours and is sweating from labor. IV fluids are started. The third note addresses acute pain in the lower abdomen and perineum after delivery and the interventions provided.

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rodolfo opido
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14K views

FDAR

This document contains 3 nursing notes documenting the care of a patient in labor and postpartum. The first note describes the patient's labor pain and contractions. The second note addresses risks of dehydration as the patient has not urinated in 4 hours and is sweating from labor. IV fluids are started. The third note addresses acute pain in the lower abdomen and perineum after delivery and the interventions provided.

Uploaded by

rodolfo opido
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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October 20,2020 Focus 10-6

11 pm Labor pain D: Mrs. F.M alert, awake and


oriented to person, time and
place. Has chief complaint of
labor pain characterized with
radiating pain from lower back
to the abdomen and relieved
when walking and sitting. The
pain starts one hour and
appears every 3-4mins.
G4 P3 AOG of 39 weeks. T:
36.8;PR: 64 bpm; RR: 20 breaths
per cycle; BP: 100/70; O2 sat of
95%. Uterine contractions
occurred every 2-3 mins with 1
min duration. Pain scale of 6. IE
done with 50% effacement, 3
cms dilatation at station -1.
Membranes remain intact.
Started to give IVF with 1L of
DLRS to run for 6 hrs with 42
drops per minute.

A: Vital signs taken and


recorded every 30 mins.
Continue monitor and record
uterine contractions every 30
mins. Patient encourage to
ambulate. Patient also change
clothes to patient’s gown.
Perform back rub to apply
counter pressure and help ease
back pain. Demonstrate proper
breathing techniques.
Encourage patient to verbalizes
her feelings and support
throughout the labor process.

R: Patient verbalized, “tumitindi


sakit ng likod at tiyan ko.” Pain
persist and increased when
ambulating.
October 21, 2020 6-2
12:00 noon
Risk for deficient fluid volume D:Patient has furrowed and
related to prolonged lack of cracked lips. Urine output of
fluid intake and extreme 100 ml last 4 hrs. with color of
sweating due to labor process deep amber. Patient has not yet
urinated as of now.
V/S of T: 36.7, RR: 20 PR: 82 and
BP of 130/90 and 02 sat of 92%.

A: Start to give IVF 1L of PNSS to


run at 8 hrs with 31-32 drops
per minute. Continue to
monitor IVF and record it. Urge
patient to drink at least one
glass (240 ml) of water every
hour. Continue to monitor I and
O.

R: Patient drink at least 240 ml


of water and does not state
feeling thirsty. With urine
output of greater than 50 ml
per hour.
3 pm 2-10
Acute pain related to afterpains D: Patient verbalized pain in her
and perineal discomfort due to lower abdomen and in
effects of vaginal birth perineum with pain scale of 4
out of 10. Intermittent pain
started last 1 hour and occurs
irregularly.
V/S of T: 37.1, RR: 16 PR: 76 and
BP of 120/80 and 02 sat of 94%.

A: Provide analgesics
(Paracetamol 500 mg) as
prescribed by Dr. Raquedan.
Apply cold compress in
perineum to alleviate perineal
edema and pain. Instruct
support system not to leave the
patient unattended and support
all throughout her postpartum
period.

R: Patient stated that the pain


is tolerable with pain scale of 2.

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