NURSE’S NOTES
SURNAME: MATTI C.S:_____ AGE: 28 HOSPITAL NO.
GIVEN NAME: MAHA SEX: F WARD/ROOM NO.: OB/GYNE WARD
Date-Shift FOCUS Data – Action – Response
11/22/21 Post Admission D: patient in OB Ward, with an IVF of PNSS;1L at 1000ml going on.-----------
7-3 Care A: Vital signs taken and recorded. CTG noted. FHT monitored and noted.---
7:00 am R: Experiencing lumbroscal pain.------
CZARINA JOY F. RAMIREZ, Student Nurse
9:00 am First Stage of labor: D: patient examined by Dr Rabino, internal exam was done and noted that
Active phase patient dilated 8cm. Oxytocin “u” ordered;regulated at 25 gtts/min
incorporated in same fluid.-----------
A: Vital signs taken and recorded. FHT monitored and noted.------
CZARINA JOY F. RAMIREZ, Student Nurse
10:00 am First Stage of Labor: D: patient’s membrane broke;noted a clear fluid discharge from the vagina.-------
Active Phase A: Vital signs taken and recorded. FHT noted. Progress of labor monitored
and noted. ------------
10:30 am A: relayed to Obstetrician. Received doctor’s order; oxytocin “u”regulated
at 10-15 gtts/min. -----------
CZARINA JOY F. RAMIREZ, Student Nurse
11:00 am First stage of labor: D: FHT noted. Vital signs taken and recorded. Did internal examination.
Transition phase noted that the cervix is 9cm to almost fully dilated. ---------
A: Referred to Dr Rabino on duty and ordered to transfer the patient to
the delivery room.
CZARINA JOY F. RAMIREZ, Student Nurse
1:15 pm Third Stage: D: patient delivered her baby and the placenta came out-------
Placental stage A: administered of 1 "U" of oxytocin IM.---------
CZARINA JOY F. RAMIREZ, Student Nurse
2:00 pm Post labor care and D: Patient trans out from DR to ward.
management A: orders as follows; ferrous sulphate 1tab OD, multi vitamins, cefuroxime
500mg BID, mefenamic acid 500mg PRN, malunggay tab 1 tab OD, perineal
care, encourage breastfeeding, V/S monitoring, watch out for vaginal
bleeding, refer as needed. Endorsed.
CZARINA JOY F. RAMIREZ, Student Nurse
