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Nurses' Notes Date Shift Time Focus D-Data A-Action R-D - Patient Was

The nurses' notes document a patient's labor and delivery experience. The 37-week pregnant patient was experiencing regular abdominal contractions and pain radiating to the pelvis, with a slight bloody mucus discharge. Her vital signs and assessments were taken and recorded. To help with pain and comfort, the nurse instructed positions, applied a perineal pad, started an IV fluid, and inserted a catheter. As the contractions continued, the patient's pain level reduced and she was transferred to another hospital for further care.

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Ma Dionela Encinas
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968 views2 pages

Nurses' Notes Date Shift Time Focus D-Data A-Action R-D - Patient Was

The nurses' notes document a patient's labor and delivery experience. The 37-week pregnant patient was experiencing regular abdominal contractions and pain radiating to the pelvis, with a slight bloody mucus discharge. Her vital signs and assessments were taken and recorded. To help with pain and comfort, the nurse instructed positions, applied a perineal pad, started an IV fluid, and inserted a catheter. As the contractions continued, the patient's pain level reduced and she was transferred to another hospital for further care.

Uploaded by

Ma Dionela Encinas
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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NURSES’ NOTES

DATE SHIFT TIME FOCUS D-DATA A-ACTION R-


RESPONSE
02-01-21 Regular abdominal contractions D- Patient was complaining
9:00 A.M and pain regular abdominal contractions
radiating to the pelvis with
slight blood tinged mucous
discharge and reported pain
with a score of 6/10 as
contractions lasts for a minute 2
hours before admission.
-Patient was 37 weeks pregnant,
G5p4, with Gestational Diabetes
and ultrasound states
that her baby was bigger than
the normal expected weight for
9:30 the gestational age.
A- Vital signs taken and recorded
as follows:
BP:120/90, RR: 22, P: 89 ,
T: 37.2
-Initial assessment was done
including:
I.E: 4cm , CbG: 200
mg/dl
-Instruct patient for comfortable
position to reduce the pain.
-Assisted the patient in placing a
perineal pad for the vaginal
discharge.
- Started PNSS IV that runs for
8 hours as ordered.
- Inserted a Foley catheter as
ordered.
-Advised NPO to the patient.
-Facilitated transfer thru
completion of referral sheet as
endorsement sheet to the
receiving facility.
- Latest CBG was checked
before transfer.
10:00 A.M - Informed the patient and
relatives about the transfer
and the plan procedure.
R- Pain was slightly reduced
from 6/10 to 4/10. The patient
was transferred to the tertiary
hospital, BRTTH.
NURSES’ NOTES

MA.DIONELA C. ENCINAS
BSN II-BUPC GROUP 7

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