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Labor and Delivery Nursing Notes

Mrs. M.B., a 32-year-old female patient, was admitted to the labor and delivery room for childbirth. Over the course of her shift from 3pm to 11pm, the nurse monitored the patient's labor pain, ineffective tissue perfusion following delivery of the placenta, and risk of infection to her perineal area postpartum. The nurse assessed the patient, administered medications and IV fluids as ordered, educated the patient, and recorded the patient's responses, which included manageable pain levels and prevention of infection through education.

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318 views3 pages

Labor and Delivery Nursing Notes

Mrs. M.B., a 32-year-old female patient, was admitted to the labor and delivery room for childbirth. Over the course of her shift from 3pm to 11pm, the nurse monitored the patient's labor pain, ineffective tissue perfusion following delivery of the placenta, and risk of infection to her perineal area postpartum. The nurse assessed the patient, administered medications and IV fluids as ordered, educated the patient, and recorded the patient's responses, which included manageable pain levels and prevention of infection through education.

Uploaded by

aron fronda
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We take content rights seriously. If you suspect this is your content, claim it here.
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NURSES' NOTES

PATIENT NAME: Mrs. M.B. AGE: 32 HOSPITAL No.: 123


PHYSICIAN: Dra. Lilibeth Hipol SEX: F WARD/ROOM: Labor and delivery room

DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE NURSSE SIGNATURE


D – The patient verbalized that “ It started to have contraction again and it was painful”.
December 13, 2021 - Facial grimacing noted at 8 pm.
3pm – 11pm shift Labor pain
- Patient winces slightly when uterine contraction occurs
3:00 pm
- The patient is feeling somewhat uncomfortable.

3:30 pm A – Monitored vital signs of both patient and the fetus.


- Assessed current knowledge of obstetric pain control measures.
- Coached use of appropriate breathing/relaxation techniques.
- Recommended that client void every 1-2 hours.
- Provided diversional activities.

4:45 pm - Administered Nubain as prescribed by the physician.

5:00 pm - Assisted the anaesthesiologist in epidural or caudal anaesthetic is to be used.

7:00 pm R – Patient was able to verbalized that pain is at manageable level.

Fronda, Aron John B. SN II /


 
Henson, Rowena
NURSES' NOTES
PATIENT NAME: Mrs. M.B AGE: 32 HOSPITAL No.: 123
PHYSICIAN: Dra. Lilibeth Hipol SEX: F WARD/ROOM: Labor and delivery room

DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE NURSSE SIGNATURE


D – The patient stated that “ I can feel some flow of blood”.
December 13, 2021 - Gush of blood during the placenta delivery
Ineffective Tissue Perfusion
3pm – 11pm shift - Dry and scaly skin
3:00 pm - Placenta was delivered.
3:45 pm A – Monitored and recorded vital signs.
- Maintained on bed rest
- Assessed skin color, temperature, moisture turgor and capillary refill.
- Monitored restlessness, anxiety, hunger and changes in level of consciousness.
- Elevated extremities above the level of heart
4:30 pm - Administered IV fluids as ordered.

4:45 pm - Administered supplemental oxygen as ordered

6:30 pm R – Patient demonstrated behaviours to improve systemic circulation as evidenced by patient normal
breathing, good capillary refill, normal skin color and normal vital signs.

Fronda, Aron John B. SN II /


 
Henson, Rowena
NURSES' NOTES
PATIENT NAME: Mrs. M.B AGE: 32 HOSPITAL No.: 123
PHYSICIAN: Dra. Lilibeth Hipol SEX: F WARD/ROOM: Labor and delivery room

DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE NURSSE SIGNATURE


D – The patient stated that” there is still small amount of blood coming out from my perineal
area”.
December 13, 2021
Risk for infection - Skin is torn due to birthing process : NSVD (Normal spontaneous vaginal delivery)
3pm – 11pm shift
3:00 pm - Patient has 6 stitches on perineal area.
- Perineal area is swollen and having redness.

3:30 pm A – Observed for localized signs of infection at the wound site.


- Monitored vital signs especially for temperature.
- Encourage use of peri-bottle after using the bathroom.
- Stressed proper hand hygiene
- Taught the client on proper dressing changes, perineal care and wound care.
4:30 pm
- Educated on and emphasized proper use of antibiotics where appropriate.

6:00 pm R – Patient remained afebrile until discharged. She verbalized understanding of importance of
preventing infection to perineal area.

Fronda, Aron John B. SN II /


 
Henson, Rowena

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