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Chart By: Sy, John Kenneth

The document summarizes the labor and delivery of Mrs. A. On February 8th, she presented with labor pains rated an 8/10 and was given relaxation techniques to alleviate the pain, which was reduced to a 3/10. On February 10th, she was experiencing strong regular contractions and was fully dilated. She was prepped for delivery and gave birth to a baby girl at 1:59 AM, with a well contracted uterus and slight vaginal bleeding.

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Kenneth Sy
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8K views1 page

Chart By: Sy, John Kenneth

The document summarizes the labor and delivery of Mrs. A. On February 8th, she presented with labor pains rated an 8/10 and was given relaxation techniques to alleviate the pain, which was reduced to a 3/10. On February 10th, she was experiencing strong regular contractions and was fully dilated. She was prepped for delivery and gave birth to a baby girl at 1:59 AM, with a well contracted uterus and slight vaginal bleeding.

Uploaded by

Kenneth Sy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Date/Time Focus Progress Notes

February 8, 2019 Labor Pain (Acute Pain) D: Complaints of Labor pain,


12:20 PM Patient verbalize “Parang
manganganak na yata ako”. Pain
scale 8/10, guarding behavior,
facial grimacing.
12:26 PM A: Help the patient to take deep
breath and relaxation techniques to
release tension from the muscle.
Keep patient comfortable and safe
and position the client into supine
lying position to alleviate the pain.
And evaluate the client’s
assessment of pain
R: Client appears relaxed resting
between contractions. Client
12:50 PM reports pain was relieved or
controlled. Pain scale of 3/10 or
below.

• February 10, 2019, Labor and Delivery D: strong regular contractions


1:00 AM observed, profuse perspiration
noted, full cervical dilatation.
1:10 AM A: Inducted to delivery room,
1:11 AM Mounted on the delivery table,
1:12 AM Positioned in lithotomy position.
Perineal preparation done.
Aseptically placed leggings and
baby's receiver on mother's
abdomen, coached on how to bear
down properly
1:59 AM Delivered an alive baby girl
2:20 AM R: With well contracted uterus and
slight vaginal bleeding, and
proceed with postpartum care

FDAR Nursing Chart


Client’s Data:
Name: Mrs. A
Birthdate: August 30, 1991
Age: 27 years
Chart by: Sy, John Kenneth

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