FOCUS CHARTING

Nurse’s Notes

Name of Patient: B.S.O.

Age: 32 yrs. old
Ward/ Bed Number: OB PHIC, Bed Number 4
Impression/ Diagnosis: G3P3 (2103) Pregnancy Uterine Full Term, Large for Gestational Age, Baby Boy, Delivered in Cephalic
Presentation via Spontaneous Vaginal Delivery
Date and time of interview: December 8, 2020; 8:00 AM

DATE/ TIME FOCUS DATA ACTION RESPONSE

December 8, Risk for deficient  24 hours MIO is 1L  Health teaching on 10:30 am. Verbalized
2020; fluid volume intake vs (include importance of understanding of
8:00 am output of mother). adequate fluid intake importance and risks of
(Monitoring Intake and (2-3L). and normal adequate fluid intake.
Output that helps amount that must be 11:30 am. Client
caregiver ensure that ingested. Highlight became more
patient has proper case where huge water cooperative and ingested
intake of fluid and other outputs are present for 300 cc of fluid. an hour
nutrients) showed that postpartum mother after intervention.
patient only consumed through diaphoresis
a total of 1000 mL and diuresis.
water in past 3 shifts.  Explain effects of
 Verbalized that even diminished fluid volume
with humid or dehydration such as
environment, she barely dizziness, fatigue and
consumes 500 mL of connection of lesser
bottled water for 8 breastmilk production
 hours. - “sa sulod sang to dehydration.
8 ka oras, wala ko gane  If not comfortable with
natunga ang isa ka litro this intervention,
na tubigan na dala gradual increase of
sakon sang akon fluid intake can be
asawa.” performed instead.
 Verbalized not wanting K.C.
to drink water and only
consume 1-1.5 liters of
water a day.
K.C.
Disturbed sleep  Unkept. Nurse notes  Teach the importance 10:30 am. Mother
pattern related to tired look as evidenced of rest in well-being of verbalizes importance of
exhaustion, by ragged appearance both mother and child. rest for both her and her
excitement of of the mother. For instance, extreme child.
childbirth and  Client verbalized sleep fatigue promotes 1:00 pm. Utilizes
environment disruption. - “natuyo pa development of breathing techniques
unconducive to rest ako ma’am kay tatlo gid postpartal depression. and other methods to
bala ka adlaw na sunod  Explain that ‘humid induce sleeping.
sunod gakadistorbo ang environment’  Mother wears clean
tulog ko kay ang ward experienced is normal and dry clothes while
du ka busy, gahod kag due to body induced sleeping.
sobra gid kainit.” diaphoresis but  Significant other
 “Ang bata ko pa abi environment must be takes care of baby
ma’am naga hibi pa maintained to keep the while mother is
kada gab e kag child warm. resting.
napadede ko pa.”  Kept clean and dry. 3:00 pm. Asleep.
K.C. Provide comfortable K.C.
and airy hospital gown.
 Promote ventilation.
 Assure mother that
noisy feedback will be
evaluated by the
authorities.
 Teach breathing
techniques, meditation
and relaxation methods
to induce sleeping.
 Encourage cooperation
of significant other in
taking care of the
baby.
K.C.