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> Admited a 27 year-old female, married, conscious and coherent, ambulatory, accompanied by relative, with a chief complaint of lumbo sacral pain, started 3 hours prior to admission; > Placed on comfortable position > VS taken and recorded as follows: T= 36.5 0C FHT = 145bpm P= 75bpm Site = RLQ R= 12bpm BP= 100/70mmHg > IE done, 5cms, (+) BOW > Consent for admission signed by relatives > Informed Dra. Balicuatro > Seen and examined by AP with orders noted and carried out as follows: > Closely watched and attended.
Time
7 am
Received with an IVF of D5 LRS 1 L + 10 units of oxytocin on around 300 cc & regulated at 42 gtts/min; consumed and removed @ 11 am
9 am With slight lochia rubra 10 am BP = 130/80 mmHg 10:30 am Visited by Dra. ________ with orders 12 nn Initial breastfeeding done / Breastfed her baby as demand 3 pm Consumed a bowl of rice gruel & 200mL of water
Sponge bath and perineal care done Endorsed for continuity of care