NURSES NOTES
NAME OF PATIENT: WARD: HOSPITAL NO.:
DATE TIME FOCUS DATA/ACTION/RESPONSE
Postpartum D - Received patient lying on bed, with IV D5LR
Monitoring 1L@kvo hooked at left metacarpal vien; Mrs. X, 35-year-
and Care old, G5P4 (4014);the pt postpartum delivering a healthy
baby girl on June 30, 2024, at 10:52 pm. Patient's vital
signs are stable: BP: 131/88 mmHg, HR: 74 bpm, RR: 21
bpm, Temp.: 36.6°C, O2Sat: 99%. The patient reports no
pain or discomfort. She is breastfeeding her baby with
proper latch technique and no complications noted. No
signs of infection, bleeding. Breast: no lesions,
discharges, or lumps noted. The abdomen is soft, non-
tender, and free of pain.
A-Monitored vital signs as ordered. Encouraged the
patient to continue breastfeeding and provided education
on proper breastfeeding techniques. Administered
postpartum medications as ordered, including oxytocin,
cefuroxime, ferrous sulfate, and mefenamic acid.
Assessed the incision site for any signs of infection or
abnormal discharge; none noted. Ensured patient
comfort by adjusting bed position for breastfeeding and
resting. Monitored for any signs of postpartum
complications such as hemorrhage, pain, or abnormal
vaginal discharge. Provided supportive care and
answered patient queries.
R - Patient tolerated medications well, with no adverse
reactions noted. Vital signs remained stable throughout
the shift. Patient successfully initiated breastfeeding with
proper latch and reported no significant discomfort. No
abnormal postpartum symptoms observed. Patient is in a
collaborative mood and is receptive to teaching. Ongoing
monitoring and care to continue with focus on recovery
and newborn care.
**FDAR Nurse's Notes for Baby**
**Focus**: Newborn Assessment and Monitoring
Data:
- A healthy baby girl delivered on June 30, 2024, at 10:52
pm.
- Newborn with appropriate muscle tone and reflexes.
- Skin color is pink, no signs of jaundice.
- Effective sucking and swallowing observed during
breastfeeding.
- Temperature: 36.7°C.
- Anthropometric measurements: Head Circumference
(HC) - 34 cm, Chest Circumference (CC) - 32 cm,
Abdominal Circumference (AC) - 31 cm, Body Length
(BL) - 50 cm.
Action:
- Conducted a full newborn assessment, including muscle
tone, reflexes, and skin condition.
- Monitored vital signs, temperature, and feeding
response.
- Encouraged breastfeeding and provided support to the
mother for proper latching and feeding.
- Educated mother on breastfeeding techniques and signs
to watch for regarding jaundice or feeding issues.
Response
- Baby is feeding well with effective sucking and
swallowing.
- Muscle tone and reflexes are appropriate for age.
- Skin remains pink, no signs of jaundice.
- Temperature stable at 36.7°C.
- Baby is calm and comfortable, showing no signs of
distress. Ongoing monitoring to continue.
