# Devise progress notes (FDARE) base on the scenario below. Jenny a 32 years old, G2P1, on her 39 3/7 gestationalweek, was admitted to Adventist Medical Center-Bacolod, On March22, 2021, at 9:30 am because of labor pains. No known medicalcondition was not

匿名用户 最后更新于 2021-12-01 19:32 护理学Nursing

# Devise progress notes (FDARE) base on the scenario below.

Jenny a 32 years old, G2P1, on her 39 3/7 gestationalweek, was admitted to Adventist Medical Center-Bacolod, On March22, 2021, at 9:30 am because of labor pains. No known medicalcondition was noted. Present pregnancy with no complications. IEdone revealed 2 cm cervical dilation upon admission. OB-Gynedecided to perform ARM (Artificial Rupture of Membrane) however,uterine contraction remains to be the same. Labor contraction atvery irregular intervals, duration of 40-55 seconds. At 2:30 pmphysician ordered Syntocinon drip at 15 mcgtts/min to titer uterinecontractions every 30 minutes. Labor progresses well at 4:30 pm,client’s noted to have regular uterine contractions 0f 10- 20minutes interval, durations of 50-75 seconds, FHB at 136beats/minutes. Second IE was done at 5 pm 8 cm cervical dilationand the woman has wheeled to the Delivery room at 7:00 pm anddelivered to a male baby with a weight of 3.5 kgs. and APGAR scoreof 9 and 10 taken at 1 and 10minutes.

Day/Shift Time

Focus

ProgressNotes (D=Data, A=Action, R=Reaction, E=Evaluation)

F1 - Labor pains

F2 - Irregular interval of uterine contractions

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