Name of Patient: Glenda Marie Cain_ Bed No.

: 369

PHYSICAL ASSESSMENT

General Condition: received from bed conscious, coherent with urinary catheter and IVF of D5LR 1L at
800cc level inserted at left metacarpal vein, infusing well.

Vital signs: BP-110/60mmHg PR- 87bpm RR- 17bpm T- 36.6˚C

Eyes: slightly pale conjunctiva

Nose: at midline, no flaring, (-) discharge

Ears: symmetrical, bean shape, (-) discharge

Mouth: symmetrical in movement, no lesions

Neck: straight, (-) mass, (-) JVD

Breast: symmetrical, (-) mass

Nipples: lactating, protruded, (-) cracked and sore

Chest: clear breath sounds, normal heart rhythm

Abdomen: with proper wound dressing and binder

Perineum: lochia rubra, with Foley catheter

Lower extremities: (-) edema nor varicosities

F-DAR CHARTING

DATE FOCUS DAR

March 27, 2019 Postpartum Care D- on bed, conscious with Foley
catheter IVF of D5LR 1L at 800cc
level inserted at left metacarpal
vein
A- tag checked, vital signs taken and
recorded, physical assessment
done, health teaching instructed,
advise danger signs of postpartum
R-the patient is positively accepted
all the advices given
Name of Patient: Glenda Marie Cain_ Bed No.: 369

PHYSICAL ASSESSMENT

General Condition: received from bed conscious, coherent

Vital signs: BP-100/60mmHg PR- 89bpm RR- 18bpm T- 37.4˚C

Eyes: slightly pale conjunctiva

Nose: at midline, no flaring, (-) discharge

Ears: symmetrical, bean shape, (-) discharge

Mouth: symmetrical in movement, no lesions

Neck: straight, (-) mass, (-) JVD

Breast: symmetrical, warm, (-) mass

Nipples: lactating, protruded, (-) cracked and sore

Chest: clear breath sounds, normal heart rhythm

Abdomen: with proper wound dressing and binder

Perineum: lochia rubra, with Foley catheter

Lower extremities: (+) edema, (-) varicosities

F-DAR CHARTING

DATE FOCUS DAR

March 28, 2019 Postpartum Care D- on bed, conscious with Foley
catheter
A- tag checked, vital signs taken and
recorded, physical assessment done
with edema of lower extremities,
health teaching instructed
especially in elevation of lower
limbs and avoid too much salty
foods, advise danger signs of
postpartum
R-the patient is positively accepted
all the advices given
MIDWIFERY CARE PLAN

PROBLEM OBJECTIVE MANAGEMENT EVALUATION

Subject: “sumasakit - To lessen the pain - Accept patient’s After midwifery
po ang tahi ko” - To make her description of pain interventions the goals
verbalized by the comfortable - Obtain vital signs are met by seeing the
patient - Promote relaxation - Encourage patients patient performed
Pain Scale: 5/10 - To move to use proper correctly and use of
As 0 is less painful appropriately breathing relaxation activities. The
and 10 is highest. techniques and patient was able to
With the pain positioning verbalized the latest
characteristics of - Assess patient’s pain scale from 5/10 to
moderate pain current use of 3/10
Objective: medications
(+) facial grimace
Vital signs taken as
follows:
BP-110/60mmHg
PR- 87bpm
RR- 17bpm
T- 36.6˚C

Name of Patient: Diana Rose Raguidin Bed No.: 301

PHYSICAL ASSESSMENT

General Condition: received from bed conscious, coherent

Vital signs: BP-110/70mmHg PR- 86bpm RR- 19bpm T- 37.2˚C

Eyes: pinkish conjunctiva

Nose: at midline, no flaring, (-) discharge

Ears: symmetrical, bean shape, (-) discharge

Mouth: symmetrical in movement, no lesions

Neck: straight, (-) mass, (-) JVD

Breast: symmetrical, (-) mass, non-tender upon palpation

Nipples: lactating, protruded, (+) cracked

Chest: clear breath sounds, normal heart rhythm

Abdomen: with proper wound dressing and binder

Perineum: lochia serosa, (-) foul smelling

Lower extremities: (-) edema and varicosities

F-DAR CHARTING

DATE FOCUS DAR

March 28, 2019 Postpartum Care D- on bed, conscious, coherent
A- tag checked, vital signs taken and
recorded, physical assessment done
with cracked nipple, health teaching
instructed, advise danger signs of
postpartum
R-the patient is positively accepted
all the advices given

MIDWIFERY CARE PLAN

PROBLEM OBJECTIVE MANAGEMENT EVALUATION

Subject: “may sugat - To lessen the pain - Accept patient’s After midwifery
po ung utong ko” - To make her description of pain interventions the goals
verbalized by the comfortable when - Obtain vital signs are met gradually by
patient breastfeeding - Encourage patients seeing the patient’s sore
Pain Scale: 4/10 - Promote relaxation to use proper nipple dry, performed
As 0 is less painful breastfeeding properly the techniques
and 10 is highest. techniques and of breastfeeding and use
With the pain positioning of relaxation activities.
characteristics of mild - Assess patient’s to The patient was able to
pain apply few drops of verbalized the latest pain
Objective: expressed milk on scale from 4/10 to 0/10
(+) sore nipples the sore nipple
(+) facial grimace
when the baby suck

Vital signs taken as

follows:
BP-110/70mmHg
PR- 86bpm
RR- 19bpm
T- 37.2˚C
NAME OF PATIENT: Monaline Valiente BED NO.: 352

PHYSICAL ASSESSMENT

General Condition: received from bed conscious, coherent

Vital signs: BP-120/80mmHg PR- 89bpm RR- 18bpm T- 36.2˚C

Eyes: pinkish conjunctiva

Nose: at midline, no flaring, (-) discharge

Ears: symmetrical, bean shape, (-) discharge

Mouth: symmetrical in movement, no lesions

Neck: straight, (-) mass, (-) JVD

Breast: symmetrical, (-) mass, non-tender

Nipples: (-) lactation, protruded, (-) cracked and sore

Chest: clear breath sounds, normal heart rhythm

Abdomen: with proper wound dressing and binder

Perineum: lochia alba, (-) foul smelling

Lower extremities: (-) edema nor varicosities

F-DAR CHARTING

DATE FOCUS DAR

March 28, 2019 Postpartum Care D- on bed, conscious, coherent
A- tag checked, vital signs taken and
recorded, physical assessment done
with complaint for insufficient
breast milk, health teaching
instructed, advise danger signs of
postpartum
R-the patient is positively accepted
all the advices given

MIDWIFERY CARE PLAN

PROBLEM OBJECTIVE MANAGEMENT EVALUATION
Subject: “Hindi po - To increase the - Accept patient’s After midwifery
sapat ung nilalabas secretion of milk description of pain interventions the goals
na gatas ng suso ko” - To increase level of - Obtain vital signs are met by seeing the
verbalized by the confidence - Apply warm patient followed the
patient - To make her compress instructions correctly
Objective: comfortable - Encourage patients and satisfy. The patient
- Insufficient - Promote relaxation to effective and was able to verbalized
breastmilk - Promote effective frequent pumping her feelings:
- Non- tender breast breastfeeding or suckling of infant “lumalabas na yung
- No one suck her to stimulate milk gatas sa suso at
breast secretion nakakapagpadede
Vital signs taken as - Eat nutritious foods narin ako ng madalas
follows: and increased fluid sa baby ko”
intake
BP-120/80mmHg
- Alternate of
PR- 89bpm
breastfeeding
RR- 18bpm
- Take time to rest
T- 36.2˚C

MIDWIFERY
CARE PLAN
 (CAESAREAN
SECTION MODULE)

4 Physical assessments
4 Focus- Data, Action and Response
3 Midwifery care plan