MATERNAL POST CESAREAN SECTION RECOVERY RECORD
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1 DELIVERY: DATE / : SEX: WEIGHT: BR: BT: ADMITTING NURSE: M F DATE / : TYPE of ANESTHESIA: ACCOMPANYING MEMBER of ANESTHESIA: DATE V I T A L S I G N S BP TEMP PULSE RESP LOC COLOR SKIN ABD DSG/ INCISION A S S E S S M E N T S EKG O 2 SAT O 2 POSITION Sensory Level Motor Funct'n INITIALS: NURSE'S SIGNATURE / TITLE: INITIALS: NURSE'S SIGNATURE / TITLE: PAGE 1 of 6
2 ALLERGIES: I:O TOTALS: Shift #1 Shift #1 INTAKE: Shift #2 OUTPUT: Shift #2 TOTAL TOTAL Bladder PALP Urine COLOR Urine CHAR A S S E S S M E N T S IV SITE FUNDUS LOCHIA PERINEUM PERICARE PAD CHGD MAINLINE IV TYPE AMT I N T A K E MAINLINE IV TYPE AMT MAINLINE IV TYPE AMT P.O. INITIALS: NURSE'S SIGNATURE / TITLE: INITIALS: NURSE'S SIGNATURE / TITLE: PAGE 2 of 6
3 TEDS ON: YES NO DATE: : N U R S I N G N O T E S NURSING NOTES SCUDS ON: YES NO O U T P U T T E A C H I N G INIT URINE EMESIS OTHER CODES RESPONSE INIT INITIALS: NURSE'S SIGNATURE / TITLE: INITIALS: NURSE'S SIGNATURE / TITLE: PAGE 3 of 6
4 PAIN SCALES: WONG-BAKER: ( Faces ) P A I N M A N A G E M E N T R E C O R D 0-10 VISUAL: 0 ( Numeric ) VERBAL: No Hurt NON-COGNITIVE: ( FLACC Scale ) [1] Sum FACE, LEGS, ACTIVITY, CRY & CONSOLABILITY FACE 0 = No particular expression LEGS 0 = Normal position, relaxed ACTIVITY 0 = Lying quietly, normal CRY 0 = No crying (awake or CONSOLABILITY 0 = Content, relaxed Scores to calculate 0 = or smile 0 = position, moves easily 0 = asleep) FLACC Score. 1 = Sporadic grimace / frown, 1 = Uneasy, restless, tense 1 = Squirming, shifting back 1 = Moans or whimpers, 1 = Reassured by sporadic hugging, [2] Record FLACC 1 = withdrawn, disinterested 1 = and forth, tense 1 = occasional complaint 1 = touching or talking to, distractable Score w/ 0-10 NUMERIC 2 = Frequent / constant frown, 2 = Kicking, or legs drawn 2 = Arched, rigid or jer 2 = Crying steadily, screams or 2 = Difficult to console or comfort Scale above. 1 =clenched jaw, quivering chin 1 = up 1 = sobs, frequent complaints COMFORT GOAL: PAIN RATING SCALE USED: MEDICATION Hurts Little Bit Hurts Little More Hurts Even More 8 9 Hurts Whole Lot WONG-BAKER FACES PAIN SCALE from Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Ahmann E, DiVito-Thomas PA, Whaley & Wong: Nursing Care of Infants & Children, 6th ed, St. Louis, MO: Mosby-Year Book Inc., 1999; Copyrighted by Mosby-Year Book, Inc. Reprinted with Permission. SEDATION (LOC) RATING PAIN RATING INTERVENTION INIT'LS EVALUATION / PAIN # 10 Worst Pain INIT'LS DATE M E D I C A T I O N A D M I N I S T R A T I O N R E C O R D MEDICATION DOSE ROUTE SITE INIT'LS DATE UP UP IV SOLUTION I N F U S I O N AMOUNT UP R E C O R D RATE NURSE INITIALS DATE NURSE CONT. DOWN DOWN INITIALS PUMP ( / ) AMOUNT WASTED Date / Time Drawn WBC HGB HCT PLTS PT PTT Fibrogen D-Dimer L A B O R A T O R Y GLU BUN NA + K + CL CO 2 CR Alk Phos R E P O R T S LDH SGOT SGPT Uric Acid Tot Prot MG ++ GLU U R I N E Prot BLD KET R E S U L T S INITIALS PAGE 4 of 6
5 A S S E S S M E N T C O D E S ( * R e q u i r e s a N U R S I N G N O T E ) LEVEL OF CONSCIOUSNESS OR SEDATION RATING: COLOR: SKIN: ABD DRESSING: S - Normal sleep, easy to arouse, oriented when awakened, appropriate cognitive N - Normal (pink) W - Warm I - Intact behavior P - Pale D - Dry D - Dry 1 - Wide awake-alert (or at baseline), oriented, initiates conversation G - Grey* C - Cool W - With drainage* 2 - Drowsy, easy to arouse, oriented & demonstrates appropriate cognitive B - Blue* M - Moist R - Dressing Reinforced* behavior when awake 3 - Drowsy, somewhat difficult to arouse, but oriented when awake EKG: VT - Ventricular Tachycardia* 4 - Difficult to rouse, confused, not oriented NSR - Normal Sinus Rythym VFib - Ventricular Fibrillation* 5 - Unarousable SB - Sinus Bradycardia AT - Atrial Tachycardia* ST - Sinus Tachycardia AFib - Atrial Fibrillation* POSITION: PAC - Premature Atrial Contraction* AF - Atrial Flutter* L Lat - Left Lateral S - Supine SF - Semi-Fowlers PVC - Premature Ventricular Contraction* A - Asytole* R Lat - Right Lateral T - Trendelenburg HF - High-Fowlers BLADDER CHECK: OXYGEN: PERINEUM: PERICARE: FUNDUS: P - Palpable Liters per minute I - Intact Y - Yes F - Firm FM - Firm w/ Massage N - Nonpalpable M - Mask RA - Room Air S - Swollen N - No B - Boggy N - Not Found* F - Foley NC - Nasal Cannula SENSORY LEVEL: URINE ASSESSMENT: IV CODES: LOCHIA: T4 - Nipple* - COLOR - - CHARACTER - O - Site without redness, RAC - Right Antecubital SC - Scant T6 - Xiphoid* Y - Yellow C - Clear swelling, induration LAC - Left Antecubital MOD - Moderate T8 - Lower Ribs A - Amber Cl - Cloudy S - Symptomatic* LLA - Left Lower Arm H - Heavy T10 - Umbilicus O - Orange S - Sediment RLA - Right Lower Arm LH - Left Hand P - Profound* T12 - Lower Abd B - Blood Tinged RH - Right Hand C - Significant Clots* R - Rubra PAIN MANAGEMENT INTERVENTIONS: PAD CHANGE: MOTOR FUNCTION: BRB - Bright Red 1 - Discuss pain management C - Relaxation P - Peripad changed 0 - Unable to move toes or bend knees Bleeding* plan with physician Technique I - Icepack changed 1 - Able to move toes; unable to bend knees 2 - Pharmacological D - Splinting C - Chux changed 2 - Able to move toes and bend knees, but weak 3 - Non-Pharmacological E - Imagery 3 - Able to move toes and bend knees easily, strong A - Position change F - Education 4 - Ambulating, if appropriate B - Music G - Other* TEACHING CODES: 11 - Wound Care 1 - Room Orientation 3 - Postoperative Care 5 - PCA 7 - Breastfeeding 9 - Security Measures 12 - Bulb Syringe 2 - Nursery Orientation 4 - APS 6 - Newborn Care 8 - Medications 10 - Pericare 13 - Incentive Spirometer Temp: Initially; every hr x 4 hrs; then every 4 hrs. Constant bedside surveillance: for at least 30 For all C-Section Patients: BP, P, R: Initially; every 15 min x 4; then every 30 min min or until stable Print a strip (6 seconds) at beginning x 2; then every hr x 2; then every 4 hrs. of recovery period and at the end. Skin Color / Condition, LOC, IV Site: Initially; PRN BP, P, R, LOC, Color, EKG & O2 Sat: Initially and Also, print a 6 second strip anytime (if changes); and upon Discharge. every 5 min x 6 (or stable); every 15 min x 6 the pattern changes. Place all strips EKG & Oxygen Sat, Fundus, Lochia, Perineum: (stable patient may be transferred or have EKG in the designated area. Initially; every 15 min x 4; then every 30 min x 2; & pulse ox dc'd); every 30 min x 2; then every hr then every hr x 2; then 4 hrs (EKG & Pulse Oximetry x 2; then every 4 hrs until transferred. PAIN MANAGEMENT: may be discontinued after 1 hr if stable). Oxygen: When started, changed or discontinued Temp, Skin, Abd, Dsg, Fundus, Lochia, I&O: Initially, before and after interven- Motor Function / Sensory Level: Initially & every hr Urine color and character, pericare / pad change, tions, and prior to transfer (see until returning to patient baseline. IV site, oxygen as per regional anesthesia. hospital standard - pain assessment Complete Post Anesthetic Score Bladder Assessment & Intake / Output: Every hr x 4 hrs Complete Post Anesthetic Score: Pericare / Pad Change: PRN & prior to discharge S T A N D A R D S O F C A R E : C e s a r e a n S e c t i o n D e l i v e ry REGIONAL ANESTHESIA: GENERAL ANESTHESIA: EKG STRIPS: to be documented at least every PAGE 5 of 6 8 hrs).
6 E K G S T R I P S H E R E POST ANESTHETIC SCORE: Criteria Score SpO2 > 95% Room Air 2 SpO2 > 95% with O2 1 SpO2 < 95% with O2 * 0 Spontaneous Resp s Airway 2 Spontaneous Resp c Airway 1 Respiratory Support Required * 0 SBP + 20mmHg Pre Op 2 SBP mmHg Pre Op 1 SBP + 50mmHg Pre Op * 0 Aware of self & surroundings 2 Arousable on Calling 1 Unresponsive to Mild Stimuli * 0 Moves 4 Extremities on Command 2 Moves 2 Extremities on Command 1 Moves 0 Extremities on Command 0 TOTAL: DISCHARGING NURSE / TITLE / : ADMIT 30 MIN 1 HR DISCH COMMENTS REPORT TO UNIT NURSE: PAGE 6 of 6
PART OF THE MEDICAL RECORD
: VITAL SIGNS FETAL HEART RATE CONTRACTIONS OB ASSESSMENT O 2 TEMP B P PULSE RESP MONITOR MODE BASELINE VARIABILITY ACCELERATION DECELERATION MONITOR MODE FREQUENCY DURATION INTENSITY RESTING TONE EFF
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