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ACCOMPLISHMENT REPORT
LABOR/DELIVERY ROOM
March 1-31, 2013
I. Assessment
1. Established rapport done through consistency of warmth and
openness
towards the patients upon interaction.
2. Obtained nursing history done through intensive interviews
using open
ended, closed ended, and probing questions when necessary.
3. Performed physical assessment for daily assessment, a 5
minute head
to toe assessment was done to all patients upon receiving them
from
the previous shift.
4. Identified subjective and objective problems of patients.
5. Detected abnormalities from the assessment and results of
diagnostics
examinations and reports. These findings are recorded and
referred to
the physicians.
6. Established nursing diagnosis based on the data gathered
using
NANDA approved Nursing Diagnosis.
II. Planning
1. Prioritized needs and problems of patients.
2. Formulated nursing care program that starts from the
admission of the
patient to the ward up to discharge from the institution.
III. Implementation
1. Carried out plan of care.
2. Administered prescribed treatment with efficiency.
3. Administered prescribed medications bearing in mind the
rights to
drug administration.
4. Gave health teachings to patients, evaluated patients through
simple
assessment questions, return demonstrations and giving of
opinions.
5. Conducted ward classes using innovative techniques so as to
facilitate
better understanding.
6. Provided social, emotional, psychological, and spiritual
support.
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7. Maintained a therapeutic environment.
IV. Evaluation
1. Evaluated effects of nursing care through reassessment of
subjective
and objective cues.
2. Notified immediate superiors for unusual, untoward, difficult
situational
conditions.
V. Documentation
1. Recorded assessments, interventions and evaluations of
nursing care.
Prepared by: Noted by:
Grace Marie R. Solis Mrs. Araceli Navarro
RnHeals Nurse Area Supervisor
Dr. Alma B. Ungab
Chief Nurse
