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.

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 RnHeals Nurse

Mrs. Araceli Navarro Area Supervisor

Dr. Alma B. Ungab Chief Nurse