Nurses Notes 113m2w

NURSES NOTES

NAME OF PATIENT:

DATE/TIME

AGE:

FOCUS Respiratory Status

DIAGNOSIS:

DATA/ACTION/RESPONSE to an alive baby out @ thru

Received from Attended by Dr. D > Appearance:  Cry and Reflexes:  Anus:  Congenital Malformalities:  Others: A> Immediate and thorough drying, secured name tag @ Right ankle  Latched-on and early skin to skin between the mother & Newborn done  Properly timed cord clamping and cutting done aseptically  Non- separation of newborn from the mother to initiate early Breastfeeding and kangaroo care done  Anthropometric measurements done  Routine Newborn Care done  Crede’s Prophylaxis O.U. given  Vitamin K 0.1ml IM given  Hepa B Vaccine 0.5ml IM given  for NBS, BCG after 24 hrs.  Kept warm and dry, placed under droplight  For CBC, PC, BT-req.  For Hgt  CXR-APL  Inserted Heplock Aseptically  Suctioned Secretions PRN  O2 Inhalation @ ________________per nasal cannula  Bagmask/Intubation:____________________________  Venoclysis:________________________________  ROD Notified, Explained to relatives abt. the baby’s condition R> Able to breathe effectively, pinkish in appearance  Roomed-In with the mother  it to NICU for further management and evaluation, Accompanied by Hold-over NOD & Relatives ________________________,RN

FM-NUR-NNHOA