Scribd
Upload
5K views2 pages

NICU Nursing Notes for Newborn Care

This document contains nurses notes for a newborn patient. It includes the patient's name, age, and diagnosis. The notes document the routine care provided to the newborn, including drying, identification, skin-to-skin contact with the mother, cord clamping and cutting, measurements, routine care, eye prophylaxis, vitamin K and hepatitis B vaccines administered. The notes also indicate the newborn was kept warm, secretions were suctioned as needed, and oxygen was provided via nasal cannula. The newborn was able to breathe effectively and appeared pinkish.

Uploaded by

Avyel Kram
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
5K views2 pages

NICU Nursing Notes for Newborn Care

This document contains nurses notes for a newborn patient. It includes the patient's name, age, and diagnosis. The notes document the routine care provided to the newborn, including drying, identification, skin-to-skin contact with the mother, cord clamping and cutting, measurements, routine care, eye prophylaxis, vitamin K and hepatitis B vaccines administered. The notes also indicate the newborn was kept warm, secretions were suctioned as needed, and oxygen was provided via nasal cannula. The newborn was able to breathe effectively and appeared pinkish.

Uploaded by

Avyel Kram
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
  • Nurses Notes

NURSES NOTES

NAME OF PATIENT:

AGE:

DIAGNOSIS:

DATE/TIME

FOCUS Respiratory Status

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 contact 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 Credes 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 babys condition R> Able to breathe effectively, pinkish in appearance Roomed-In with the mother Admit to NICU for further management and evaluation, Accompanied by Hold-over NOD & Relatives ________________________,RN

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

FM-NUR-NNHOA

NURSES NOTES NAME OF PATIENT: AGE: DIAGNOSIS: DATE/TIME FOCUS DATA/ACTION/RESPONSE Received from to an a
FM-NUR-NNHOA

You might also like