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  • Nurses Notes

    Transféré par

    Avyel Kram
    9K vues2 pages
    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.

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    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.

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    Attribution Non-Commercial (BY-NC)
    Téléchargez comme DOC, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    9K vues2 pages

    Nurses Notes

    Transféré par

    Avyel Kram
    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.

    Droits d'auteur :

    Attribution Non-Commercial (BY-NC)
    Téléchargez comme DOC, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 2

    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

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