NURSERY TEMPLATE Benguet General Hospital

DATE & TIME

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FOCUS

PROGRESS NOTES (DAR CHARTING)

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Immediate Newborn D>Born an alive baby boy/girl via NSD attended by Dr. (OBCare GYNE)____________. (For private patients, pls. include that baby was received by Dr. ____________ (Pediatrician) >Into DR from OR an alive baby _______ cuddled by Dr.____________. >With loud/weak cry; with 1-2 loose/tight cord loop, thin/thick meconium stain; pinkinsh/acrocyanotic in color; caput succedaneum, with abundant/moderate/scant vernix casseosa noted all over the body/back/buttocks/groin/armpit; with moderate lanugo at the back; with strong flexion and extension of extremities; with positive urine output; with positive stool, APGAR score of _______, _______ at 1 and 5 minutes respectively. Promoting Bonding, >Placed on mothers abdomen, immediate wiping of oronasal secretions Airway and Cord and blood stain done; initiated bonding with mother through skin to Care skin contact; cord clamped and cut aseptically when pulsation stopped; placed under radiant warmer; oronasal secretion suctioned (if it was done); Hooked to oxygen via face mask/nasal cannula. >Anthropometric measurement taken as follows: Wt ______kgs, LData and _____cms, HC-_______cm, CC-______cm, AbC-_____cm, ArmC-____cm, foot Identification prints taken; clothed baby and placed name tag on left foot; credes prophylaxis applied on both eyes from inner canthus to outer canthus and Vit. K 0.1 mL given IM at left vastus lateralis. >0.5 mL HepB administered via IM at right vastus lateralis, monitored accordingly. Hep B vaccination >Seen and examined by Dr._______________. >Cleansed breast of mother, latching done with good/fair sucking reflex noted. Nutrition and R>With latest vital signs of Temp-_______C, CR-_______bpm, RRBonding ______cpm. Unit Transfer >Brought to OB ward beside mother per stretcher accompanied by IWOD/RNSE on duty/SNOD.

RECEIVING BABY UNDER RADIANT WARMER (CS)

DATE
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FOCUS
Immediate Newborn Care

PROGRESS NOTES
D>Received an alive baby ____ under radiant warmer with ongoing oxygen per nasal cannula at ____LPM >With loud /weak cry, pinkish/acrocyanotic, with initial vital signs of Temp- ____C, CR-____,RR-______. >Nasal flaring/grunting/club foot. A>promoted safety by putting pillow at the side, Monitoted vital signs and recorded. (More interventions) >Latching done to mother at PACU?OB with good/fair sucking reflex R>With latest vital signs of Temp____, CR____, RR_____ >Roomed into mother at OB/PACU cuddled by NOD.

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Nutrition and Bonding Unit Transfer