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Date/Time Focus Data, Action, Response

This document contains medical records documenting the care of a newborn and mother over several days: - The newborn was assessed daily, vital signs were taken and recorded, the newborn was breastfeeding with strict precautions and receiving newborn care. - The mother was also assessed daily in the postpartum period, encouraged to breastfeed, and given advice on hygiene. - On the third day, the newborn was sleeping and attending by the mother, breathing normally and breastfeeding, with all assessments normal.

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Roland Yuste
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15K views3 pages

Date/Time Focus Data, Action, Response

This document contains medical records documenting the care of a newborn and mother over several days: - The newborn was assessed daily, vital signs were taken and recorded, the newborn was breastfeeding with strict precautions and receiving newborn care. - The mother was also assessed daily in the postpartum period, encouraged to breastfeed, and given advice on hygiene. - On the third day, the newborn was sleeping and attending by the mother, breathing normally and breastfeeding, with all assessments normal.

Uploaded by

Roland Yuste
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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DATE/TIME FOCUS DATA, ACTION, RESPONSE

04/27/2020 post endorsement D-Awake, Reactive and


assessment Responsive to tactile stimuli,
0600h
attended by mother, Still for
newborn screening test, still for
newborn hearing screening test,
Still for Bcg vaccine, on
breastfeeding with strict
aspiration precaution

Newborn Care
0800h D- term birth male

A- assessed, vital signs taken and


recorded, daily cord care done,
kept monitored
0900h
R- newborn care done

DATE/TIME FOCUS DATA, ACTION, RESPONSE

04/28/20 post endorsement D- term birth male


assessment
0600h assessed, vital signs taken
and recorded, daily cord care
done, kept monitored
R- newborn care done

D- S/P NSD
post partum care
0800h A- assessed, vital signs taken
and recorded, encouraged
breastfeeding with strict
aspiration precaution, advised
daily hygiene and perineal
hygiene emphasized

R- post partum care done


0900h
04/29/20 post endorsement D- asleep, attended by the
assessment mother, reactive and responsive
0600h
to tactile stimuli, on breastfeeding
with strict aspiration precaution,
both bands checked, not in
distress

newborn care D- term birth male


0800h
A- assessed, vital signs taken
and recorded, encourage mother
breastfeeding with strict
aspiration precaution, kept
monitored, not in
distress
0900h
R- newborn care done

DATE/TIME FOCUS DATA, ACTION, RESPONSE

05/01/20 post transfer assessment D- live term baby boy, reactive


and responsive to tactile stimuli,
1000h
on breastfeeding with strict
aspiration precaution, not in
distress

1100h Newborn Care D- Assessed, vital signs taken and


recorded, encouraged to be breast
fed with strict aspiration precaution
and daily cord care done, not in
distress

R- Newborn care done


l1130h

05/01/05 Post Transfer Assessment D- received patient post NSD,


conscious and coherent, with IVF
1000h
of D5LR 1liter + oxytocin 10 units
10gtts/minute at the level of
800ml, on diet as tolerated, on
oral medications
05/01/20 Post partum Care D- post NSD

1100h A- Assessed, Vital signs taken and


recorded, advised mother to
breastfeed with strict aspiration
precaution, advised daily hygiene
and perineal hygiene emphasized

R- post partum care done


1130h

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