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                                                                                                                                                 Affix Patient ID Label                                                                                                                                                                                 Affix Patient ID Label                                                                                                                                                                                       Affix Patient ID Label                                                                                                                                                             Affix Patient ID Label
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              Newborn Flowsheet                                                                                                                                                              Newborn Flowsheet                                                                                                                                                                                                           Newborn Flowsheet                                                                                                                                                                      Plan of Care for Newborn
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Diagnosis:
               DATE:                                                              0700-1500                                                           TIME:                                   DATE:                                                           1500-2300                                                                                        TIME:                                                      DATE:                                                                       2300-0700                                                           TIME:                                 Hyperbilirubinemia        Ineffective airway clearance
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Hypoglycemia              Ineffective thermoregulation
                    Time:                                                                     RESPIRATORY                                                                                       Time:                                                                     RESPIRATORY                                                                                                                                             Time:                                                                           RESPIRATORY                                                                                   Ineffective breastfeeding
                    Weight (Grams/Pounds):                                                            Breath sounds clear, equal                                                                Weight (Grams/Pounds):                                                            Breath sounds clear, equal                                                                                                                      Weight (Grams/Pounds):                                                                  Breath sounds clear, equal
                    Temperature:                                                                      No distress noted                                                                         Temperature:                                                                      No distress noted                                                                                                                               Temperature:                                                                            No distress noted                                                                           NURSING DIAGNOSIS                                  NURSING INTERVENTIONS                                               EXPECTED OUTCOME
                    Apical Rate:                                                                      Diminished            Right        Left                                                   Apical Rate:                                                                      Diminished            Right        Left                                                                                                         Apical Rate:                                                                            Diminished            Right        Left                                             Ineffective airway clearance              Position the infant’s head to the side and suction the mouth          Newborn will maintain a patent airway and show
                    Respiratory Rate:                                                                 Rales                 Right        Left                                                   Respiratory Rate:                                                                 Rales                 Right        Left                                                                                                         Respiratory Rate:                                                                       Rales                 Right        Left                                             related to excessive secretions           as needed with a bulb syringe. If the nose also requires              no signs of respiratory distress throughout the
                    NIPS Score:                                                                       Rhonchi               Right        Left                                                   NIPS Score:                                                                       Rhonchi               Right        Left                                                                                                         NIPS Score:                                                                             Rhonchi               Right        Left                                             in airways.                               suctioning, suction it gently after suctioning the mouth.             admission, as demonstrated by respiratory rate of
                                                                                                      Stridor               Right        Left                                                                                                                                     Stridor               Right        Left                                                                                                                                                                                                 Stridor               Right        Left                                                                                                                                                             30 to 60 breaths per minute, apical pulse rate of
                                                                                                      Physician notified of abnormal findings                                                                                                                                     Physician notified of abnormal findings                                                                                                                                                                                                 Physician notified of abnormal findings                                             DATE:                                     Change the infant’s position frequently.                              120 to 160 beats per minute, clear breath sounds,
                    Breastfeeding Latch-see below key                                                                                                                                           Breastfeeding Latch                                                                                                                                                                                                               Breastfeeding Latch                                                                                                                                                                                                                                                                         and no cyanosis, retractions, flaring or grunting.
                                                                                              CARDIOVASCULAR                                                                                                                                                              CARDIOVASCULAR                                                                                                                                                                                                                          CARDIOVASCULAR                                                                              TIME:                                     Provide reassurance to the parents.
                    Time:                                                   O          R                                                                                                        Time:                                                   O          R                                                                                                                                                              Time:                                                           O     R
                                                                                                      Normal heart sounds-Strong, regular beat                                                                                                                                    Normal heart sounds-Strong, regular beat                                                                                                                                                                                                Normal heart sounds-Strong, regular beat                                            INITIALS:                                 Demonstrate and explain use of the bulb syringe to parent(s).         Before discharge, parent(s) will demonstrate correct
                    L           A    T        C         H                                                                                                                                       L           A    T        C         H                                                                                                                                                                                             L             A              T               C       H                                                                                                                                                                                                                                      use of the bulb syringe and verbalize when it should
                    Time:                                                                             Irregular heart beat                                                                      Time:                                                                             Irregular heart beat                                                                                                                            Time:                                                                                   Irregular heart beat                                                                                                          Assess their ability and make suggestions as needed during
                                                                                                      Murmur auscultated                                                                                                                                                          Murmur auscultated                                                                                                                                                                                                                      Murmur auscultated                                                                                                            return demonstration.                                                 be used.
                    L           A    T        C         H                                                                                                                                       L           A    T        C         H                                                                                                                                                                                             L             A              T               C       H
                    Time:                                                                             Physician notified of abnormal findings                                                   Time:                                                                             Physician notified of abnormal findings                                                                                                         Time:                                                                                   Physician notified of abnormal findings
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Continue to observe newborn for signs of respiratory distress, ACHIEVED:
                    L           A    T        C         H                                                                                                                                       L           A    T        C         H                                                                                                                                                                                             L             A              T               C       H                                                                                                                                                                such as cyanosis, retractions, nasal flaring, and grunting.    Yes No INITIALS:
                    Time:                                                                     NEUROLOGICAL                                                                                      Time:                                                                     NEUROLOGICAL                                                                                                                                            Time:                                                                           NEUROLOGICAL
                    L           A    T        C         H                                             Alert and Active                                                                          L           A    T        C         H                                             Alert and Active                                                                                                                                L             A              T               C       H                                  Alert and Active                                                                                                              Notify pediatrician of any abnormalities.
                                                                                                      Lethargic                                                                                                                                                                   Lethargic                                                                                                                                                                                                                               Lethargic
                       Type of Formula:                                                                                                                                                            Type of Formula:                                                                                                                                                                                                                   Type of Formula:                                                                                                                                                        Risk for ineffective thermoregulation     Teach parent(s) to keep newborn wrapped as much as                    Newborn will maintain a temperature within the
                                                                                                      Irritable                                                                                                                                                                   Irritable                                                                                                                                                                                                                               Irritable                                                                           related to parental lack of knowledge     possible holding newborn skin to skin.                                normal range of 36.5 degrees to 37.3 degrees
                    Time:                          Amount (ml):                                       Normal Reflexes      Moro Suck                                                            Time:                          Amount (ml):                                       Normal Reflexes      Moro Suck                                                                                                                  Time:                                            Amount (ml):                           Normal Reflexes      Moro Suck                                                      of newborn thermoregulation abilities                                                                           Celsius (97.7 degrees to 99.1 degrees Fahrenheit)
                    Time:                          Amount (ml):                                           Swallow Root                                                                          Time:                          Amount (ml):                                           Swallow Root                                                                                                                                Time:                                            Amount (ml):                               Swallow Root                                                                    and needs.                                Place the infant, wearing only a diaper and a cap, next to            axillary throughout stay.
                    Time:                          Amount (ml):                                       Fontanels soft and flat                                                                   Time:                          Amount (ml):                                       Fontanels soft and flat                                                                                                                         Time:                                            Amount (ml):                           Fontanels soft and flat                                                                                                       mother’s skin.
                                                                                                      Physician notified of abnormal findings                                                                                                                                     Physician notified of abnormal findings                                                                                                                                                                                                 Physician notified of abnormal findings                                             DATE:                                                                                                           Parent(s) will verbalize and practice methods of
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Teach parent(s) to dry infant promptly whenever he /she are           preventing heat loss by the end of the first day.




                                                                 F




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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               F
                                                                                              MUSCULOSKELETAL                                                                                                                                                             MUSCULOSKELETAL                                                                                                                                                                                                                         MUSCULOSKELETAL                                                                             TIME:                                     wet, such as during bathing and when changing wet diapers




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               F
                    Urine:                                                                                                                                                                      Urine:                                                                                                                                                                                                                            Urine:
                                                                                                      Normal muscle tone                                                                                                                                                          Normal muscle tone                                                                                                                                                                                                                      Normal muscle tone                                                                                                            or clothing.                                                     ACHIEVED:
                      First Void    Time:                                                                                                                                                         First Void    Time:                                                                                                                                                                                                               First Void               Time:                                                                                                                                            INITIALS:
                    Void Count:                                                                       Symmetrical movement of extremities                                                       Void Count:                                                                       Symmetrical movement of extremities                                                                                                             Void Count:                                                                             Symmetrical movement of extremities                                                                                           Assess the infant’s axillary temperature. If his/her temperature Yes No INITIALS:
                                                                                                      Limited range of motion                                                                                                                                                     Limited range of motion                                                                                                                                                                                                                 Limited range of motion
                                                                O




                                                                                                                                                                                                                                            O




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              O
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        is still low, or has repeated episodes of low temperature,




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              O
                    Stool:                                                                            Physician notified of abnormal findings                                                   Stool:                                                                            Physician notified of abnormal findings                                                                                                         Stool:                                                                                  Physician notified of abnormal findings                                                                                       notify pediatrician.
                      First Stool Time:                                                                                                                                                           First Stool Time:                                                                                                                                                                                                                 First Stool Time:
                    Stool Count:                                                              GASTROINTESTINAL/GENITOURINARY                                                                    Stool Count:                                                              GASTROINTESTINAL/GENITOURINARY                                                                                                                          Stool Count:                                                                    GASTROINTESTINAL/GENITOURINARY                                                                                                        Check the newborn’s blood glucose levels according to
                    Amount: Trace Small Medium Large                                                  Abdomen soft and round/nondistended                                                       Amount: Trace Small Medium Large                                                  Abdomen soft and round/nondistended                                                                                                             Amount: Trace Small Medium Large                                                        Abdomen soft and round/nondistended                                                                                           protocol if infant becomes jittery or lethargic.
                    Consistency: Soft Seedy Loose Watery                                                                                                                                        Consistency: Soft Seedy Loose Watery                                                                                                                                                                                              Consistency: Soft Seedy Loose Watery
                                                               O




                                                                                                                                                                                                                                           O




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             O
                                                                                                      Bowel sounds present                                                                                                                                                        Bowel sounds present                                                                                                                                                                                                                    Bowel sounds present




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             O
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Risk for hypoglycemia caused by           Assist the breastfeeding mother with feedings. If unable to           Newborn responds to interventions, by the absence
                      Other:                                                                            Hyperactive                                                                               Other:                                                                            Hyperactive                                                                                                                                     Other:                                                                                  Hyperactive                                                                       depleted glycogen stores as evidenced     nurse the infant immediately, feed the infant formula and help        of hypoglycemia, as evidenced by blood glucose
                    Description: Meconium Yellow Green                                                  Hypoactive                                                                              Description: Meconium Yellow Green                                                  Hypoactive                                                                                                                                    Description: Meconium Yellow Green                                                        Hypoactive                                                                        by glucose levels below 40 mg/dL.         her breastfeed at the next feeding.                                   level above 40 mg/dL.
                      Brown Other:                                                                    Distended                                                                                   Brown Other:                                                                    Distended                                                                                                                                         Brown Other:                                                                          Distended
                      Meconium obtained and sent to lab. Time:                                        Bowel sounds absent                                                                         Meconium obtained and sent to lab. Time:                                        Bowel sounds absent                                                                                                                               Meconium obtained and sent to lab. Time:                                              Bowel sounds absent                                                                                                           Assist with formula-feeding mothers with positioning the infant ACHIEVED:
                                                             PR




                                                                                                                                                                                                                                         PR




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           PR
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        and the bottle. Explain the need for prompt feeding in infants Yes No INITIALS:




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           PR
                      Meconium results received.                                                      Physician notified of abnormal findings                                                     Meconium results received.                                                      Physician notified of abnormal findings                                                                                                           Meconium results received.                                                            Physician notified of abnormal findings                                             DATE:
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        with hypoglycemia.
                    Emesis:                                                                                                                                                                     Emesis:                                                                                                                                                                                                                           Emesis:                                                                                                                                                                     TIME:
                    Time:                Amount (ml):
                                                                                              CIRCUMCISION                                                                                      Time:                Amount (ml):
                                                                                                                                                                                                                                                                          CIRCUMCISION                                                                                                                                            Time:                              Amount (ml):
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  CIRCUMCISION                                                                                                                          Place newborn on the Hypoglycemia protocol for glucose
                                                                                              Time:                    Physician:                                                                                                                                         Time:                               Physician:                                                                                                                                                                                          Time:                    Physician:                                                         INITIALS:                                 screening.
                                                                                              Type:   Gomco                                                                                                                                                               Type:   Gomco                                                                                                                                                                                                                           Type:   Gomco
                    Glucose Screening:                                                                Plastibell                                                                                Glucose Screening:                                                                Plastibell                                                                                                                                      Glucose Screening:                                                                      Plastibell                                                                                                                    Keep pediatrician aware of newborn’s status.
                    Time:                 Result (mg/dL):                                     Circumcision care:    Initial dressing changed. Time:                                             Time:                 Result (mg/dL):                                     Circumcision care:    Initial dressing changed. Time:                                                                                                   Time:                 Result (mg/dL):                                           Circumcision care:    Initial dressing changed. Time:                                                                                 Assess for signs of other complications, such as drop in
                    Time:                 Result (mg/dL):                                                           Petroleum Gauze                                                             Time:                 Result (mg/dL):                                                           Petroleum Gauze                                                                                                                   Time:                 Result (mg/dL):                                                                 Petroleum Gauze                                                                                                 temperature, or respiratory distress.
                    Time:                 Result (mg/dL):                                                           Other:                                                                      Time:                 Result (mg/dL):                                                           Other:                                                                                                                            Time:                 Result (mg/dL):                                                                 Other:
                    Bilimeter (at 24 hours of age):                                           Circumcision condition:     Healing                                                               Bilimeter (at 24 hours of age):                                           Circumcision condition:     Healing                                                                                                                     Bilimeter (at 24 hours of age):                                                 Circumcision condition:     Healing                                                         Risk for hyperbilirubinemia related to    Assess for jaundice every 8 hours along with vital signs.          Newborn bilirubin serum levels are within normal
                                                                                                                          Bleeding                                                                                                                                                                    Bleeding                                                                                                                                                                                                                                Bleeding                                                        prematurity/bruising/poor intake/Rh or                                                                       limits.
                    Time:                 Result (mg/dL):                                                                                                                                       Time:                 Result (mg/dL):                                                                                                                                                                                             Time:                 Result (mg/dL):                                                                                                                                       ABO incompatibility, as evidenced by      Discuss importance of adequate feedings to stimulate passage
                    Bilirubin:                                                                                            Redness                                                               Bilirubin:                                                                                            Redness                                                                                                                     Bilirubin:                                                                                                  Redness                                                                                                   of stools and help prevent high levels of bilirubin in the infant. ACHIEVED:
                                                                                                                          Discharge                                                                                                                                                                   Discharge                                                                                                                                                                                                                               Discharge                                                       elevated bilirubin levels.
                    Time:                 Result (mg/dL):                                                                                                                                       Time:                 Result (mg/dL):                                                                                                                                                                                             Time:                 Result (mg/dL):                                                                                                                                                                                 Instruct to feed every 2 to 3 hours.
                                                                                                                          Swollen                                                                                                                                                                     Swollen                                                                                                                                                                                                                                 Swollen                                                                                                                                                                      Yes No INITIALS:
                    Newborn Screening (at 24 hours of age or greater).                                                                                                                          Newborn Screening (at 24 hours of age or greater).                                                                                                                                                                                Newborn Screening (at 24 hours of age or greater).                                                                                                                          DATE:
                    Time:                                                                                                 Other:                                                                Time:                                                                                                 Other:                                                                                                                      Time:                                                                                                       Other:                                                                                                    Obtain transcutaneous bilirubin measurement using the
                    Hearing Screen:                                                                                                                                                             Hearing Screen:                                                                                                                                                                                                                   Hearing Screen:                                                                                                                                                             TIME:                                     bilimeter. If the bilimeter registers greater than 7, then obtain
                       Required     Completed:      Right ear pass                            SKIN/CORD CARE                                                                                       Required     Completed:      Right ear pass                            SKIN/CORD CARE                                                                                                                                             Required     Completed:      Right ear pass                                  SKIN/CORD CARE                                                                                                                        total and direct serum bilirubin level per protocol.
                                                                                                      Skin intact/dry/warm                                                                                                                                                        Skin intact/dry/warm                                                                                                                                                                                                                    Skin intact/dry/warm                                                                INITIALS:
                                                    Right ear failed                                                                                                                                                            Right ear failed                                                                                                                                                                                                                  Right ear failed                                                                                                                                                                      Notify pediatrician of bilirubin serum results.
                                                    Left ear pass                                     Skin moist                                                                                                                Left ear pass                                     Skin moist                                                                                                                                                                      Left ear pass                                           Skin moist
                                                    Left ear failed                                   Good skin tugor                                                                                                           Left ear failed                                   Good skin tugor                                                                                                                                                                 Left ear failed                                         Good skin tugor                                                                     Ineffective breastfeeding as evidenced    Breastfeeding mother will be encouraged to put the newborn            Mother attempts to feed infant 8-12 times in
                                                                                                      Skin cold                                                                                                                                                                   Skin cold                                                                                                                                                                                                                               Skin cold                                                                           by poor latch/nipple confusion/suckling   skin to skin and to breastfeed within the first hour postpartum       24 hours. Initiates feeding from one breast and
                                                                                                      Skin peeling Rash Petechia                                                                                                                                                  Skin peeling Rash Petechia                                                                                                                                                                                                              Skin peeling Rash Petechia                                                          difficulties/breast engorgement.          or within one hour of mother’s responsiveness after an                continues until the infant discontinues the feeding.
                       Identification band on. #                                                                                                                                                   Identification band on. #                                                                                                                                                                                                          Identification band on. #                                                                                                                                                                                         operative delivery.                                                   Burps the infant, and places him/her on the second
                       HUGS tag on. #                                                                 Color pink Pale Dusky Mottled             Cyanosis   Jaundice                                HUGS tag on. #                                                                 Color pink Pale Dusky Mottled                                      Cyanosis             Jaundice                                                    HUGS tag on. #                                                                      Color pink Pale Dusky Mottled             Cyanosis   Jaundice                                                                                                                                       breast. Mother states that infant feeds for 10-20
                       Parent eye contact noted.                                                      Physician notified of abnormal findings                                                      Parent eye contact noted.                                                      Physician notified of abnormal findings                                                                                                             Parent eye contact noted.                                                           Physician notified of abnormal findings                                             DATE:                                     Breastfeeding mother will be instructed to recognize and              minutes on each breast per feeding.
PROOF 4




                       Parent holding/cuddling. Positive parental interaction noted.                                                                                                               Parent holding/cuddling. Positive parental interaction noted.                                                                                                                                                                      Parent holding/cuddling. Positive parental interaction noted.                                                                                                                                                     respond appropriately to early newborn feeding cues.
                       Non parental interaction with newborn noted.                           CORD CARE                                                                                            Non parental interaction with newborn noted.                           CORD CARE                                                                                                                                                   Non parental interaction with newborn noted.                                CORD CARE                                                                                   TIME:                                                                                                           Infant urinates in first 24 hours of life=1 urine.
                                                                                                      Moist                                                                                                                                                                       Moist                                                                                                                                                                                                                                   Moist                                                                                                                         Mother will be assessed at least once a shift for effective           Day 2=2 urine
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              INITIALS:                                                                                                       Day 3 and 4= 4-6 urines
                                                                                                      Dry/drying                                                                                                                                                                  Dry/drying                                                                                                                                                                                                                              Dry/drying                                                                                                                    breastfeeding and instructed on management of breastfeeding
                    Initials:                                                                         Oozing                                                                                    Initials:                                                                         Oozing                                                                                                                                          Initials:                                                                               Oozing                                                                                                                        (i.e. latch on, positioning, frequency of feedings, exclusive         Day 5= 6-8 wet diapers.
                                                                                                      Umbilical hernia                                                                                                                                                            Umbilical hernia                                                                                                                                                                                                                        Umbilical hernia                                                                                                              breastfeeding).                                                       At least 6 urinations per day and 3-4 yellow
                    Signature:                                                                        Cord clamped                                                                              Signature:                                                                        Cord clamped                                                                                                                                    Signature:                                                                              Cord clamped                                                                                                                                                                                        seedy stools per day by the 5th day of age.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Staff to refer to breastfeeding basic protocol for management
                                                                                                      Cord clamp removed                                                                                                                                                          Cord clamp removed                                                                                                                                                                                                                      Cord clamp removed                                                                                                            of breastfeeding issues. Lactation consultant to be consulted
                    Date:                     Time:                                                   Physician notified of abnormal findings                                                   Date:                     Time:                                                   Physician notified of abnormal findings                                                                                                         Date:                                        Time:                                      Physician notified of abnormal findings                                                                                                                                                             ACHIEVED:
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        for ineffective breastfeeding (i.e. cleft palate, inverted nipples)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        and /or separation of the mother/newborn.                             Yes No INITIALS:
8110039878




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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Teach mother how to use a breast pump and store her milk.
               All temperatures are axillary unless noted. LATCH KEY L=Latch A=Audible Swallow T=Type of Nipple C=Comfort of Mother’s Nipples H=Help Required                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           Instruct her to pump her breasts for 15 to 20 minutes every
               (0-2 points possible for each indicator). Document interventions/outcomes for scores less than 7 under Narrative notes. O=Observed R=Reported.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           2 to 3 hours during the day, and once or twice at night
               NIPS=Neonatal Infant Pain Scoring System                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 (when infant is unable to feed).
               4856MR (5/11) HFWH                                                                                                                                         Nursing               4856MR (5/11)                                                                                                                                                                                                                     4856MR (5/11)                                                                                                                                                               4856MR (5/11)                                                                                                                                                Page 4 of 8


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                                                                                    Newborn Flowsheet                                                                                                                                                   Newborn Flowsheet                                                                                                                                                      Newborn Flowsheet
               Additional Narrative Notes:                                           DATE:                                                             0700-1500                                                           TIME:                         DATE:                                                           1500-2300                                                           TIME:                              DATE:                                                           2300-0700                                                           TIME:
               DATE/TIME:                                                               Time:                                                                      RESPIRATORY                                                                             Time:                                                                     RESPIRATORY                                                                                  Time:                                                                     RESPIRATORY
                                                                                        Weight (Grams/Pounds):                                                             Breath sounds clear, equal                                                      Weight (Grams/Pounds):                                                            Breath sounds clear, equal                                                           Weight (Grams/Pounds):                                                            Breath sounds clear, equal
                                                                                        Temperature:                                                                       No distress noted                                                               Temperature:                                                                      No distress noted                                                                    Temperature:                                                                      No distress noted
                                                                                        Apical Rate:                                                                       Diminished            Right        Left                                         Apical Rate:                                                                      Diminished            Right        Left                                              Apical Rate:                                                                      Diminished            Right        Left
                                                                                        Respiratory Rate:                                                                  Rales                 Right        Left                                         Respiratory Rate:                                                                 Rales                 Right        Left                                              Respiratory Rate:                                                                 Rales                 Right        Left
                                                                                        NIPS Score:                                                                        Rhonchi               Right        Left                                         NIPS Score:                                                                       Rhonchi               Right        Left                                              NIPS Score:                                                                       Rhonchi               Right        Left
                                                                                                                                                                           Stridor               Right        Left                                                                                                                           Stridor               Right        Left                                                                                                                                Stridor               Right        Left
                                                                                                                                                                           Physician notified of abnormal findings                                                                                                                           Physician notified of abnormal findings                                                                                                                                Physician notified of abnormal findings
                                                                                        Breastfeeding Latch                                                                                                                                                Breastfeeding Latch                                                                                                                                                    Breastfeeding Latch
                                                                                        Time:                                                    O          R      CARDIOVASCULAR                                                                          Time:                                                   O          R      CARDIOVASCULAR                                                                               Time:                                                   O          R      CARDIOVASCULAR
                                                                                        L           A     T        C         H                                             Normal heart sounds-Strong, regular beat                                        L           A    T        C         H                                             Normal heart sounds-Strong, regular beat                                             L           A    T        C         H                                             Normal heart sounds-Strong, regular beat
                                                                                        Time:                                                                              Irregular heart beat                                                            Time:                                                                             Irregular heart beat                                                                 Time:                                                                             Irregular heart beat
                                                                                        L           A     T        C         H                                             Murmur auscultated                                                              L           A    T        C         H                                             Murmur auscultated                                                                   L           A    T        C         H                                             Murmur auscultated
                                                                                        Time:                                                                              Physician notified of abnormal findings                                         Time:                                                                             Physician notified of abnormal findings                                              Time:                                                                             Physician notified of abnormal findings
                                                                                        L           A     T        C         H                                                                                                                             L           A    T        C         H                                                                                                                                  L           A    T        C         H
                                                                                        Time:                                                                      NEUROLOGICAL                                                                            Time:                                                                     NEUROLOGICAL                                                                                 Time:                                                                     NEUROLOGICAL
                                                                                        L           A     T        C         H                                             Alert and Active                                                                L           A    T        C         H                                             Alert and Active                                                                     L           A    T        C         H                                             Alert and Active
                                                                                                                                                                           Lethargic                                                                                                                                                         Lethargic                                                                                                                                                              Lethargic
                                                                                            Type of Formula:                                                               Irritable                                                                          Type of Formula:                                                               Irritable                                                                               Type of Formula:                                                               Irritable
                                                                                                                                                                           Normal Reflexes      Moro Suck                                                                                                                                    Normal Reflexes      Moro Suck                                                                                                                                         Normal Reflexes      Moro Suck
                                                                                        Time:                           Amount (ml):                                                                                                                       Time:                          Amount (ml):                                                                                                                            Time:                          Amount (ml):




                                                                                                                                                                                                                                                                                                                           F
                                                                                                                                                                               Swallow Root                                                                                                                                                      Swallow Root                                                                                                                                                           Swallow Root
                                                                                        Time:                           Amount (ml):                                                                                                                       Time:                          Amount (ml):                                                                                                                            Time:                          Amount (ml):
                                                                                                                                                                           Fontanels soft and flat                                                                                                                                           Fontanels soft and flat                                                                                                                                                Fontanels soft and flat




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 F
                                                                                        Time:                           Amount (ml):                                                                                                                       Time:                          Amount (ml):                                                                                                                            Time:                          Amount (ml):
                                                                                                                                                                           Physician notified of abnormal findings                                                                                                                           Physician notified of abnormal findings                                                                                                                                Physician notified of abnormal findings




                                                                                                                                                                                                                                                                                                                          O
                                                 F




                                                                                                                                                         F
                                                                                        Urine:                                                                     MUSCULOSKELETAL                                                                         Urine:                                                                    MUSCULOSKELETAL                                                                              Urine:                                                                    MUSCULOSKELETAL




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                O
                                                                                          First Void     Time:                                                             Normal muscle tone                                                                First Void    Time:                                                             Normal muscle tone                                                                     First Void    Time:                                                             Normal muscle tone
                                                                                        Void Count:                                                                        Symmetrical movement of extremities                                             Void Count:                                                                       Symmetrical movement of extremities                                                  Void Count:                                                                       Symmetrical movement of extremities

                                                O                                                                                                                          Limited range of motion                                                                                                                                           Limited range of motion                                                                                                                                                Limited range of motion




                                                                                                                                                        O
                                                                                        Stool:                                                                                                                                                             Stool:                                                                                                                                                                 Stool:




                                                                                                                                                                                                                                                                                                                         O
                                                                                                                                                                           Physician notified of abnormal findings                                                                                                                           Physician notified of abnormal findings                                                                                                                                Physician notified of abnormal findings
                                                                                          First Stool Time:                                                                                                                                                  First Stool Time:                                                                                                                                                      First Stool Time:




                                                                                                                                                                                                                                                                                                                                                                                                                                                                               O
                                                                                        Stool Count:                                                               GASTROINTESTINAL/GENITOURINARY                                                          Stool Count:                                                              GASTROINTESTINAL/GENITOURINARY                                                               Stool Count:                                                              GASTROINTESTINAL/GENITOURINARY
                                                                                        Amount: Trace Small Medium Large                                                   Abdomen soft and round/nondistended                                             Amount: Trace Small Medium Large                                                  Abdomen soft and round/nondistended                                                  Amount: Trace Small Medium Large                                                  Abdomen soft and round/nondistended
                                               O




                                                                                                                                                       O
                                                                                        Consistency: Soft Seedy Loose Watery                                               Bowel sounds present                                                            Consistency: Soft Seedy Loose Watery                                              Bowel sounds present                                                                 Consistency: Soft Seedy Loose Watery                                              Bowel sounds present




                                                                                                                                                                                                                                                                                                                       PR
                                                                                          Other:                                                                             Hyperactive                                                                     Other:                                                                            Hyperactive                                                                          Other:                                                                            Hyperactive




                                                                                                                                                                                                                                                                                                                                                                                                                                                                             PR
                                                                                        Description: Meconium Yellow Green                                                   Hypoactive                                                                    Description: Meconium Yellow Green                                                  Hypoactive                                                                         Description: Meconium Yellow Green                                                  Hypoactive
                                                                                          Brown Other:                                                                     Distended                                                                         Brown Other:                                                                    Distended                                                                              Brown Other:                                                                    Distended
                                                                                          Meconium obtained and sent to lab. Time:                                                                                                                           Meconium obtained and sent to lab. Time:                                                                                                                               Meconium obtained and sent to lab. Time:
                                             PR

                                                                                                                                                                           Bowel sounds absent                                                                                                                                               Bowel sounds absent                                                                                                                                                    Bowel sounds absent




                                                                                                                                                     PR
                                                                                          Meconium results received.                                                       Physician notified of abnormal findings                                           Meconium results received.                                                      Physician notified of abnormal findings                                                Meconium results received.                                                      Physician notified of abnormal findings
                                                                                        Emesis:                                                                                                                                                            Emesis:                                                                                                                                                                Emesis:
                                                                                        Time:                 Amount (ml):
                                                                                                                                                                   CIRCUMCISION                                                                            Time:                Amount (ml):
                                                                                                                                                                                                                                                                                                                                     CIRCUMCISION                                                                                 Time:                Amount (ml):
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            CIRCUMCISION
                                                                                                                                                                   Time:                    Physician:                                                                                                                               Time:                    Physician:                                                                                                                                    Time:                    Physician:
                                                                                                                                                                   Type:   Gomco                                                                                                                                                     Type:   Gomco                                                                                                                                                          Type:   Gomco
                                                                                        Glucose Screening:                                                                 Plastibell                                                                      Glucose Screening:                                                                Plastibell                                                                           Glucose Screening:                                                                Plastibell
                                                                                        Time:                 Result (mg/dL):                                      Circumcision care:    Initial dressing changed. Time:                                   Time:                 Result (mg/dL):                                     Circumcision care:    Initial dressing changed. Time:                                        Time:                 Result (mg/dL):                                     Circumcision care:    Initial dressing changed. Time:
                                                                                        Time:                 Result (mg/dL):                                                            Petroleum Gauze                                                   Time:                 Result (mg/dL):                                                           Petroleum Gauze                                                        Time:                 Result (mg/dL):                                                           Petroleum Gauze
                                                                                        Time:                 Result (mg/dL):                                                            Other:                                                            Time:                 Result (mg/dL):                                                           Other:                                                                 Time:                 Result (mg/dL):                                                           Other:
                                                                                        Bilimeter (at 24 hours of age):                                            Circumcision condition:     Healing                                                     Bilimeter (at 24 hours of age):                                           Circumcision condition:     Healing                                                          Bilimeter (at 24 hours of age):                                           Circumcision condition:     Healing
                                                                                        Time:                 Result (mg/dL):                                                                  Bleeding                                                    Time:                 Result (mg/dL):                                                                 Bleeding                                                         Time:                 Result (mg/dL):                                                                 Bleeding
                                                                                        Bilirubin:                                                                                             Redness                                                     Bilirubin:                                                                                            Redness                                                          Bilirubin:                                                                                            Redness
                                                                                        Time:                 Result (mg/dL):                                                                  Discharge                                                   Time:                 Result (mg/dL):                                                                 Discharge                                                        Time:                 Result (mg/dL):                                                                 Discharge
                                                                                        Newborn Screening (at 24 hours of age or greater).                                                     Swollen                                                     Newborn Screening (at 24 hours of age or greater).                                                    Swollen                                                          Newborn Screening (at 24 hours of age or greater).                                                    Swollen
                                                                                        Time:                                                                                                  Other:                                                      Time:                                                                                                 Other:                                                           Time:                                                                                                 Other:
                                                                                        Hearing Screen:                                                                                                                                                    Hearing Screen:                                                                                                                                                        Hearing Screen:
                                                                                           Required     Completed:      Right ear pass                             SKIN/CORD CARE                                                                             Required     Completed:      Right ear pass                            SKIN/CORD CARE                                                                                  Required     Completed:      Right ear pass                            SKIN/CORD CARE
                                                                                                                        Right ear failed                                   Skin intact/dry/warm                                                                                            Right ear failed                                  Skin intact/dry/warm                                                                                                 Right ear failed                                  Skin intact/dry/warm
                                                                                                                        Left ear pass                                      Skin moist                                                                                                      Left ear pass                                     Skin moist                                                                                                           Left ear pass                                     Skin moist
                                                                                                                        Left ear failed                                    Good skin tugor                                                                                                 Left ear failed                                   Good skin tugor                                                                                                      Left ear failed                                   Good skin tugor
                                                                                                                                                                           Skin cold                                                                                                                                                         Skin cold                                                                                                                                                              Skin cold
                                                                                            Identification band on. #                                                      Skin peeling Rash Petechia                                                         Identification band on. #                                                      Skin peeling Rash Petechia                                                              Identification band on. #                                                      Skin peeling Rash Petechia
                                                                                            HUGS tag on. #                                                                 Color pink Pale Dusky Mottled             Cyanosis   Jaundice                      HUGS tag on. #                                                                 Color pink Pale Dusky Mottled             Cyanosis   Jaundice                           HUGS tag on. #                                                                 Color pink Pale Dusky Mottled             Cyanosis   Jaundice
                                                                                            Parent eye contact noted.                                                      Physician notified of abnormal findings                                            Parent eye contact noted.                                                      Physician notified of abnormal findings                                                 Parent eye contact noted.                                                      Physician notified of abnormal findings
                                                                                            Parent holding/cuddling. Positive parental interaction noted.                                                                                                     Parent holding/cuddling. Positive parental interaction noted.                                                                                                          Parent holding/cuddling. Positive parental interaction noted.
                                                                                            Non parental interaction with newborn noted.                           CORD CARE                                                                                  Non parental interaction with newborn noted.                           CORD CARE                                                                                       Non parental interaction with newborn noted.                           CORD CARE
                                                                                                                                                                           Moist                                                                                                                                                             Moist                                                                                                                                                                  Moist
                                                                                                                                                                           Dry/drying                                                                                                                                                        Dry/drying                                                                                                                                                             Dry/drying
                                                                                        Initials:                                                                          Oozing                                                                          Initials:                                                                         Oozing                                                                               Initials:                                                                         Oozing
                                                                                                                                                                           Umbilical hernia                                                                                                                                                  Umbilical hernia                                                                                                                                                       Umbilical hernia
B-1A




                                                                                        Signature:                                                                         Cord clamped                                                                    Signature:                                                                        Cord clamped                                                                         Signature:                                                                        Cord clamped
                                                                                                                                                                           Cord clamp removed                                                                                                                                                Cord clamp removed                                                                                                                                                     Cord clamp removed
                                                                                        Date:                      Time:                                                   Physician notified of abnormal findings                                         Date:                     Time:                                                   Physician notified of abnormal findings                                              Date:                     Time:                                                   Physician notified of abnormal findings
8110039878




                                                                           (PERF)




                                                                                                                                                                                                                                               (PERF)




                                                                                                                                                                                                                                                                                                                                                                                                                      (PERF)
                                                                                     Key:                                                                                                                                        Page 6 of 8                                                                                                                                                            Page 7 of 8                                                                                                                                                            Page 8 of 8
                                                                                     All temperatures are axillary unless noted. LATCH KEY L=Latch A=Audible Swallow T=Type of Nipple C=Comfort of Mother’s Nipples H=Help Required
                                                                                     (0-2 points possible for each indicator). Document interventions/outcomes for scores less than 7 under Narrative notes. O=Observed R=Reported.
                                                                                     NIPS=Neonatal Infant Pain Scoring System
                                                                                     4856MR (5/11) HFWH                                                                                                                             Nursing                4856MR (5/11)                                                                                                                                                          4856MR (5/11)
               4856MR (5/11)                                 Page 5 of 8

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posted:12/25/2011
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