NURSES' NOTES

PATIENT NAME:
Baby girl Wency AGE: HOSPITAL NO:
PHYSICIAN:
Dr.Somerz SEX: FEMALE WARD/ROOM: NICU

DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE NURSE SIGNATURE

07/6/2021      
Difficulty establishing D- Mother Verbalized
4:15 pm respirations at birth. “Nung nakita ko yung anak ko,pagkapanganak ko sakanya,parang iba yung  karlo
kulay nya,maasul”.
-Skin pale and somewhat cyanotic
-Persistent bradycardia with CR of 55
- O2 Sat of 75.
    - respiration is absent  

    A - Assessed respiratory status, noting signs of respiratory distress (e.g.,  

tachypnea, nasal flaring, grunting, retractions, rhonchi, or crackles)
    A- Assessed skin color for development of cyanosis.  karlo
A - Promoted rest, minimize stimulation & energy expenditure
A- Maintained ET tube, mechanical ventilation, and supplemental warm
4:55   humidified oxygen.  karlo
A – Maintained ET tube, mechanical ventilation, and supplemental warm
6:00   humidified oxygen.  
A- Auscultated breath sounds, noting areas of decreased air-flow or presence
    of adventitious sound  karlo

7:00am    karlo
R - Patient was able to gradually wean to room air and breathe normally
    without supplemental oxygen.  

       

       
 NURSES' NOTES

PATIENT NAME:
Baby girl Wency AGE: HOSPITAL NO:
PHYSICIAN:
Dr.Somerz SEX: Female WARD/ROOM: : (NICU)

DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE NURSE SIGNATURE

05/23/2021      
D – Mother verbalized:
4:15 pm Inadequate perfusion “Mahina ang tibok ng puso ng anak ko” .Decreased capillary refill, Poor  karlo

    perfusion with O2 Sat of 75,Skin or temperature changes and Weak pulses  

A – Noted quality and strength of peripheral pulses.
    A -Assessed respiratory rate, depth, and quality  
     karlo

A - Assessed respiratory rate, depth, and quality.

4:55   A -Assessed skin for changes in color, temperature and moisture.  

6:00   A - Elevated affected extremities with edema once in a while.  

A -Provided a quiet, restful atmosphere
     karlo
R - Patient was able to demonstrated increased perfusion as evidenced by
warm and dry skin, strong peripheral pulses, normal vital signs, adequate urine
output and increased capillary refill.
7:00am    karlo
 NURSES' NOTES

PATIENT NAME:
Baby Wency AGE: HOSPITAL NO.:
PHYSICIAN:
Dr.Somerz SEX: Female WARD/ROOM: : (NICU)

DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE NURSE SIGNATURE

06/01/2021      
D – Premature
4:15 pm Risk for infection - Immune systems aren’t fully developed  karlo
- Low Resistance to Infection
-Vital sign as follows: poor perfusion with O2 Sat of 75, decreased, and
    persistent bradycardia with CR of 55.  

     
A – Reviewed maternal record for evidence of any risk factors.
    A - Provided prescribed eye prophylaxis.  karlo
A – Monitored vital signs.
A –Have all care providers, including parents, practice good hand-washing
4:55   techniques before handling newborn.  karlo

6:00   A – Kept genital area clean and dry using proper cleansing techniques.  
A - Kept umbilical stump clean and dry and keep exposed to air.
     karlo

7:00am    karlo
R - Neonates’ vital signs was able to remained within normal range, while
    remaining alert and active without signs or symptoms of infection.