Date/time Focus Data / Action / Responses

12/18/22 New born D- Born spontaneously to an alive baby boy with one loop of cord around the
care neck tightly coiled. Attended by ----- with the supervision of ------ with no
cry, cyanosis
8:20 am. A-Immediate and thorough drying done, properly
Timed cord clamping and cutting aseptically done, identified with tag and
showed gender to mother
R- Immediately brought to NICU for continuity of care. Endorsed to NICU staff.
Signature of DR NOD
8:21 am For routine > Admitted an alive baby (boy/girl) delivered via NSD/LTCS/VBAC O
Newborn D- Acrocyanosis; good cry and activity; with whitish/yellowish/greenish
care and gelatenous umbilical cord, with 2 arteries and 1 vein. Ears aligned with
Assessmen outer canthus of both eyes; mouth opens evenly when crying; with intact
t and hard palate; with symmetrical chest expansion upon breathing; with
soft globular abdomen upon palpation; well flexed extremities and patent
anus; body temperature ( c ), RR= ( cpm ), PR= ( bpm ).
A- Wiped secretion from mouth and nose; immediate and
thorough drying done, properly placed on mother’s abdomen for skin to
skin contact, Identification tag compared with mother’s name placed on the
left/right ankle. Temperature checked per rectum, weight and
anthropometric measurement taken and recorded. Vitamin K 1 mg. injected
intramuscularly at right vastus lateralis. Hepa B vaccine 0.5 ml. given IM at
left vastus lateralis. Applied Erythromycin ophthalmic ointment on both eyes
from inner to outer canthus after initial bathing. Mummified and placed
back to mother’s abdomen. Received by mother after identification of
gender and tag. Encouraged exclusive breast feeding. Emphasized proper
positioning when feeding and burping technique. Advised to report to NICU
NOD for any untoward signs and symptoms noted. Evaluated by NICU NOD
Miss_________. (State the name of NOD who perform Ballards scoring)
10:10 am R- Latching done with good sucking reflex, burping and importance of
Newborn screening instructed. Endorsed to NOD, kept warm and
comfortable in mother’s chest.
Signature / countersigned by CI / checked by NOD Note:

> Once the mother received the NB, let her sign at the Doctors order sheet and indicate the date and time she signed. After she signed, it is the
right time for us to give her (mother) information about the NB or health teaching.

Health Teaching/Education:
1. Encourage Breast feeding. Benefits of breast milk/ burping techniques, positioning when feeding (breast)
2. Explain about any untoward signs and symptoms of NB that should be reported to NICU NOD or NICU staff immediately. Such
as:
> Cyanotic, DOB, long hours of sleep without demand on feeding, Rales sound on breathing, bleeding on umbilical stump, skin
rashes, non-stop crying, difficulty on sucking, etc.
3. Inform about the prophylaxis given to NB:
> first dose of Hepa B Vaccine,
> Vit. K to prevent bleeding,
> Erythromycin Ophthalmic ointment applied to both eyes to prevent eye infection or irritation. (be sure of the correct
spelling)
4. That the BCG will be given before they will be discharge at the ward.
5. Explain that 2nd dose of Hepa B vaccine be received or be given at the BHC in their place.

ASSESSMENT FORM
 Bed No. with Philhealth/4P

Name: _Baby Boy Ballesteros Osongco

WT: Mother : Ma. Corazon Ballesteros Osongco

HC: Father : Eduardo Rondilla Osongco
CC: Civil Status: Married
AC: Age of Mother: never mind
Length: Parity: G2 P1
Temp: PNCU: (prenatal Check-up) where and how many times
CR: Maternal illness: Cough and colds (7th month)
RR: Tetanus toxoid: 2X
AS: LMP:
Address:
Contact number:

INITIAL ASSESSMENT:

 Good cry after >NSD-Boy/ LTCS-Boy/VBAC-Boy or Girl @ 8:20 am

stimulation >Good cry and active
>Acrocyanosis
> Normocephalic/ caput succedaneum / molding head
> Flat fontanelle
> Symmetrical eyes and ears
> Outer canthus of eyes are aligned with upper pinna of ears
> Midline nasal septum/ occasional nasal flaring
> Intact hard and soft palate
> Regular chest expansion, RR= 45cpm.
> Symmetrical nipples
> Soft abdomen
> Whitish umbilical cord with 2 arteries and 1 vein
> Well- formed scrotum with testes down and good rugae (for boy) /
if girl ( well formed Labias) or prominent clitoris
> Patent anal opening
> Good flexion on upper and lower extremities
> No signs of respiratory distress

Normal RR of NB
RR= 30 to 60 cpm if rested/asleep
RR= 40 to 60 cpm when awake

Maternal Illness: Cardiac disease, Lung problem, Hepa B, Asthma, STD/STI

Cough, fever, Colds, UTI (Indicate at what month of pregnancy did she experience)