ROUTINE NOTES

S : RECEVIED THE BABY FROM NIGHT DUTY STAFF.BABY IS INSIDE THE INCUBATOR ON OXYGEN
L/MINUTE VIA NASAL CANNULA.ATTACHED TO CARDIAC MONITOR FOR CLOSE OBSERVATION OF VITAL
SIGNS.IV CANNULA G INTACT ON HAND WITH INTRAVENOUS FLUID 10% WATER AT ML/HOUR ON
FLOW.ON INTRAVENOUS ANTIBIOTICS.

O:

A:

P:

I:

VITAL SIGNS CHECKED AND RECORED.DIAPER CARE DONE.

SEEN AND EXAMINED THE BABY BY DR AND MADE ORDERS ,NOTED AND CARRIED OUT.

INJECTION AMPICILLIN MG SLOW PUSH INTRAVENOUSLY GIVEN CHECKED BY ANOTHER REGISTERED

NURSE.

INJECTION GENTAMYCIN MG OVER 30 MINUTES INFUSION GIVEN.

NEW ADMISSION
EXTRACTED AN ALIVE BABY BY CEASARIAN SECTION CONDUCTED BY DR AND ATTENDED BY MYSELF AND
DR.BABY CRIED IMMEADIETLY AFTER BIRTH SHOWN TO MOTHER TRANSFERRED UNDER THE RADIANT
WARMER.GENTLE ORAL AND NASAL SUCTION DONE.VITAMIN K 1MILLIGRAM GIVEN OVER THE RIGHT
THIGH.CORD CLAMPED AND CUT.MEASUREMENT TAKEN.IDENTIFICATION BAND ATTACHED TO THE
LEGS.BABY SHIFTED TO NICU FOR OBSERVATION,MOTHER WAS INFORMED.

BABY SHIFTED TO NICU AND KEPT INSIDE THE INCUBATOR.ATTACHED TO THE CARDIAC MONITOR
VITALS CHECKED AND RECORED.
CALLED FATHER AND INFORMED HIM TO COME TO NICU.

1610>BABY HAD TACHYPNEAS SEEN BY DR SARA AND ORDERED TO OBSERVE FOR 30 MINUTES MORE.

1640>DR ORDERED FOR ADMISSION DUE TO TACHYPNEA.FATHER WAS INFORMED HE CAME AND
SIGNED CONSENT.WRITTEN ORDERS WERE MADE BY DR SARA ,ADMISSION IN NICU,NPO,IV FLUID 70
ML/KG/DAY 10% DEXTROSE,CBC,RBS,BLOOD CULTURE,VBG,ALL ORDERS WERE NOTED AND
CARRIEDOUT.

IV CANNULA INSERTED ASEPTICALLY ON THE RIGHT HAND AND BLOOD SAMPLE EXTRACTED.VBG AND
RBS 2.4 DONE REPORT SEEN BY DR SARA

INTRAVENOUSE FLUID STRATED AT 9.7ML/HOUR.

BLOOD SAMPLE SENT TO LAB RESULTS TO BE FOLLOW.

DISCHARGE
1030H>BCG(0731G043/0700S4014 )AND HEPATITIS(AHBVC959BI) GIVEN ON THE LEFT ARM AND LEFT
THIGH RESPECTIVELY.

1100H>IV CANNULA REMOVED ASEPTICALLY NO ACTIVE BLEEDING NOTED.

1130H>BREAST FEED GIVEN BY THE MOTHER GOOD SUCKING .PASSED MECONIUM DIAPER CARE DONE.

BILL SETTLED.BABY DRESSED UP WELL.ALL DOCUMENTS GIVEN TO MOTHER INCLUDING,DISCHARGE

SUMMARY,PINK AND AND COPY CARD,APPOINTMENT SLIP,ALCOHOL SWABS,CHEXST XRAY REPORT AND
CD .HEALTH EDUCATION GIVEN REGARDING BREAST FEEDING,ROUTINE CARE OF THE EYES AND
CORD,BURPING AFTER FEEDING,IMMUNIZATION.ALSO EXPLAINED TO COME AFTER 2 DAYS TO CHECK
BILIRUBIN.

BABY DISCHARGED HOME WITH PARENTS IN A STABLE VITAL CONDITION.