Cebu Institute Of Technology – University

c o l l e g e o f n u r s i n g and allied health sciences

RECORD OF IMMEDIATE NEWBORN CARE

Cord Care No. _______
Name of Institution : _____________________ Case/Hospital Number : ___________
Name of Baby : _______________________________ Gender : __________________
Date and Time Delivered: _____________ / ______AM/PM Mode of Delivery: ______________
Diagnosis : __________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Anthropometric Measurements : Length (cm) :________________________________
Weight (grams) :________________________________
Head Circumference (cm): _____________________________
Chest Circumference (cm): _____________________________
Mid-Arm Circumference (cm): __________________________
APGAR Score (1 & 5 mins) : _______ / _________ Ballard’s Score (weeks) :____________
Vital Signs : T = ___________ HR = ___________ RR = ___________
Please tick the details which were observed:
Skin to skin contact: ( ) Breastfeeding: ( )
Positioning: Neck not flexed/twisted ( ) Attachment: Mouth wide open ( )
Chin on Breast ( ) Lower lip turned outward ( )
Chest to chest ( ) Chin touching breast ( )
Support whole body ( ) Suckling slow and deep ( )
Medications Given :
Credes Prophylaxis : __ AM/PM Vitamin K: ___ AM/PM Hepatitis B Vaccine: ___AM/PM
Name of Mother : ______________________ Age: ________ Marital Status: __________
Address : __________________________________ Contact #: ______________
Gravida : __________ Parity: _________ G-T-P-A-L-M: ___________________
Diagnosis : __________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Physician (OB) : __________________________ Physician (Pedia) _______________
Handled By : __________________________________________________________
Assisted By : __________________________________________________________

_____________________________________ _______________________________________
Name & Signature of Student Name & Signature of D.R. Staff Nurse

_____________________________________ _______________________________________
Name & Signature of Supervising Name & Signature of D.R. Supervisor
Clinical Instructor