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Newborn Care FDAR Charting Guide

This document contains nursing notes from April 27th to May 1st documenting the care of a newborn male infant and his mother postpartum. The notes include assessments of the newborn's condition, vital signs, feeding, and care provided. The mother's postpartum care is also noted, including encouragement of breastfeeding, hygiene advice, and monitoring of her recovery.

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Roland Yuste
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16K views2 pages

Newborn Care FDAR Charting Guide

This document contains nursing notes from April 27th to May 1st documenting the care of a newborn male infant and his mother postpartum. The notes include assessments of the newborn's condition, vital signs, feeding, and care provided. The mother's postpartum care is also noted, including encouragement of breastfeeding, hygiene advice, and monitoring of her recovery.

Uploaded by

Roland Yuste
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

DATE/TIM FOCUS DATA, ACTION, RESPONSE

E
04/27/2020 post endorsement assessment D-Awake, Reactive and Responsive to tactile
0600h stimuli, attended by mother, Still for
newborn screening test, still for newborn
hearing screening test, Still for Bcg vaccine,
on breastfeeding with strict aspiration
precaution

0800h Newborn Care D- term birth male


A- assessed, vital signs taken and recorded,
daily cord care done, kept monitored
R- newborn care done

DATE/TIME FOCUS DATA, ACTION, RESPONSE


04/28/20 post endorsement assessment D- term birth male
0600h A- assessed, vital signs taken and
recorded, daily cord care done,
kept monitored
R- newborn care done

0800h post partum care D- S/P NSD


A- assessed, vital signs taken and
recorded, encouraged breastfeeding with
strict aspiration precaution, advised daily
hygiene and perineal hygiene emphasized
R- post partum care done
04/29/20 post endorsement assessment D- asleep, attended by the mother,
0600h reactive and responsive to tactile stimuli,
on breastfeeding with strict aspiration
precaution, both bands checked, not in
distress

0800h newborn care D- term birth male


A- assessed, vital signs taken and
recorded, encourage mother
breastfeeding with strict aspiration
precaution, kept monitored, not in
distress
R- newborn care done
DATE/TIME FOCUS DATA, ACTION, RESPONSE
05/01/20 post transfer assessment D- live term baby boy, reactive and
1000h responsive to tactile stimuli, on breastfeeding
with strict aspiration precaution, not in
distress

1100h Newborn Care D- Assessed, vital signs taken and recorded,


encouraged to be breast fed with strict
aspiration precaution and daily cord care
done, not in distress
R- Newborn care done
05/01/05 Post Transfer Assessment D- received patient post NSD, conscious and
1000h coherent, with IVF of D5LR 1liter + oxytocin
10 units 10gtts/minute at the level of 800ml,
on diet as tolerated, on oral medications

05/01/20 Post partum Care D- post NSD


1100h A- Assessed, Vital signs taken and recorded,
advised mother to breastfeed with strict
aspiration precaution, advised daily hygiene
and perineal hygiene emphasized
R- post partum care done

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