Nursing Documentation in Neonatal Records

Newborn Information:

• Newborn’s name, father’s name, and mother’s name
• Gender of the newborn
• Gestational age
• Address
• Parent’s contact number

Birth Information:

• Date, place, and type of delivery
• Resuscitation steps and Apgar score (if born in the hospital)
• Vaccination details (vaccine name, date, and notes)
• Pain assessment using the CRIES neonatal pain scale
• Identification of allergies (medications, food, skin-related, unknown)
• Documentation of congenital anomalies (head, mouth, limbs, nose, eyes, body, etc.)

Maternal Information:

• Mother’s age
• Parental consanguinity
• Chronic diseases in the mother (diabetes, hypertension, heart diseases, tuberculosis, etc.)
• Maternal fever during pregnancy
• Premature rupture of membranes
• Mother’s blood type and Rh factor
• Number of previous pregnancies and deliveries
• Medical follow-up during pregnancy
• Previous premature births or sick newborns
• Family history of genetic diseases

Second: Daily Neonatal Monitoring Data

Vital Signs:

• Respiration rate: Recorded every 3 hours, noting chest retractions, grunting, or apnea
• Temperature: Recorded every 3 hours
• Heart rate: Recorded every 3 hours
• Blood pressure: Recorded every 3 hours if stable, hourly if on mechanical ventilation
• Post-surgical monitoring: Vital signs recorded every 15 minutes for the first hour, then every 30 minutes for another hour, then hourly until stable

Growth Measurements:

• Weight: Recorded daily; twice daily if <1000g, plotted on a weight chart
• Length: Recorded at admission and weekly
• Head circumference: Recorded at admission and weekly (daily in cases of intracranial hemorrhage, hydrocephalus, or birth asphyxia)
• Abdominal circumference: Measured at each shift when enteral feeding starts for preterm newborns or in case of umbilical catheter placement

Daily Monitoring:

• Capillary refill time: Checked every 3 hours with vital signs
• Level of consciousness: Assessed every 3 hours with vital signs
• Skin color: Evaluated every 3 hours with vital signs
• Blood glucose level: Measured daily or as per physician’s instructions
• Feeding method: Documented with type and quantity (for formula feeding)
• Intravenous cannula: Placement date recorded, changed every 72 hours
• Feeding tube: Placement and change dates documented (every 72 hours or as needed)
• Fluid balance: Documented every 3 hours, including:
• Urine and stool output, noting stool color and consistency
• Vomiting and gastric aspiration, recording color and consistency
• Daily laboratory tests: Recorded
• IV fluids preparation: Date of solution preparation recorded, discarded if unused after 24 hours

Third: Respiratory Distress Cases

Oxygen Therapy:

• Mode of oxygen delivery and flow rate (L/min)
• Blood oxygen saturation levels
• Time of oxygen saturation probe placement and its change every 4 hours

Suctioning:

• Documented suction site (mouth, nose, trachea), quantity, and color

IV Fluids:

• Type of fluid, rate of administration, time, person administering, and components, including added medications
• Fluid input and output recorded every 3 hours, summarized every 24 hours in the fluid balance chart

Respiratory Support (CPAP & Mechanical Ventilation):

• CPAP and ventilator readings documented hourly
• Endotracheal tube position at the upper lip recorded
• Endotracheal tube repositioning documented

Fourth: Neonatal Jaundice Cases

• Number of phototherapy units used
• Neonatal positioning changes every 2 hours
• Skin condition and any phototherapy side effects documented
• Laboratory test results recorded
• Time of exchange transfusion (if performed) documented

Fifth: Seizure Cases

A seizure chart is maintained, including:

• Seizure location, time of occurrence, duration, associated symptoms, nursing intervention, and prescribed treatment as per physician’s orders

Sixth: Infant of a Diabetic Mother (IDM) Cases

Blood glucose monitoring follows a specific schedule:

• Twice within the first hour
• Twice within two hours
• Twice within four hours
• Then every 8 hours until glucose levels stabilize

Seventh: Medication Administration

• Type of medication, dosage, and method of administration are documented