USF 4467 Clinical Doc MBU - Mother Baby Form student_DNVAA Jahr pate_2[20]1% Patient intial: Marital Status_™\_Gravida 4 r_3 p_0 AO LS DeliveryDate and Time 2/18 OWL YAS[B 00:00. AROM/SROM Date and Time: ARD™M " ceaiyMeconium Vagina or C/S? Reason for c/s?_ 2, gor:_©) _ rubella Non-Roas(*)_chiamyec:_© Blood type Dt_HIv Tyeatedeh a DAE] Matera eset CONDITION couoR [Suet Engorged, Re Pain oa eros, Alba ons aMfouNT veasts {lita rin cacedvened | Latha | Now, Sanaa Noderate Her ‘BREATH SOUNDS | clots {more than a quarter) __| Normal ear, equa bilateral) ‘DOR Unequal, congested, diminished, rales, rhonch), Present,Absenr wheezing | CONDON HEIGHT ] Imac, ecchymoss, hematoma, Puy | tunis FY— Fete st, | edema, clean ger breath below , EnIsIOTOMY POSITION Ep[siotomy | ciean, dy, ntact, separated, edema, [Milo Right of umbilicus, left of umbilicus | (PArineUm) | reg ONSITENCY : HEMORRHOIDS cc{ Fas Rony, frm wt manage presen aga ederstous INCISION f/5) thrombosed soft pain ters | Normal NIA DEA Clean dry. intact Kozan edema, ‘minimal edema of the pedal and red, pretibial areas ‘rainage, D+ Marked edema ofthe lower separated, cextreities and hands unseen vg | Be dema ofthe face and hands, lower DRESSING FCS) NTR pHaman’s | abdominal wall and sacrum Normal (ry and intact), Changed, No dressing) (C@rdiovasC.) | 44 anasarca (generalized massive Ee Sutures/staples remove a edema) & ascites ‘ABDOMEN ‘CALE TENDERNESS [Soft Distended Gegatis>Postive indicate right oft BOgL SOUNDS HOMAN'S SIGN Bowel peace, hypoactive, fats Negative, Positive indicate ight or STOOLS left | gorse so, tid [ mgop nAiON {sic toreeriv, amicus bse, straight ath, ndweling Cath Enjotional | deoressed abil, flat affect Bladder | CATHETER stdtus LEVEL OF CONSCIOUSNESS Patent, irrigated, changed, discontinued (indicpte {Alert confused, lethargic, oriented, time) (none, putN/A) sleepin, non-response arousable Problem ust: S Panis peaking sVily outcomes: PA will express waderstanding of dic tducahon before dic Inenentons: AKiliae GpANKh ean. material, waive Hanator 1Pad evauaton THAMSIatoY WAC UT Lized To go ovey Ale WitD, Pt. expressec WNAestANA NA and had all oWeshons nnswercd. PE was provided aii alo Whom Spavis Rev, 08/14/13 wvitteyyUSF 4467 Clinical Doc MBU - Mother Baby Form student UMW Gi TAMleh pate 2] 20/1% Patient intial: 1 C Blood Type:_0 + Coombs: pu Done? Yep ar_v 2/18/18 % smin # days/hours old_‘L dans Cord vessels #__~ APGAR: 1 Resuscitation required @ birth? (Describe) WO Feeding: Bottle: Formula type —_Last feed, frequency_M11S_, for 25 17010 BreasiVolume/frequency ~ 43 howt tarcH__9|_____—_— Forall tems below: Only circle what you actully perform/observe. Any questions «review with instructor DAYTIME ‘eonatal Assessment DAYTIME | Neonatal Assessment. ‘COLOR BOWEL SOUNDS Ba pale, ruddy, cyano, arocyanoti, [Womitphyperactve, ypoactive jaundiced MEN Fiauscie TONE ———S~S*~S*S*S*S*S omen Sha, steed ad muscle IDF fered poston), asiuicus cot (Sen pnt se tne th sae LEVEL OF CONSCIOUSNESS applied INSPECTION [ies ethargsleping oncesonste, rouble Palmar crease Sits or poldacty, ow Upper syndacti eens [ttrynen, hgh itched eremites | REUROMUSCULAR FONTANELS Head lag, Palmar grasp present,/ absent tO Out f absent) ‘SKELETAL i [SaEATHSOUNDS Ortoian’s and Balow’s: Positive or negative: { noxmsfea, equal. bilateral, OR Talpesequiovarus (Clubfoot) Unegu dimished, ale, onc wheezing luteal fedssmetia- non symmetrical INSPECTION Skin: presence o absence of tuts of ha Tcl faring Gunn. Retractng sinuses, protrusions Aral opening pater HEART SOUNDS Spine | patent Agi, eg, Mucor | sero Trunkincuration: present is oral hip tums to ‘CAPILLARY REFLL side stroked, absent Resa, RESPIRATORY EFFORT sri OR Gre tine forref_ 2 sec o" om PULSES ‘FEMALES ‘ole GFERAR weak, absent Edema: presenabrent;> facial resent weak, absent vata dcharge=Ted ee, wie wal femora present weak absent | alts 6 ue basse Urethral meatus: at glans, hypospadias, we 12% _e_WO _ sadist eres eplpadus; testes in scrotum or undescended 6a {6tesap onsen presen, ees, problem ust_jaundi ed (Wai); : 10.) outcomes Pt Will evperience decrentod ,amnidice before 2-day Ffwwith pediatrician Inevenions EMwunlagi Freqwent fords tof dlinnina tip, Ms tov woreeniig, jaundice, ansure F]M appointment is sthidulad Evaluation: Pi. will schedule F[M Appumtment, already has es Yelationship with pedi ates Cte us oe PL Was VrOvided education or yaMndit, feeding tov, Rev, 08/14/13 ev and SIS of WoKtruna, yaundie/increased inl