NURSES' NOTES

PATIENT NAME:
N/A - Baby Boy AGE: Newborn Weight: 3 kg HOSPITAL NO.: 1234
PHYSICIAN:
Dra. Matilda SEX: Male Height: 50 cm WARD/ROOM: NICU

DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE NURSE SIGNATURE

09-20-2021 Risk for Ineffective D – Patient’s vital signs are as follow: CR = 125 bpm, RR = 45 bpm,  
7:00 am- 3:00 pm Thermoregulation Temperature = 36.7 °C, O2 Sat = 97%
shift
7:30 am A – Monitored the newborn’s temperature.  

8:00 am - Dried, swaddled, and placed the infant skin-to-skin with the  
mother.
8:20 am - Covered the newborn with warm blankets and a cap.
8: 30 am - Covered the surfaces where the newborn is placed with warm
blankets.
9:00 am - Adjusted the room temperature.  

3:00 pm   R - The neonate was able to maintain a normal body temperature.  Vanquiray, Princess
M., SN
 DATE/TIME
09-20-2021
7:00 am- 3:00
pm shift

9:30 am

10:00 am

10:30 am

11:00 am

11:30 am

3:00 pm

DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE NURSE SIGNATURE

09-20-2021 Risk for Fall D - 1 min after the delivery, the baby is very active and  
7:00 am- 3:00 strongly moving his extremities, a lot.
pm shift

11:00 am 5 mins after delivery:  

The baby also has increased movement actively and cries so loud
 

11:30 am A- Ensured that family is aware of issues related to safety and risk  
for falls.
 

- Provided a safe environment to eliminate risk for falls.

- Kept bed in low position with brakes on and bed ends in place.  

- Provided enough room for the baby to move and extend his arms and  
legs.
 
 -Instructed family in techniques to prevent injury as putting the side rails  
high and being a responsible watcher of the baby.
     

  R- Baby is being ensured and cared which made him safe and secured.  

- Parents has portrayed understanding of the role of keeping the risk of

the baby from falling being prevented.
    Vanquiray, Princess
M., SN