Newborn Care: Skills workshop Clinical notes and observation


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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents

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Newborn Care: Skills workshop Clinical notes and observation

  1. 1. Skills workshop: Clinical notes and observations 5-b Always sign your notes Objectives Every time you write clinical notes you should sign (and write) your name. The rest of the When you have completed this skills health team then knows who wrote the notes. workshop you should be able to: 5-c The ‘soap’ method of writing notes • Write good clinical notes. • Record routine observations. When an infant is examined for the first time the clinical notes should include: 1. The story (i.e. the history)WRITING GOOD 2. The observations (i.e. the physical examination and investigations)CLINICAL NOTES 3. The assessment 4. The planGood clinical notes, which form the patient In order to remember these important stepsrecord, should be accurate, brief and easy to in writing clinical notes, remember the wordread. In addition, they must be systematic. ‘SOAP’. The letters in SOAP stand for Story–Therefore, they should be written in an Observations–Assessment–Plan.orderly, logical way so that all staff memberscan understand them. 5-d The story5-a The date and time Good notes should always start with the history (i.e. the history of the pregnancy,Whenever notes are written it is important labour, delivery and events after delivery).to give the date and the time that the record A history should always be taken beforeis made. It is then possible to know when the examining an infant.observation was made or care was given.
  2. 2. 108 NEWBORN CARE5-e The observations after delivery and at 45 minutes after birth the blood glucose concentration, measuredThe observations include the findings of the with a reagent strip, is 1.5 mmol/l. Whilephysical examination and the results of any starting an intravenous infusion, the infant’sadditional investigations done, e.g. packed cell skin temperature falls to 34.5 °C.volume or chest X-ray. You should be able to identify at least 45-f The assessment problems. Each will have to be managed.Once you have recorded the results of thehistory, the physical examination and the 5-h The managementinvestigations, you must make an assessment Finally the management of the infant mustof the infant’s condition. For example, you be planned. The management consists of theshould ask yourself: nursing care, the observations needed, the1. Is the infant sick or well? medical treatment, and the management of the2. Is the infant at high risk or low risk for parents. clinical problems?3. What clinical problems does the infant 5-i An example of good ‘soap’ notes have at present?The assessment must not be forgotten as acarefully recorded history and examination are 14-1-2008 10:30of little value if you are unable to assess what S:the results mean. The management depends 18 year old primip. Booked. Spontaneouson an accurate assessment of the infant’s preterm labour. 35 weeks by dates andproblems. If you cannot identify the problems palpation. No signs of fetal will not be able to plan the correct NVD 06:15. Apgar scores 4 and 9.treatment. Assessing an infant’s problems Intubation and ventilation needed forcorrectly takes a lot of practice. 3 minutes. Thereafter infant moved to nursery.5-g The problem list O:When the assessment is made, it is very Male infant. Weight 2000 g.helpful to compile a problem list. Each clinical Assessed gestational age 36 weeks.problem that you identify from the story Active. No congenital abnormalities.and observations must be listed separately. A Skin temperature 36 oC.typical problem list looks like this: RS – Respiratory distress with recession1. Unmarried, teenage mother. and a respiratory rate of 65 breaths2. Preterm delivery. per minute. Infant needs 50% head box3. Jaundice. oxygen to remain pink. CVS – Heart rate 150/min. Well perfused.You now have a good idea of the clinical GIT – Abdomen normal.problems that require management. CNS – Appears normal. Fontanelle flat.Read the following case history and draw up Blood glucose 3.0 mmol/l. PCV 60%.your own problem list: A: After a normal vaginal delivery at 40 weeks, 1. Preterm delivery. an infant has Apgar scores of 3 and 8 and 2. Neonatal asphyxia. requires mask ventilation. The birth weight 3. Respiratory distress. is 2300 g. The infant is not put to the breast
  3. 3. SK ILLS WORKSHOP : CLINICAL NOTES AND OBSER VATIONS 109P: 5-k Problem-orientated patient record1. Incubator. When writing follow-up notes, the SOAP2. Neonatalyte IVI at 4 dpm. system can be applied to each problem in3. Nasogastric tube. Nil per mouth. turn. This method is known as the problem-4. Routine observations. orientated patient record. It is very useful in5. Head box oxygen. a nursery where infants may need ongoing6. Speak to parents. care for days or weeks. Each day the problem7. Arrange transfer to level 2 hospital. list of the previous day is examined. You must decide which problems remain unresolvedSigned: Sr. Mowtana and, therefore, must be carried over to the next day. Resolved problems can be dropped fromThese brief notes give all the important the list. After reviewing the record for the pastinformation in a simple and systematic 24 hours and examining the infant, any newmanner. Try to write your notes using the problems are added to the previous list.SOAP method. For example, on day 2, the infant described in 5-i is doing well. The respiratory distress has5-j An example of poor notes improved slightly but the infant has developed a mild conjunctivitis. The problem list for day 2 should, therefore, be:No antenatal care. Antepartumhaemorrhage. 1. Preterm infant.Normal delivery. 2000 g. Female, term 2. Respiratory distress.infant. 3. Conjunctivitis.Good Apgar scores. Vitamin K given. The problem of neonatal asphyxia has beenTemp. 36 oC. Infant looks pale. Blood removed from the problem list, as it hasglucose normal. resolved and no longer has any effect on theNo respiratory distress. Heart rate infant, while the new problem of conjunctivitis200/min. has been added to the list.Abdomen normal. Sucks poorly.Keep nil per mouth. Neonatalyte infusion Again the SOAP system can be used, but nowstarted at 5 dpm. it is applied to each problem in the problemHb. 10 g/dl. Blood taken for cross match. list. For example:Nurse in incubator. 15/1/08 09:00Although most of the information is given, 1. Preterm infant.these notes are not systematic and, therefore, S:they are difficult to understand. Notice how No problems during the night. Passedthe history, examination and investigations meconium. No apnoea.are mixed up in a disorganised way. There isno problem list so that the reader is not sure O:what problems have been identified. There is Active. Abdomen normal. Not pale. Bloodalso no date or signature. Try to rewrite these glucose and temperature normal.notes using the SOAP method. Do not forget A:to draw up a problem list. No change. P: 1. Keep in incubator.
  4. 4. 110 NEWBORN CARE2. Start 2 x 12 feeds of expressed breast list should be drawn up and the SOAP methodmilk. used to write notes under each problem.3. Continue Neonatalyte at 4 dpm. 5-l A common patient record2. Respiratory distress. It is far more efficient if both the medical andS: nursing staff use the same patient notes. InOxygen requirements came down slightly all clinics and hospitals the records should beduring the night. shared. All members of the health team should learn how to keep systematic patient records.O:Mild recession. Respiratory rate 55/min. 5-m AbbreviationsChest clear with good air entry. Pinkwith normal oxygen saturation in 40% To save time and space, abbreviations arehead box oxygen. Blood gases normal. often used in the patient record. A list of the commonly used abbreviations in yourA: nursery should be drawn up and displayedImproving. Diagnosis probably hyaline in the nursery. Below is a list of some of themembrane disease. commonly used abbreviations in the notes ofP: newborn infants:1. Continue head box oxygen. AFIS Amniotic fluid infection syndrome,2. Repeat blood gas analysis at lunch i.e. chorioamnionitistime. AGA Appropriate weight for gestational age3. Conjunctivitis. CNS Central nervous systemS: CPAP Continuous positive airways pressureEyes became sticky during the night. CVS Cardiovascular systemSwabbed with saline. EBM Expressed breast milkO:Mild purulent discharge from both eyes. FAS Fetal alcohol syndromeEyelids not swollen. GIT Gastro-intestinal tractA: Hb HaemoglobinProbably Gonococcal conjunctivitis. HC Head circumferenceP:1. Pus swab for laboratory. HMD Hyaline membrane disease2. Clean eyes every 2 hours. IDM Infant of a diabetic mother3. Chloromycetin eye drops 2 hourly.4. Ceftriaxone 100 mg IMI. IMI Intramuscular injection IV IntravenousSigned: Dr A. Smith LBW Low birth weightThis example shows how simple, short, NEC Necrotising enterocolitisproblem-orientated notes can give a very clear PCV Packed cell volumerecord of the patient’s progress. This is far betterthan pages and pages of jumbled notes. Each PDA Patent ductus arteriosusday, after the infant has been carefully examined RDS Respiratory distress syndromeand the observations chart read, the problem
  5. 5. SK ILLS WORKSHOP : CLINICAL NOTES AND OBSER VATIONS 111RS Respiratory system the same principle for recording clinical observations.TSB Total serum bilirubinUGA Underweight for gestational age See Figure 5.A, an example of a chart used for the routine observations of sick infants.RECORDING ROUTINEOBSERVATIONS RECORDING FLUID INTAKE AND OUTPUT5-n The observation chart The total amount of fluid given to a sickRoutine observations made on sick infants infant (the intake) and lost by a sick infantby nurses or doctors must be recorded on a (the output) should be carefully recorded onspecial chart. The usual observations are: an intake and output chart so that the fluid balance can be calculated each day.1. Heart (pulse) rate.2. Respiratory rate.3. Skin or axillary temperature. 5-p Recording fluid intake4. Incubator temperature (if the infant is in The fluid may be given by mouth, nasogastric or an incubator). orogastric tube, or by intravenous infusion. The5. Percentage oxygen given (FiO2). type, volume and time of each oral or tube feed6. Pattern of respiration (recession, grunting, must be noted on the chart by the nurse who shallow or irregular). has given the feed. The type of intravenous fluid7. Colour. given, together with the time it was started, the8. Apnoea. time it was completed and the volume received,9. Blood glucose concentration. must also be carefully recorded. The daily volume of each type of fluid intake is5-0 Using an observation chart recorded separately and then added togetherThe names of the different observations are to give the total intake for the 24 hour period.listed along the top of the chart at the head of It is essential that clear instructions are givenseparate columns. Each time an observation each day for both milk and intravenous made, the date and time must be recorded The type of oral or tube feed to be given,as well as the observer’s name. The result together with the volume and frequency ofof the observation is then recorded in the feeds, must be clearly written on the intakecorrect column. A column is also available for chart. In addition, the type of intravenous fluidcomments to be written. It is very important and the drip rate must also be stated.that the person recording the observationknows whether the result is normal orabnormal. Some people prefer to write 5-q Recording fluid outputabnormal results in red. The record on the Fluid may be lost in the urine, stool, vomitusobservation chart is started when observations or may be aspiration from a nasogastric oron a sick infant begin. Usually a new page orogastric tube. Less commonly, fluid mayis started each day, most commonly in the be lost via a drain from the chest or othermorning when the day staff take over duty site. Some forms of fluid loss, such as in thefrom the night staff. stools and from the lungs and skin, cannotDifferent observation charts are used in be measured easily and therefore are notdifferent hospitals. However, they all use routinely recorded. If necessary, they can be measured or calculated. Even very small
  6. 6. 112 NEWBORN CAREvolumes of fluid loss may be important in a In many small infants, only a record of thesmall infant. frequency of wet nappies is kept. Most infants have about 8–10 wet nappies a day.Urine has to be collected in a urine bag,aspirated via a catheter and measured with a The number of vomits, and whether they areplastic syringe if an accurate record of urine large or small, must be carefully recorded.output is to be kept. This is often difficult, If the stomach is aspirated before feeds,especially in a female infant, as the urine tends an accurate record of the volume of fluidto leak out of the bag. In addition, removing aspirated should also be kept.a urine bag may damage the infant’s skin. The number and appearance of stools passedDisposable nappies can be weighed dry and is recorded. Loose stools may contain a lot ofwet with urine to calculate output. This is fluid and, therefore, must be recorded carefully.usually done in a level 3 nursery. Therefore, anaccurate record of the volume of urine passed Each type of fluid loss is recorded separatelyis only kept when there is a clinical indication, and then added up at the end of the 24 houre.g. possible dehydration or renal failure. Most period to give the total measured output. Theinfants pass about 2 ml/kg/hour. Oliguria in a difference between the intake and the outputnewborn infant is defined as a urine output of over 24 hours is called the daily fluid balance.less than 1 ml/kg/hour. See Figure 5.B, an example of an intake and output chart.
  7. 7. Newborn Observation Chart Name: Hospital no.: Weight: Date: 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 00:00 01:00 02:00 03:00 04:00 05:00 06:00 Respiratory rate Grunting Recession Apnoea Heart rate Temp: infant Temp: incubator Colour Oxygen % Oxygen saturation Blood glucose Remarks:Figure 5.A: An example of a chart used for the routine observations of sick infants.
  8. 8. Doctor’s orders Drops per minute Signature Instructions oral/tube feeding Name of patient Instructions intravenous intake Folder number 1. Sex 2. Race 3. Age 4. Ward 5. 6. TPN orders Oral Volume Urine Position Gastric Other Time intake or Flushed Time Vomitus B.A. SIGN. Put up Given checked aspirate Vol. S.G. drainage feed type 07:00 07:00 08:00 08:00 09:00 09:00 Nurses record 10:00 10:00 Intravenous intake 11:00 11:00 Type of Time put Time com- Volume 12:00 12:00 Sign. fluid up pleted given 13:00 13:00 14:00 14:00 15:00 15:00Figure 5.B: An example of an intake and output chart. 16:00 16:00 17:00 17:00 18:00 18:00 19:00 19:00 20:00 20:00 21:00 21:00 22:00 22:00 Nurses record TPN intake 23:00 23:00 00:00 00:00 01:00 01:00 02:00 02:00 03:00 03:00 04:00 04:00 05:00 05:00 06:00 06:00 Total per Mouth Total intravenous (IV) Totals Tube IV Oral/Tube Total intake + = MLS Signature of nurse Total output MLS