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

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 plan
Good clinical notes, which form the patient
In order to remember these important steps
record, should be accurate, brief and easy to
in writing clinical notes, remember the word
read. 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 members
can understand them.
5-d The story
5-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 before
is made. It is then possible to know when the
examining an infant.
observation was made or care was given.

2. 108 NEWBORN CARE
5-e The observations after delivery and at 45 minutes after birth
the blood glucose concentration, measured
The observations include the findings of the
with a reagent strip, is 1.5 mmol/l. While
physical examination and the results of any
starting an intravenous infusion, the infant’s
additional 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 4
5-f The assessment problems. Each will have to be managed.
Once you have recorded the results of the
history, the physical examination and the 5-h The management
investigations, you must make an assessment
Finally the management of the infant must
of the infant’s condition. For example, you
be planned. The management consists of the
should ask yourself:
nursing care, the observations needed, the
1. Is the infant sick or well? medical treatment, and the management of the
2. 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 a
carefully recorded history and examination are 14-1-2008 10:30
of little value if you are unable to assess what
S:
the results mean. The management depends
18 year old primip. Booked. Spontaneous
on an accurate assessment of the infant’s
preterm labour. 35 weeks by dates and
problems. If you cannot identify the problems
palpation. No signs of fetal distress.
you 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 for
correctly 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 recession
1. Unmarried, teenage mother. and a respiratory rate of 65 breaths
2. Preterm delivery. per minute. Infant needs 50% head box
3. 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. SK ILLS WORKSHOP : CLINICAL NOTES AND OBSER VATIONS 109
P: 5-k Problem-orientated patient record
1. Incubator.
When writing follow-up notes, the SOAP
2. Neonatalyte IVI at 4 dpm.
system can be applied to each problem in
3. Nasogastric tube. Nil per mouth.
turn. This method is known as the problem-
4. Routine observations.
orientated patient record. It is very useful in
5. Head box oxygen.
a nursery where infants may need ongoing
6. Speak to parents.
care for days or weeks. Each day the problem
7. Arrange transfer to level 2 hospital.
list of the previous day is examined. You must
decide which problems remain unresolved
Signed: Sr. Mowtana
and, therefore, must be carried over to the next
day. Resolved problems can be dropped from
These brief notes give all the important the list. After reviewing the record for the past
information in a simple and systematic 24 hours and examining the infant, any new
manner. 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 has
5-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. Antepartum
haemorrhage. 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 been
Temp. 36 oC. Infant looks pale. Blood removed from the problem list, as it has
glucose normal. resolved and no longer has any effect on the
No respiratory distress. Heart rate infant, while the new problem of conjunctivitis
200/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 now
started at 5 dpm. it is applied to each problem in the problem
Hb. 10 g/dl. Blood taken for cross match. list. For example:
Nurse in incubator.
15/1/08 09:00
Although 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. Passed
the history, examination and investigations meconium. No apnoea.
are mixed up in a disorganised way. There is
no problem list so that the reader is not sure O:
what problems have been identified. There is Active. Abdomen normal. Not pale. Blood
also 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. 110 NEWBORN CARE
2. Start 2 x 12 feeds of expressed breast list should be drawn up and the SOAP method
milk. used to write notes under each problem.
3. Continue Neonatalyte at 4 dpm.
5-l A common patient record
2. Respiratory distress. It is far more efficient if both the medical and
S: nursing staff use the same patient notes. In
Oxygen requirements came down slightly all clinics and hospitals the records should be
during 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 Abbreviations
Chest clear with good air entry. Pink
with normal oxygen saturation in 40% To save time and space, abbreviations are
head box oxygen. Blood gases normal. often used in the patient record. A list of
the commonly used abbreviations in your
A:
nursery should be drawn up and displayed
Improving. Diagnosis probably hyaline
in the nursery. Below is a list of some of the
membrane disease.
commonly used abbreviations in the notes of
P: newborn infants:
1. Continue head box oxygen.
AFIS Amniotic fluid infection syndrome,
2. Repeat blood gas analysis at lunch
i.e. chorioamnionitis
time.
AGA Appropriate weight for gestational age
3. Conjunctivitis. CNS Central nervous system
S: CPAP Continuous positive airways pressure
Eyes became sticky during the night.
CVS Cardiovascular system
Swabbed with saline.
EBM Expressed breast milk
O:
Mild purulent discharge from both eyes. FAS Fetal alcohol syndrome
Eyelids not swollen. GIT Gastro-intestinal tract
A: Hb Haemoglobin
Probably Gonococcal conjunctivitis.
HC Head circumference
P:
1. Pus swab for laboratory. HMD Hyaline membrane disease
2. Clean eyes every 2 hours. IDM Infant of a diabetic mother
3. Chloromycetin eye drops 2 hourly.
4. Ceftriaxone 100 mg IMI. IMI Intramuscular injection
IV Intravenous
Signed: Dr A. Smith
LBW Low birth weight
This example shows how simple, short, NEC Necrotising enterocolitis
problem-orientated notes can give a very clear PCV Packed cell volume
record of the patient’s progress. This is far better
than pages and pages of jumbled notes. Each PDA Patent ductus arteriosus
day, after the infant has been carefully examined RDS Respiratory distress syndrome
and the observations chart read, the problem

5. SK ILLS WORKSHOP : CLINICAL NOTES AND OBSER VATIONS 111
RS Respiratory system the same principle for recording clinical
observations.
TSB Total serum bilirubin
UGA Underweight for gestational age See Figure 5.A, an example of a chart used for
the routine observations of sick infants.
RECORDING ROUTINE
OBSERVATIONS RECORDING FLUID INTAKE
AND OUTPUT
5-n The observation chart
The total amount of fluid given to a sick
Routine observations made on sick infants infant (the intake) and lost by a sick infant
by nurses or doctors must be recorded on a (the output) should be carefully recorded on
special 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 intake
4. Incubator temperature (if the infant is in The fluid may be given by mouth, nasogastric or
an incubator). orogastric tube, or by intravenous infusion. The
5. Percentage oxygen given (FiO2). type, volume and time of each oral or tube feed
6. 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 fluid
7. Colour. given, together with the time it was started, the
8. 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 is
5-0 Using an observation chart
recorded separately and then added together
The 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 given
separate columns. Each time an observation
each day for both milk and intravenous fluids.
is 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 of
of the observation is then recorded in the
feeds, must be clearly written on the intake
correct column. A column is also available for
chart. In addition, the type of intravenous fluid
comments to be written. It is very important
and the drip rate must also be stated.
that the person recording the observation
knows whether the result is normal or
abnormal. Some people prefer to write 5-q Recording fluid output
abnormal results in red. The record on the Fluid may be lost in the urine, stool, vomitus
observation chart is started when observations or may be aspiration from a nasogastric or
on a sick infant begin. Usually a new page orogastric tube. Less commonly, fluid may
is started each day, most commonly in the be lost via a drain from the chest or other
morning when the day staff take over duty site. Some forms of fluid loss, such as in the
from the night staff. stools and from the lungs and skin, cannot
Different observation charts are used in be measured easily and therefore are not
different hospitals. However, they all use routinely recorded. If necessary, they can
be measured or calculated. Even very small

6. 112 NEWBORN CARE
volumes of fluid loss may be important in a In many small infants, only a record of the
small 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 are
plastic 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 fluid
to 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 passed
Disposable nappies can be weighed dry and
is recorded. Loose stools may contain a lot of
wet with urine to calculate output. This is
fluid and, therefore, must be recorded carefully.
usually done in a level 3 nursery. Therefore, an
accurate record of the volume of urine passed Each type of fluid loss is recorded separately
is only kept when there is a clinical indication, and then added up at the end of the 24 hour
e.g. possible dehydration or renal failure. Most period to give the total measured output. The
infants pass about 2 ml/kg/hour. Oliguria in a difference between the intake and the output
newborn 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. 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. 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 15:00
Figure 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