NICU Post Conference Report Form (Don’t forget your prepsheet)
Student Name ________________________ Unit________ Patient Initials _________
Clinical Date _____________________
GTPAL __________Maternal Age_______ Marital status _____ Ethnicity _________ Allergies_________ Pt’s Date of admission: __________
Current Chief Complaint (why is infant in the hospital) ______________________________________ (IE: Premie at 29+3 D/T maternal
preeclampsia or preterm labor)
Reason for Admission (mom’s reason for admission to hospital): ________________________________________
LNMP__________ EDC___________ EGA __________ Current Diet: _________________________
MOB Blood type /Rh ____Infant Blood type/Rh _____ Rubella _____ HIV ______ HBsAG ____ GBS ____ VDRL____ STDs______ HCT/HGB _______
OB HX ____________________________ Medical History ______________________
(Including this pregnancy)
(If pertinent)
Mom’s Pain Management (Labor) ______________________
Mom’s Current Pain Management __________________________________
FOB Involved? __________ Support System: _______________ Hx Drugs/ETOH/Smoking _____________ CPS Involvement ? ________________
Delivery Summary
AROM / SROM Date/ Time: _______
FHTs: ________ Date/Time of Delivery: ________________________
C: clear O: malodorous C: Thin
A: moderate
Type NSVD / C-Section
Assist
Forceps / Vacuum
If C/S Reason:________
Episiotomy: none midline mediolateral
Laceration: None 1o 2o 3o 4o
Perineal / Labial (bilateral) / Periurethral / Cervical
SEX: _________________
Infant Vital Signs: Temp ______
Other: ____________________________
Resuscitation
Apgar Score
1 min --------5 min ______
HR
0 1 2
0 1 2
HR ______ Resp _____ B/P ____
Resp
0 1 2
0 1 2
Tone
0 1 2
0 1 2
Reflex
0 1 2
0 1 2
Color
0 1 2
0 1 2
Position and Presentation OA
Vertex: ROA / ROT / ROP / LOA / LOT / LOP
Breech: Complete / Frank / Footling / Shoulder
Birth Weight: Gms ______ lbs ____oz _____
SGA / AGA / LGA
Other contributing medical issues:
Post Delivery Medications: Amount, # doses?
Pitocin:
Methergine:
Hemabate:
Cytotec:
# of Vessels _________
Cord Characteristics
Nuchal Cord x _______
Infant to Nurs/NICU/ PP unit with mom
Number of days Old ___________
Other Concerns:
Infant Medications
Erythromycin Date/Time: ________ Hepatitis B Date/Time: ____________
Vitamin K Date/Time: ________
Other?
_____________________________________________
EBL:
QBL
In Del/Rec Room: Breastfeeding ________ min Bottle feeding _______ oz
Complications of Delivery: (Maternal Fever/Non reassuring FHR, Other)
Birth Trauma: (Mom or Infant)
Length of time ROM prior to delivery? _________
Maternal GBS Status + / Treatment? Drug, dose _______________________
Number of Doses” ___________________________
NICU Assessment
Current Age: _____________ days old
Yest wgt: Gms ______ lbs. ______oz _____
SGA / AGA / LGA
Today’s Gms ______ lbs. _____ oz ______
SGA / AGA / LGA
Daily fluid and calorie requirement: ___________mL __________kCal
(See Prep Sheet)
Daily fluid and calorie received: ___________mL __________kCal
Breast / Formula: Type _______________ Cal/oz __________
Orders For Feedings: _____________________
General:
Vital Signs: T _____ BP ____ HR ______ R ______
O2 Sat _____ (HR/RR determined over full minute each)
Open Crib / Warmer / Isolette
Gestational Age Assessment Score: _______________
Tone: Well flexed / Mild flexion / Flaccid
Activity: Alert/Active / Sleeping / Irritable / Jittery
Skin: ____________ Lanugo: _________ (From Gest Age
Assessment)
Head Shape: ______________ Molding: ____________
Caput Succedaneum / Cephalohematoma
Ant Fontanelle: Soft / Flat / Bulging
Post Fontanelle: Soft / Flat / Bulging
Eyes: Normal placement / Open Fused / Clear
Ears: Symmetrical / Normal placement / Ear tags ________
Mouth: Symmetric movement / Intact Palate / Intact Lips
Full ROM Neck __________ Clavicle intact __________
Systems:
Cardiovascular: Regular rate/rhythm / Murmur / Brachial
Pulse / Femoral Pulse
Resp: Rm Air / O2 ___ L/min CPAP / Vent
NGT / OGT
Breath Sounds: _______________ WOB: _________________
Nasal Patency Bilat / Flaring
Retractions: _________ Cap Refill__________ (Core/Circumoral)
Breasts: 1-2 mm / 3-4 mm / 5 -10mm breast bud
Abdomen: Soft, Non-Tender / Firm / Distended
Bowel Sounds: Active X4 quad / Absent Stool # _________ Type________
Anal Patency (+) (-)
GU: Void # ________ Bladder distention _____________
Male: Circ? Type? _________ Testes Descended bilat ________
Female: Genital Maturity Description____________________ (From Gest Age Assessment)
Skin: Color _____ Acrocyanosis / Mottling / Ecchymosis / Jaundice
Mongolian Spots: Location: _____________ Size_____________
Neuromusculoskeletal: Spine Straight / Tuft of Hair / Sacral Dimple
Arms Symmetrical Size / Movement Symmetrical
Hands: Solid Palmer Creases / 5 Fingers Each Hand /
Webbing
Symmetrical Size / Movement Symmetrical
Planter Creases: Faint / Anterior Transverse only / Anterior 2/3 / Entire sole /
foot / Webbing
5 Toes each
Bonding Behaviors: _______________________________
________________________________________________
Major Focus/Concern: ___________________________
_______________________________________________
Nursing Actions to Address Concern:
________________________________________
________________________________________
Other Concerns related to the infant/family? More
on back if needed ________________________
_______________________________________
Past issues since admission to NICU __________
________________________________________
Reflexes: Rooting / Sucking / Palmer Grasp / Plantar Grasp /
Moro / Babinski
Breast or Bottle feeding concerns/referrals: (How is feeding going?)
Blood Glucose:
Date/Time
1.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
3.
______________________________________________
__________________________________________________________________________
__________________________________________________________________________
4.
______________________________________________
______________________________________________
F/U
Education Topics : Be SPECIFIC – not just the topic Minimum of 5
What did infant do when above reflexes elicited?
______________________________________________
Intervention
Other: (Bili levels/Treatment etc)
2.
______________________________________________
Result
__________________________________________________________________________
__________________________________________________________________________
5.
__________________________________________________________________________
__________________________________________________________________________
Compare your NICU patient to others in the NICU and evaluate the differences in assessment findings among various gestational ages.
Created 3/2021 bkh