Practical Nursing Skills-NEWBORN SOAP NOTE-2021

RF is a 6-week-old newborn male patient presents in mother’s arms, who’s mother states he has been running a fever for 2 days and seems to have reduced time breastfeeding, and reduced amount of baby formula consumed. ➢ C ...

RF is a 6-week-old newborn male patient presents in mother’s arms, who’s mother states he has been running a fever for 2 days and seems to have reduced time breastfeeding, and reduced amount of baby formula consumed. ➢ Chief Complaint (CC): • The Mother states “My baby has had a fever for 2 days and I’m very worried.” ➢ History of Present Illness (HPI): • The mother states that she noticed RF was warmer to the touch, so she took an axillary temperature of the baby which was 100.8F two days ago, and yesterday RF’s temperature was 101.9F. She noticed also that his appetite had reduced as he would not feed as much from her breast, refused to latch on, and when given baby formula RF would not consume more than 1 oz. The mother reports that RF has been more fussy than usual and wakes up crying more times than usual in these last two days. This morning the mother states that RF was lethargic and did not breast feed but did prefer small amount of formula less than 2oz.soapsoap notenewborncaseRF is a 6-week-old newborn male patient presents in mother’s arms, who’s mother states he has been running a fever for 2 days and seems to have reduced time breastfeeding, and reduced amount of baby formula consumed. ➢ Chief Complaint (CC): • The Mother states “My baby has had a fever for 2 days and I’m very worried.” ➢ History of Present Illness (HPI): • The mother states that she noticed RF was warmer to the touch, so she took an axillary temperature of the baby which was 100.8F two days ago, and yesterday RF’s temperature was 101.9F. She noticed also that his appetite had reduced as he would not feed as much from her breast, refused to latch on, and when given baby formula RF would not consume more than 1 oz. The mother reports that RF has been more fussy than usual and wakes up crying more times than usual in these last two days. This morning the mother states that RF was lethargic and did not breast feed but did prefer small amount of formula less than 2oz.newbornsoap notesoapmotherchild