TITLE: GUIDELINE FOR THE USE OF SCN FLOW SHEET

1. Place a patient label in the upper left corner.
2. Write the month, date, and year on the date line.
3. Write narrative concerning infant’s changes in assessment and care as needed. All disciplines may use this area. Entries are timed and signed.
4. Check CPT/MDI/suction column when appropriate, and complete comment section using legend.
5. Describe X-rays taken. ET position may be described under comment section.
6. Describe any change in position.
7. Indicate procedures performed using legend.
8. List any additional information under comment section.
9. Initial any entry.
10. Initial and date all protocols currently being used, using the date the protocol was initially activated.
11. Write in the date when the outcomes to a protocol have been met to d/c the protocol.
12. Write in the name of the infant.
13. Write in the date and time the assessment is completed, and the shift.
14. Check all appropriate responses in indicated areas and provide additional information as needed. Briefly describe other general conditions and any specific abnormalities for each system as indicated.
15. Explain any details concerning patient’s condition not previously described, such as: chest tube, warming blankets, etc.
16. List IV fluid(s) the patient is receiving at the time of assessment. State the rate of infusion of each fluid. State the location of central line(s) or peripheral IV(s). Complete tape/dressing and site columns for each line using legend. Describe location and site of each heparin lock.
17. After receiving and verifying current orders, kardex, MDPEF,and armbands; hugs band; suction equipment, place a check in appropriate blanks.
18. Signature of nurse completing assessment.
19. Repeat 13-18 for P shift.
20. Write patient’s name as indicated on patient label.
21. Write the month, date, and year on the date line.
22. Write the current day’s weight of the infant.
23. Write in the previous day’s weight of the infant.
24. Complete the time of entry at the top of columns.
25. Write in infant’s temperature including Axillary temperature, skin temperature, control point, and ambient temperature.
26. Complete vital signs section as indicated.

28. Indicate with a check to confirm that the monitor is on and alarm limits are set.
29. Write in current pulse oximeter reading and indicate when pulse ox site is changed.
30. Initial the entry.
31. Complete this section utilizing the activity and breath sounds legend.
32. Place a check mark and initial when infant is assessed.
33. Document when cord care and fetal scalp monitor site care are done. Document the presence of bililights and bilimask.
34. Indicate number of episodes of apnea/bradycardia/desaturation using slash marks. Describe stimulation required to reverse using the legend and any precipitating factors.
35. Indicate mode of oxygen delivery, oxygen concentration, liters per minute if on cannula, temperature of heater if on hood, and initials.
36. Indicate quality of feeding using legend, duration of feed, who fed the infant, and if there were any desaturations/bradycardias, or color changes during the feed.
37. Use legend to indicate OG placement check and tubing changes.
38. Indicate volume fed to infant.
39. Add together for a running total.
40. Amount of residual or emesis.
41. Indicate type of formula.
42. Indicate route of feeds, such as po, og, ng.
43. Print name of each intravenous fluid or blood product.
44. For continuous infusing IV, list the pump count in the first half of the column. In the second half of the column, list amount of fluid infused since last entry. For fluids infusing over four hours or less, enter amount infused every hour.
45. Total of all IV fluids or blood products for that entry.
46. Using legend, indicate when these procedures occur.
47. Record volume of all flushes and medications used this entry.
48. Add total in column and enter amount here.
49. Enter running total of all fluid infused.
50. If infant is on I & O, place diaper weight here, if not on I & O, place a check mark.
51. Enter running total of urine.
52. Complete as indicated when doing urine checks.
53. Enter amount and color of stool.
54. Enter results of stool guiac.
55. In first half of column, enter amount of gastric output. In second half of column, place the running total.
56. Record amount of blood out in the first half of the column. In the second half of the column, enter the running total. The total column is zeroed when the infant receives a blood transfusion.
57.  

1. Record the medication name, dose administered, route of administration and frequency of administration ordered in the space provided.
2. Record the time the medication is administered.
3. Record the initials of the person who administered the medication below the time entered.

58. Record Pain Assessment
59.  

a. Enter lab values in column corresponding to time of draw.

b. To be completed by laboratory technicians when lab is drawn, indicating type of lab drawn.

a. Enter time, source results entered by lab tech.

b. Pulse ox, Fl02, lpm that were in effect when blood gas was drawn in entered by nurse.

61. Complete, using legend as needed.
62. Describe interactions with parents as needed. Teaching documented of MDPEF.
63. Write in date of last parent contact.
64. Enter time and measurements taken.
65. Describe consults, ultrasound, or misc.
66. Record time and breast feeding observations using legend.
67. Record running total of blood out.
68. Record 24 hour total of gastric output.
69. Record 24 hour total of stool output.
70. Record 24 hour total of urine output.
71. Combine urine output, stool output, and gastric output.
72. List date and time of last stool.
73. Calculate cc/kg/day of feeds.
74. Record 24 hour total cc’s of feeds.
75. Record 24 hour total of IV fluids given.
76. Combine feeding and IV totals for total intake.
77. Each provider making entries records signature and initials in this area.

RESOURCE PERSON(S): Marie Patterson, RN, CSM; Pam McMillian, RN

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