Connecticut Children’s NICU

at UConn Health Center

282 Washington Street
Hartford, CT 06106
(Patient Identification)
Newborn/Intermediate Flowsheet – Date:
RN SIGNATURE INITIALS RN SIGNATURE INITIALS RN SIGNATURE INITIALS RN SIGNATURE INITIALS

VITAL SIGNS ASSESSMENTS PAIN RESPIRATORY SUPPORT SUCTION

Screen
Time ISC INFANT HR RR BP BP BREATH EQUAL GRUNT COLOR SKIN RASH ABD UMB FONT TONE CIRC SOURCE
MEAN SOUNDS TEMP SITE  TIME MODE FiO2 FLOW SPO2 Oximeter NEB TYPE INIT
TREND SITE RX
SKIN RESP AIR ’D
TEMP BED QUAL PATTERN S/D SITE ENTRY RETR FLARIN PERF TURGOR EDEMA BS GIRTH ACTIV CRY POSIT CPT
* AMOUNT

Eff. 9/1/11 Rev. Page 1 of 4

 Connecticut Children’s NICU
at UConn Health Center
282 Washington Street
Hartford, CT 06106
(Patient Identification)
Newborn/Intermediate Flowsheet – Date:
Standards of Care SHIFT SHIFT
Care of the Infant with: SAFETY: WEIGHT: KG LB
Admission to the Newborn Nursery ALARMS: Birth Weight:
Apnea/ Bradycardia /Periodic Breathing HR: HIGH / LOW Yesterday:
Breastfeeding/Breast Pumping

Bronchodilators RR: HIGH/Apnea > 20 sec. Today:

Cardiorespiratory Monitor
Central Lines Pulse Oximetry: Low Wt change:
Circumcision
Developmental Assessment and Care Security Sensor On: Length: OFC:
Discharge Planning: Neonatal Corrected Gestational Age:
Feeding: NG/OG/Continuous/Intermittent EQUIPMENT: Mom’s Room #
GE Reflux Resuscicard Care Level:
Grieving Bag/Mask & O2 Flow Physician:
Hospitalized Infant: Care of the Family Suction Set-up
IV Therapy ID & Blood Bracelet BLOOD GAS RESULTS
Kangaroo Care Evacuation Pack & ID Time Site pH pCO2 pO2 BE

Pain Screening and Assessment PHOTOTHERAPY:

Phototherapy/Biliblanket Photo Tx Intensity
Pulse Oximetry Eye Patches
Skin Care: Neonatal Serum Bili Level LAB TESTS/RESULTS
Time Site Gluc HCT
Steroids HYGIENE: Meter
TESTS AND RESULTS
Supplemental Oxygen Bath/Linens
Thermoregulation Cord Care
Well Newborn Circ. Care
Other: Nares Care
Mouth Care STOOL/URINE RESULTS

PARENT COMMUNICATION:
COMMENTS:
PATIENT AND FAMILY TEACHING RECORDS:
Family Education of the hospitalized Infant
BPD
Others:

Eff. 9/1/11 Rev. Page 2 of 4

 Connecticut Children’s NICU
at UConn Health Center
282 Washington Street
Hartford, CT 06106
(Patient Identification)
Newborn/Intermediate Flowsheet – Date:
GENERAL GRUNTING UMBILICAL POSITION/MISC STOOL COLOR ORAL(PO) FEEDING DESCRIPTION BEHAVIOR DURING BREASTFEEDING
R – Right A – Audible w/naked CORD P - Prone M – Meconium 1 Latches on without difficulty with strong,
L – Left ear O - Off S – Supine Y – Yellow BEHAVIOR BEFORE FEEDING steady and rhythmic sucks; briefly pauses
 - Done S – Stethescope only D - Dry R - Rt. Side Down G – Green 1 Infant awakens on own signaling and readily resumes sucking; frequent,
- - Absent Int - Intermittent W - Wet L - Lt. Side Down B – Brown hunger with crying or fussing; shows coordinated suck- swallowing heard
+ - Present Cl - Clamped HOB - Head of Bed Up FB – Frank Blood hunger cues (rooting, sucking, 2 Latches on without difficulty with strong,
 - Increased COLOR DG - Drainage HOB - Head of Bed searching, hand to mouth). steady and rhythmic sucks; briefly pauses
 - Decreased P - Pink R – Erythema Down CONSISTENCY 2 Infant awakens on own, may remain and resumes sucking without help; some
‡ - Asymmetrical W – Pale confined to IS – Infant Seat S – Soft quietly alert, drowsy or begin fussing or swallowing heard.
= - Equal D – Dusky stump SW – Swaddled W - Watery moving, may show some hunger cues 3 Latches on with minimum difficulty; sucks
 - Changed C – Cyanotic Rt – Erythema SG – Swing P – Pasty (rooting, sucking, searching, hand to are short and quick without steady rhythm;
J – Jaundiced extended to H – Held SD – Seedy mouth). pauses and needs help to resume sucking;
BED PL – Plethoric abdominal Mu – Mucous 3 Infant awakens with care-giving and occasional swallowing heard.
I – Isolette M – Mottled wall OXYGEN MODE begins to show hunger cues (rooting, 4 Roots or licks; latches on with difficulty;
OC – Open Crib A -Acrocyannosis I – Isolette ENTERAL FEEDS sucking, searching, show hand to briefly maintains latchon or does not suck;
OW – Open Warmer FONTANELLE H – Hood MODE mouth, fussing). no swallowing heard.
PERFUSION S – Soft, Flat NC – Nasal Cannula Po – Nipple 4 Infant awakens with care-giving, 5 Roots or licks; unable to latch on for
HR QUALITY N – CRT < 3 sec. F – Full MT – Mist tent BF – Breastfeeding appears quietly awake or somewhat breastfeeding attempt.
R – Regular A – CRT > 3 sec. T – Tense TC – Trach Collar CNG – Continuous drowsy with limited hunger cues 6 No effort (sleepy, lacks energy, has no
I – Irregular B – Bulging CPT Nasogastric (rooting, sucking, searching, hand to interest, cries, squirms, or pushes away)
M – Murmur SKIN TEMP D – Depressed P – Percussion NG/OG – Gavage mouth). despite much assistance, unable to
RESP. PATTERN W – Warm V – Vibration 5 Infant remains asleep or drowsy. successfully attempt breastfeeding.
R – Regular C – Cool ACTIVITY IV SITE CHECK 6 Infant appears to have limited
IR – Irregular H – Hot ++ - Active, Alert SUCTION SOURCE W – Warm physiological stamina required to RESPONSE TO FEEDING
S – Shallow D - Diaphoretic + - Active to stim O – Oral C – Cool sustain control and endurance for 1 Appears satiated and comfortable; becomes
PB – Periodic L - Lethargic N- Nares E – Edematous feeding attempt. relaxed, quietly interactive or sleepy without
Breathing TURGOR S - Sleeping R – Erythematous BEHAVIOR DURING BOTTLE FEEDING physiologic changes.
G – Good NC - Non- SUCTION AMOUNT N – Non-indurated, 1 Energetic with steady, coordinated 2 Becomes tired and fatigued from feeding; has
BP SITE F – Fair consolable S – Small Non-edematous, suck-swallow throughout feeding; min minimal  in HR, resp, color or tone.
LA – Left Arm P – Poor Q – Quiet Mo – Moderate Non-erythematous to no  in resp. effort or color; easily 3 Exhausted or taxed by feeding; has
RA – Right Arm C - Crepitus L – Large Bl – Blanched maintains tone, posture, remains calm changes in resp, color, loss of tone or other
LL – Left Calf TONE and completes feeding. physiologic signs (hiccups, grunts/sounds,
RL – Right Calf RASH SITE N - Normal TYPE IV LOCATION 2 Initially energetic with steady, cough/choke, head bobbing,  O2 sats)
LT – Left Thigh PA – Perianal  - Hypertonic Th – Thin RAc – Right Antecubital coordinated suck-swallow; has some resulting from efforts to feed.
RT – Right Thigh PN – Perineal  - Hypotonic Tk – Thick LAc – Left Antecubital challenges (suck-swallow 4 Has difficulty settling; appears
G – Generalized J - Jittery C – Clear RF – Right Foot coordination,  in resp. effort, color, uncomfortable following feeding (shifting
BREATH SOUNDS T – Trunk C – Clonus W – White LF – Left Foot tone, posture or state) with support, is within position, straining, spitting, fussiness
Cr – Crackles Y – Yellow RH – Right Hand able to complete feeding. and/or increased respiratory effort).
C – Clear EDEMA CRY G – Green LH – Left Hand 3 Initially slow to start or passive; has
CO – Coarse G – Generalized L - Lusty, BRB – Bright Red Blood RW – Right Wrist challenges (with suck-swallow SUPPORTS
W – Wheeze Ex – Hands and Feet Vigorous P – Plugs LW – Left Wrist coordination, resp. effort, color, tone, OB - Occasional Breaks/Pauses
S – Stridor PO – Periorbital W - Weak Br – Brown RAk – Right Ankle posture or state); needs support FB - Frequent Breaks/Pauses
Hi - High-pitched LAk – Left Ankle throughout and may or may not PH - Pacing Help
AIR ENTRY
ABDOMINAL A - Appropriate ASPIRATE TYPE S – Scalp complete feeding. BU - Frequent Burps
G – Good
S – Soft for age M – Mucous B – Broviac 4 Initially energetic or slow to start; FA -Flow Adjustment
L – Limited
ND – Non-Distended HO-Hoarse F – Formula PQ – Per-Q-Line becomes disorganized; shows SP - Sidelying Position
T – Tight
Ts – Tense Q - Quiet B – Bilious instability (in suck-swallow OP - Other Position
EQUALITY Tn – Tender FB – Frank Blood BLOOD GAS SITE coordination, resp. effort, color, tone, CS - Chin/Cheek Support
++ - Bilaterally DC – Discolored PAIN SCREEN CG – Coffee Ground HS – Heel Stick posture or state); is unable to complete OX - Oxygen
RorL - Diminished D – Distended  pain screen A – Air VS – Venous Stick feeding. EN - Environment
 - Diminished F – Full performed-no FS – Finger Stick 5 (*) Concerning feeding behaviors or Other - Specify
bilaterally “triggers” for pain DISPOSITION Art – Arterial Stick oral motor patterns; may appear
BOWEL SOUNDS *Refer to pain A – Aspirate disinterested or upset with feeding TYPE OF NIPPLE
RETRACTIONS - - Absent assessment D- Discarded CIRC attempts or may awaken but is unable Y - Yellow SF- Slow Flow
M – Minimal + - Present, Active scale R- Ref CL – Clean to coordinate suck-swallow for feeding. R - Red P - Playtex
MO – Moderate  - Decreased DG – Drainage N - Nuk H - Haeberman
S – Severe  - Hyperactive BL - Bleeding G – Gerber Premie SL=Slit

Eff. 9/1/11 Rev. Page 3 of 4

 Connecticut Children’s NICU
at UConn Health Center
282 Washington Street
Hartford, CT 06106
(Patient Identification)
Newborn/Intermediate Flowsheet – Date:
ENTERAL INTAKE PARENTERAL INTAKE OUTPUT
Solution: FORMULA FORMULA TYPE/CALORIE
MODE TOTAL E URINE STOOL SCF-SPECIAL CARE
T F M AMT
S-SIMILAC
I O E Dext% Total IL Total Site COLOR
M R ASP S CONSIS SFe-SIMILAC WITH Fe
AMT Alim-ALIMENTUM
#1__________________________
E M I
U Type S BM-BREAST MILK
L RATE Hourly Rate NS-NEOSURE
A Bolus Hourly URINE ISO-ISOMIL #2__________________________
Rate Hourly Location W/STOOL
PREG-PREGESTIMIL
ENF-ENFAMIL
SUPPLEMENTS #3__________________________
NC-NATURAL CARE
NSP- NEOSURE POWDER
NCTP-NEOCATE POWDER
HMF-HUMAN MILK FORTIFIER
RC-RICE CEREAL

ORAL (PO) FEEDING DESCRIPTION * See Codes

T Behavior Attempt Behavior Response Type
I During
M Before PO to Duration Supports of
Feeding Y/N Feeding Feeding Nipple
E
BOTTLE BREAST

COMMENTS:_______________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Eff. 9/1/11 Rev. Page 4 of 4