nr. 097e_smc
DESCRIPTION
formulare MS RMTRANSCRIPT
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DOCUMENTAIE MEDICALFormular
nr. 097/e
Ministerul Sntii al Republicii Moldova
_________________________________________________________________ denumirea instituiei
Aprobat de MS al RM
nr. 828 din 31.10. 2011
FOAIE DE OBSERVAIE A NOU-NSCUTULUI nr. ___________
Mama
Tata
Copilul
Grupa de snge
Factor Rhesus-
Numele, prenumele mamei _________________________________________________________________________________________, ,
Numr de identificare _______________________________________ Numrul poliei de asigurare _______________________________
Vrsta mamei _________________________________ Naionalitatea (etnia) _________________________________________________ ()
Adresa la domiciliu _______________________________________________________________________________________________
Studii: primare, medii incomplete, medii medii speciale, superioare incomplete, superioare: , , , , , Starea familial: cstorie nregistrat, cstorie nenregistrat, necstorit (a specifica) : , , ()
Serviciul n afara casei pe parcursul sarcinii_____________________________________________________________________________
Locul de munc __________________________________________________________________________________________________
Profesia sau funcia _______________________________________________________________________________________________
Condiiile de munc: favorabile sau nocive. A indica factorii nocivi ________________________________________ : .
Date despre sntatea tatlui
Vrsta tatlui __________________ Relaii de rudenie ntre soi ____________________________________________________________
Date antecedente despre familie ______________________________________________________________________________________
Ziua
Luna
Anul
Ora
Min..
S-a nscut
Internat
Externat
Decedat
Transferat
Unde
Registru de internare nr. __________________________________
Salonul copilului nr. _____________________________________
Patul copilului nr. _______________________________________
Salonul mamei nr. _______________________________________
Patul mamei nr. _________________________________________
Copilul transferat n salonul nr. _____________________________ ,
patul nr. _______________________________
Data transferrii _________________________________________
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2Anamneza ginecologic i obstetrical
A cta graviditate______________________________________ , a cta natere________________________________________________ Natere la termen da, nu (a specifica), dac nu, la ______________________________________________________ sptmni de gestaie , (), , Natere: monofetal, multipl (a specifica), la natere multipl s-a nscut al ctelea la numr________________________: , (), Ruptura membranelor amniotice a avut loc la ___________________________________________________________________________ ora
Durata travaliului: 18 ore (a specifica) : 18 . ()Prezentaia ______________________________________________________________________________________________________Complicaii n natere din partea mamei i copilului ______________________________________________________________________ Administrarea: analgezicelor ____________________ , anesteticelor ___________________ , oxitocinelor______________________ ,: eficacitatea lor ___________________________________________________________________________________________________ Intervenii chirurgicale _____________________________________________________________________________________________ Afeciuni, complicaii n perioada sarcinii ______________________________________________________________________________, _______________________________________________________________________________________________________________
Durata naterii pe perioade: I perioad______________________________ , II perioad____________________________ , : particularitile evoluiei, interveniile _________________________________________________________________________________ , Perioada alichidian ______________________________________________________________________________________________ , Caracteristica apelor fetale __________________________________________________________________________________________
S-a nscut
Perimetrul
Asfixie
Sex viu
mort(a indica pn la saun timpul travaliului)
(
)
Nscutla termen,prematur
-, -
Greuta-tea
(masa)n g
()
Talia, cm, cranian
cutieitoracice
durata--
msuri de reanimare
Etapele eseniale de reanimare a nou-nscutului
Msuri iniiale: plasarea sub o surs de lumin radiant_________________ , tergerea copilului _________________ : Permeabilizarea cilor respiratorii: :poziionarea nou-nscutului ______________________ , dezobstruarea gurii _____________________ , nasului_________________________ , traheei_________________, introducerea sondei endotraheale _____________________________ Meninerea respiraiei: stimularea tactil________________________________________ , ventilare cu presiune pozitiv : prin inspiraie: a) balon cu masc _______________________________ , b) balon cu sond endotraheal ___________________________ : Meninerea circulaiei: masaj cardiac extern _________ , medicamente: Adrenalin (doza, numrul de administrri) ________ : : (, )Volumul expanderii (doza, numrul de administrri) ______________ Bicarbonat de sodiu (doza, numrul de administrri) ____________ (, ) (, )Naloxon (doza, numrul de administrri) ______________________________________________________________________________ (, )Respiraie autonom dup_______________________________ minute. Oprirea reanimrii la______________________________ minute .
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3Aprecierea strii nou-nscutului dup scara Apgar
Timpul dupnatere
Btile inimii
Respiraia
Culoarea epidermei
Tonusul muscular
Reflexe
Aprecierea npuncte
Aplicarea pe burta mamei n contact "piele-la-piele" imediat dup natere _____________________________________________________
Aplicat la sn: n primele 30 minute_________________ , n primele 2 ore ____________________ , dup 2 ore _______________ : 30 2 2
Malformaii congenitale ____________________________________________________________________________________________
Traume puerperale ________________________________________________________________________________________________
Profilaxia gonoblenoreei (denumirea medicamentului, ora) _________________________________________________________________ ( , )
_______________________________________________________________________________________________________________
Naterea asistat de (numele, prenumele i calificarea specialistului i moaei) _________________________________________________ ( )
Copilul transferat n secia nou-nscuilor _______ _____________________20 _____ , ora _______________ _____________ min. .
Starea copilului la transferare din sala de natere ________________________________________________________________________ .
_________________________________________________ , culoarea tegumentelor, caracterul strigtului ________________________ ,
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
A predat copilul moaa ____________________________________________________________________________________________
A preluat i a prelucrat asistenta medical ______________________________________________________________________________
Diagnosticul preliminar ____________________________________________________________________________________________
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Diagnosticul definitiv _____________________________________________________________________________________________
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4Primul examen al copilului n salonul (secia ) nou-nscuilor ______ __________________________20____ () data examenului Date generale: :Starea general (poziia copilului, caracterul strigtului) ___________________________________________________________________ ( , )_______________________________________________________________________________________________________________
Tegumentele _____________________________________________________________________________________________________
Mucoasele vizibile ________________________________________________________________________________________________
Bontul ombilical _________________________________________________________________________________________________
Examinarea neurologic: :Activitatea motorie spontan: sczut____________________________________, intens __________________________ . : Tremor: ndelungat ____________________ , de amplitudine mic__________________ , de amplitudine nalt_____________________: Tonus muscular: distonie muscular _____________, hipertonie muscular __________________ , hipertonie extensorie __________ , : hipotonie muscular: generalizat _________ , local________ , poziie extensorie a picioarelor _______, retroflexia capului _________ : Examenul capului: :Forma: brahicefalie, dolicocefalie, asimetrie, oxicefalie (a specifica). Configuraia________ Suturile (cm) _______: , , , (). ()Palparea capului: oase integre, bosa serosangvin, cefalohematom, hemoragie subaponeurotic, : , , , ,
hernie cerebral, infiltrate, abcese (a specifica) __________________________________________________________________ , , () a indica lipsete
Starea fontanelelor (dimensiuni, proeminena, a specifica i indica): fontanela mare ____ , fontanela mic ___ , fontanele laterale ___ (, , ): Reflexe necondiionate: labial, de cercetare, Babkin, de prehensiune, Moro, de aprare, Galant, : , , , , , , ,Peres, Bauer, de sugere (a specifica), , ()Simptomatologia ocular patologic: ptoz, nistagmus vertical, rotator, orizontal, lagoftalm, strabism convergent, : , , , , , ,strabism divergent, simptom Graefe, simptom "apus de soare", pareza privirii, simptom "ochi de ppu", mioz, , , , , , ,midriaz, anizocorie (a specifica, ce lipsete a indica) _______________________________________________________________, (, )Convulsii: tonice, clonice, mioclonale, fragmentare (a specifica, ce lipsete a indica)_______________________ .: , , , (, )Statutul somatic: :Forma cutiei toracice ______________________________________________________________________________________________
Respiraia, starea plmnilor, aprecierea dup scara Silverman n caz de insuficien pulmonar ____________________________________, , _________________________________________________________________________________ FR/minut _____________________
/
Cordul (limita, prezena suflurilor, caracterul ritmului) ____________________________________________________________________ (, , )_______________________________________________________________________________________________________________
_______________________________________________________________ , pulsul _________________________________________
Organele cavitii abdominale: ficatul, splina ___________________________________________________________________________ : , _______________________________________________________________________________________________________________
Eliminarea meconiului _____________________________________________________________________________________________
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5Miciunea _______________________________________________________________________________________________________Organele genitale externe __________________________________________________________________________________________ Prezena anusului _________________________________________________________________________________________________ Starea articulaiilor coxofemurale ____________________________________________________________________________________ Concluzia i diagnosticul preliminar __________________________________________________________________________________ _______________________________________________________________________________________________________________
Prescripii i argumentarea lor _______________________________________________________________________________________ _______________________________________________________________________________________________________________
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Datele privind supravegherea nou-nscutului de ctre asistenta medical
Schimbarea strii
mucoasa
Data
Ziua
de
via
Tem
pera
tura
Gre
utat
ea (m
asa)
(
)
prez
ena
criz
elor
de a
sfix
ie
ochi
lor
cavi
tii
buc
ale
tegu
men
telo
r
Act
ivita
tea
refle
xulu
i de
suge
re
Car
acte
rul s
caun
ului
Mic
iune
a
Tim
pul c
der
ii bo
ntul
uiom
bilic
al
Star
ea p
lgi
i om
bilic
ale
Sem
ntu
ra
d1
s
d2
s
d3
s
d4
s
d5
s
d6
s
d7
s
Not: La nou-nscuii prematuri cu greutatea sub 1500 g se va msura temperatura axial i rectal.: 1500
Vaccinarea contra tuberculozei
Data
Ziua vieii
Doza
Nr. serieivaccinului
Termenulvalabilitii
Reacia la vaccin
Semntura
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6Vaccinarea nu s-a efectuat (a indica cauza) _____________________________________________________________________________ ( )_______________________________________________________________________________________________________________
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ALIMENTAIA NOU-NSCUTULUI (eviden n grame) ( )
1 2 3 4 5Ziua vieii
alptare
alptare
alptare
alptare
alptare
6 7 8 9 10Ziua vieii
alptare
alptare
alptare
alptare
alptare
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7Zilnicul medicului-pediatru -
Data
Ziua vieii
Datele examenului, examinrii ,
Prescripii
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8Zilnicul medicului-pediatru -
Data
Ziua vieii
Datele examenului, examinrii ,
Prescripii
-
9Zilnicul medicului-pediatru -
Data
Ziua vieii
Datele examenului, examinrii ,
Prescripii
-
10
Zilnicul medicului-pediatru -
Data
Ziua vieii
Datele examenului, examinrii ,
Prescripii
-
11
Zilnicul medicului-pediatru -
Data
Ziua vieii
Datele examenului, examinrii ,
Prescripii
-
12
Epicriza _______________________________________________________________________________________________________________________________________________________________________________________________________________________
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Starea copilului la externare (transferare) ______________________________________________________________________________ ()_______________________________________________________________________________________________________________
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Recomandri medicului de familie ___________________________________________________________________________________ _______________________________________________________________________________________________________________
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Data _____________________ A predat copilul________________________________________________________ semntura asistentei medicale
_____________________ A preluat copilul _______________________________________________________ semntura asistentei medicale
Certificatul medical constatator al naterii copilului a primit ________________________________________________________________ semntura mamei
Instituia de asisten medical primar la locul de trai _______________________________ despre externarea copilului este ntiinat denumirea
_______ ________________________________ 20 _______
Telefonograma a transmis___________________________________________ , a recepionat ___________________________________
FOAIE DE OBSERVAIE A NOU-NSCUTULUI nr. Datele privind supravegherea nou-nscutului de ctre asistenta medical