Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Umbilical Cord Care
Cord care begins in the newborn nursery and is continued until the stump falls off and the area is totally healed. Complete healing may take several weeks.
I. Subjective data
A. Cord clamped; drying begins within hours.
B. Clamp removed on first or second day of life
C. Black, hard stump remains attached for approximately 6 to 12 days.
II. Objective data
A. Stump clean and dry
B. No inflammation surrounding umbilicus
C. No bleeding, discharge, or odor
III. Assessment: Normal healing of umbilical cord
IV. Plan
A. Wash with soap and water and dry thoroughly twice a day.
B. Apply antibiotic ointment (Neosporin) to umbilicus 2 to 3 times a day.
C. Clean depression with a cotton swab after stump falls off.
V. Education
A. Keep diapers folded below umbilicus.
B. With disposable diapers, fold plastic to the outside.
C. Keep rubber pants below umbilicus.
D. Watch for oozing, odor, bleeding, or inflammation.
E. A small amount of discharge is normal for 1 to 2 days after the cord drops off.
F. Keep depression clean and dry. It can become a site for the collection of dead skin, powder, and so forth, leading to infection.
VI. Follow-up: None necessary unless bleeding, discharge, odor, swelling, or inflammation occurs.
VII. Complications: Infection
VIII. Consultation/referral
A. Bleeding
B. Discharge
C. Foul odor
D. Edema
E. Inflammation
F. Moistness at base of cord (may be urachus)