Newborn Physical Assessment Please use the following code:
+ = Present/normal = Not present NA = Not applicable Admission data (This will be obtained from the babys chart!): Temp __37.4____ HR ___148___ Resp ___58___ Bld glucose ___n/a___ APGAR Score 1 min __7___ 5 min __9__ Resuscitation measures: 20 sec of PP ventilation ____________________________________________________________________ Ilotycin 12:50 (time) Vit K 12:50 (time) Length ____20____ Wt. ___8lb 2oz_____ Nursed in L&D Yes After you have read the infants chart and gathered the information, give your assessment of this infants status when it was 1 hour after birth (give details, not good) Infant was crying occasionally, attempting to nurse from mothers breast, breath sounds are clear, all motor functions appear to be intact at this time, movement of all extremities is visible, no visible abnormalities present.
NOW YOU ARE READY TO DO A PHYSICAL ASSESSMEDNT ON THIS BABY (to be completed by you the day you are caring for the baby): Temp __36.6____ HR __140____ Resp __48____ Color: Pink ___+___ Pale ______ Mottles ______ Plethoric ______ Jaundice ______ Stained ______ Acrocyanosis ______ Skin: Clear ___+___ Pressure marks ______ Abrasions ______ Dry ___+___ Ecchymosis ______ Petechiae ______ Nevi ______ Milia ___+___ Rash ______ Lanugo ___+___ Vernix __+____ Mongolian spots ___+___ Respirations: Regular ____+__ Grunting ______ Abdominal ______ Retracting ______ Shallow ______ Nasal flaring ______ Sighing ______ Other ______ Cry: Lusty ___+___ Weak ______ Shrill ______ Head: Symmerty/shape _____+_____ Molding __________ Cephalhematoma _____ Caput succedaneum ______ ISE mark ______ Other ______ Anterior fontanel: Flat __+____ Full ______ Depressed ______ Posterior fontanel: Flat ___+___ Full ______ Depressed ______ Sutures Overriding Separated Approximated Coronal ________ ________ _____+______ Sagittal ________ ________ _____+______ Lambdoidal ________ ________ _____+______ Ears: (describe exact location & how you determined if it was normal) Position: Normal ___+___ Abnormal ______ Describe normal position -vertical placement, well- formed and complete, upper ear meets head even with imaginary line drawn from outer canthus of eye. Skin tags ______ Nose: Symmetry ____+____ Flaring ______ Patent: Left __+___ Right ___+__ Eyes: (describe what you found) Right Left Subconjunctival hemorrhage ___+__ ___ Nevi on lids _____ _____ Edema _____ _____ Red reflex _____ _____ Other _____ _____
Genitals: Voided: Date ____n/a____ Time ____n/a____ Color of urine ________________ Male: Urethral orifice: Normal position ____n/a____ Abnormal (describe) n/a Testes (#/location) n/a Scrotum ___n/a___ Pendulous __n/a____ Rugated __n/a____ Other Female: Labia majora: Completely covers minora __+___ Partially covers minora _____ Labia minora protruding ______ Vaginal discharge ______ Hymenal tag ______ Posterior: Pilonidal dimple ______ Truft of hair ______ Spinal column: Symmetry ___+___ Intact ___+___ Anal patency: Y Stool N Type ______ Anterior Abd: Symmetry __+____ Other ____________________ Cord: # of vessels __3____ Protruding base ______ Extremities:
Right Left Symmetry ___+___ __+____ Movement ___+___ ___+___ Digits (number) __10____ __10____ Flexion creases ___+___ ___+___ Palmar creases ___+___ __+____ Sole creases __+___ ___+___ Hips: Intact Dislocated/subluxation Right __+____ ______ Left ___+___ ______ Neuro-muscular: Tone: Normal ___+___ Lethargic ______ Rigid ______ Tremors ______ Reflexes: Reflex: Describe what you observed Describe the procedures Describe normal responses Rooting: RN placed finger in corner of babies mouth brushing cheek, baby turned head touch or stroke from side of mouth toward cheek infant turns head to side touched Sucking: RN placed pinky in infants mouth causing a suckling effect place nipple or gloved finger in mouth, rub against palate infant begins to suck Moro: The baby was allowed to drop back slightly causing arms and legs to wave wildly let infants head drop back approx. 30 degrees sharp extension and abduction of arms followed by flexion and adduction to embrace position Stepping: baby was held up causing legs to lift alternately
hold infant so feet touch solid surface infant lifts alternate feet as if walking Grasp/hand: baby clenched finger
press finger against base of infants fingers fingers curl tightly Grasp/foot: toes closed over finger
press finger against base of infants toes toes curl forward What is your overall assessment and prognosis for this infant (do not say good): Sutures palpable with small separation between each, anterior fontanel diamond-shaped, posterior fontanel triangular, hair silky and soft, ears well-formed and complete, symmetric appearance and movement of face, parts proportional and appropriately placed, chest cylinder shaped, abdomen rounded and soft, bowel sounds present, labia majora dark, covered labia minora, reflexes present and intact, vitals WNL, equal and bilateral movement of extremities, correct number and formation of fingers and toes, legs equal in length, abduct equally, normal position of feet, no openings observed or felt in vertebral column, anus patent. Prognosis is a healthy baby girl with all neurological and physical functions in tact at this time.
On the basis of your assessment, list 2-3 nursing diagnoses for this baby and all the teaching interventions you would use for each nursing diagnosis. Please include the rationale for your actions. You must have at least two references besides your textbooks for your rationales. Be sure your assessment and interventions correspond to your Nursing Diagnosis. Nursing Diagnosis Necessary Assessments/Interventions Rationale risk for infection r/t open umbilical stump
Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature. instruct family members on proper hand hygiene before handling baby, sponge bathe baby until cord falls off, proper education on stump cleansing It is important to note that the exposed necrotic tissue of the umbilical stump is readily colonized and infected by pathogenic bacteria. Ready access of the bacteria into the systemic circulation places neonates at high risk for infection (McConnell, Lee, Couilard, & Sherrill, 2004, p. 211). Although cord infections are rare in the United States, proper precautions are a must still. ineffective thermoregulation r/t immaturity of neuroendocrine system
Routinely measure temperature of infant in the axilla using electronic thermometer, keep head covered, use blankets to keep infant warm, keep infant covered during procedures, transport and testing, keep room warm. Immediately after delivery if no action is taken, the core and skin temperatures of a term neonate can decrease at a rate of approximately 0.1C and 0.3C per minute respectively (Waldron & MacKinnon, 2007, p. 101). This is where skin to skin contact is important immediately after birth to allow for conduction of body heat from mother, also drying of baby and placing in warm dry blanket will assist with
maintaining of body heat. Another factor is the body surface area of the baby, the baby will lose heat due to evaporation, convection, conduction and radiation (Murray & McKinney, 2014, p. 372). breastfeeding r/t normal oral structure and gestational age greater than 34 weeks
encourage and facilitate early skin-to-skin contact, rooming- in and breastfeeding on demand, monitor breastfeeding process and identify opportunities to enhance knowledge and experience regarding breastfeeding, give encouragement/positive feedback related to breastfeeding mother-infant interactions, monitor for s/s of nipple pain and/or trauma, monitor infant responses to breastfeeding Benefits of breastfeeding include: immunologic benefits, lower incidence of diabetes, asthma, obesity, some cancers, SIDS, properties of breast milk change as babies needs change, constipation less likely, less likely to result in overfeeding (Murray & McKinney, 2014, p.439). Benefits to mother: oxytocin release enhances uterine involution, reduction in the incidence of some cancers, mother more likely to rest while feeding, convenience, economical, infant less likely to be ill (Murray & McKinney, 2014, p.439). References McConnell, T. P., Lee, C. W., Couilard, M., & Sherrill, W. W. (2004). Trends in umbilical cord care: scientific evidence for practice. Newborn & Infant Nursing Reviews, 4(4), 211-222. Retrieved from http://www.medscape.com/viewarticle/497030_3 Murray, S. S., & McKinney, E. S. (2014). Foundations of Maternal-Newborn and Womens Health Nursing (6th ed.). St. Louis, MO: Elsevier Saunders. Waldron, S., & MacKinnon, R. (2007). Neonatal thermoregulation. Infant, 3(3), 101-104. Retrieved from http://www.infantgrapevine.co.uk/pdf/inf_015_nor.pdf