Running head: NEWBORN ASSESSMENT

Newborn Assessment Abbey Longstreth Ferris State ni!ersity

NEWBORN ASSESSMENT Newborn Assessment Newborn Physical Assessment Please use the following code: # $ %resent&norma' $ Not (resent NA $ Not a(('i)ab'e Admission data (This will be obtained from the babys chart!): Tem( *+,.R 1// Res( -" - min 1 6it 7 1*13 4time5 B'd g'u)ose N&A Resus)itation measures: N&A Length "3,- in Wt, *,-+ 'b A%0AR S)ore 1 min 1 2'oty)in 1*13 4time5 .e( B 1*13 Nursed in L89 Y N

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A:ter you ha!e read the in:ant;s )hart and gathered the in:ormation< gi!e your assessment o: this in:ant;s status when it was 1 hour a:ter birth 4gi!e detai's< not =good>5 A%0AR s)ore: 1 minute $ 1< - minutes $ 1, Stab'e and (rogressing a((ro(riate'y, Bowe's wor?ing a((ro(riate'y aeb me))onium (assed dire)t'y a:ter birth, E::e)ti!e'y breast:eeding within 1 hour (ost birth, S?in@to@s?in (er:ormed dire)t'y a:ter birth :or a'most the :u'' hour< he'(ing to estab'ish mother@baby )onne)tion and tem(erature regu'ation whi'e en)ouraging breast:eeding, 2: tem(erature stab'es we''@regu'ated< baby shou'd be stab'e :or :urther head@to@ toe assessment< bath< shots< :oot (rints< et), NOW AO ARE REA9A TO 9O A %.AS2BAL ASSESSME9NT ON T.2S BABA 4to be )om('eted by you the day you are )aring :or the baby5: Tem( *+,1 Color: %in? # Daundi)e C Skin: B'ear # E))hymosis C Rash C Sha''ow C Bry: Lusty # Lanugo C Res irations: Regu'ar # Nasa' :'aring C Wea? C .R 1// %a'e C Stained C Res( -" Mott'es C A)ro)yanosis C Abrasions C Ne!i C Abdomina' C Other N&A Mo'ding C Be(ha'hematoma C Mongo'ian s(ots C Retra)ting C 9ry C Mi'ia C %ete)hiae # 6erniE C 0runting C Sighing C Shri'' C %'ethori) C

%ressure mar?s #

!ead: Symmerty&sha(e Round< no dis:ormaties

NEWBORN ASSESSMENT Ba(ut su))edaneum C Anterior :ontane': F'at # %osterior :ontane': F'at # Sutures Borona' Sagitta' Lambdoida' %osition: Norma' # S?in tags C Nose: Symmetry # F'aring C %atent: Le:t # Right Sub)onFun)ti!e hemorrhage Ne!i on 'ids Edema Red re:'eE Other #outh: Mu)ous membranes: %in? # Teeth N&A E(stein;s (ear's C Abnorma' N&A Abnorma' N&A 9roo(ing C Fra)ture N&A Engorgement N&A Time 1"1Bo'or o: urine B'ear Other N&A Abnorma' 4des)ribe5 N&A Symmetry # Sha(e EGua' bi'atera''y, Symmetri)a' eE(ansion, .ard (a'ate: 2nta)t # So:t (a'ate: 2nta)t # Li(s: B'e:t C B'a!i)'es: 2nta)t # .eart sound: RRR # C C # N&A N&A %a'e C Right # Le:t C C
#

* 2SE mar? C Fu'' C Fu'' C Se(arated C C C Other N&A 9e(ressed C 9e(ressed C A((roEimated # # #

O!erriding C C C

"ars: 4des)ribe eEa)t 'o)ation 8 how you determined i: it was norma'5 Abnorma' C 9es)ribe norma' (osition A'igned with the outer )anthi o: the eyes, So:t and ('iab'e,

"yes: 4des)ribe what you :ound5

N&A N&A Byanoti) C

Anterior chest: Symmetri)a' # Breasts: %a'(ab'e tissue #

$enitals: 6oided: 9ate 1&"&1*

Ma'e: rethra' ori:i)e: Norma' (osition #

NEWBORN ASSESSMENT Testes 4H&'o)ation5 " des)ended testes, Firm and smooth< eGua' siIe bi'atera''y, S)rotum # %endu'ous C Rugated # Other N&A Fema'e: Labia maFora: Bom('ete'y )o!ers minora N&A Labia minora (rotruding N&A Posterior: %i'onida' dim('e N&A S(ina' )o'umn: Symmetry # Ana' (aten)y: Y N Anterior Abd: Symmetry # "%tremities: Right Symmetry Mo!ement 9igits 4number5 F'eEion )reases %a'mar )reases So'e )reases !i s: 2nta)t Right Le:t # # 9is'o)ated&sub'uEation N&A N&A Lethargi) C Tremors C # # # # # Le:t # # # # # Stoo' Y N 6agina' dis)harge N&A Tru:t o: hair N&A Ty(e Me))onium Other N&A %rotruding base N&A 2nta)t #

%artia''y )o!ers minora N&A .ymena' tag N&A

Bord: H o: !esse's * 4" arteries< 1 !ein5

Neuro&muscular: Tone: Norma' # Rigid C

NEWBORN ASSESSMENT Re:'eEes: Re:'eE: 9es)ribe what you obser!ed Rooting: 9es)ribe the (ro)edures Stro?e the newborns )hee?

9es)ribe norma' res(onses When the side o: a babyJs )hee? is tou)hed< the head turns and his or her mouth Krea)hesK toward it A newborn su)?s when a ni(('e or :inger is ('a)ed in his or her mouth A start'ed newborn throws out his or her arms and s(reads the :ingers

Su)?ing:

0ent'y stimu'ate the newborn;s 'i(s by tou)hing them %'a)e the newborn on his or her ba)?< su((ort the u((er body weight by the arms< use a 'i:ting motion without )om('ete'y 'i:ting the baby o:: the sur:a)e< then re'ease the arms sudden'y .o'd the newborn u(right and in)'ined :orward o!er a :'at sur:a)e

Moro:

Ste((ing:

The newborn shou'd ma?e a ste((ing motion or wa'?ing when it is he'd u(right o!er a sur:a)e A newborn gras(s a :inger that is ('a)ed on his or her (a'm A newborns toes )ur's around a :inger when it is ('a)ed on his or her :oot

0ras(&hand:

%'a)e a :inger on the newborns o(en (a'm

0ras(&:oot:

%'a)e a :inger Fust be'ow the newborns toes

What is your o!era'' assessment and (rognosis :or this in:ant 4do not say =good>5: Strong< e::e)ti!e )ry< remo!ing se)retions in 'ungs, EGua'< e::e)ti!e breathing (attern, Moderate tem(erature regu'ation< stabi'iIed with baby warmed and b'an?ets, rinary and bowe's wor?ing e::e)ti!e'y aeb baby !oiding me))onium and )'ear< ye''ow urine, No abnorma' :indings noted,

NEWBORN ASSESSMENT

Baby stab'e and no eEtraordinary measures needed at this time, Mother and baby are stab'e and )an be sa:e'y mo!ed to the (ost(artum unit :or :urther monitoring,

NEWBORN ASSESSMENT

On the basis o: your assessment< 'ist at 'east '() nursing diagnosis :or this baby and a'' the tea)hing inter!entions you wou'd use :or ea)h nursing diagnosis, %'ease in)'ude the rationa'e :or your a)tions, Aou must ha!e at 'east two re:eren)es besides your teEtboo?s :or your rationa'es, Be sure your assessment and inter!entions )orres(ond to your Nursing 9iagnosis,

Nursing *iagnosis E::e)ti!e breast:eeding r&t in:ant gestationa' age M*/ wee?s aeb (ositi!e su)?ing re:'eE

Necessary Assessments+,nter-entions Rationale 0OAL: %atient wi'' maintain e::e)ti!e =9emand :eedings ha!e been asso)iated with )ontinuation o: breast:eeding by 1&""&1" breast:eeding / to + wee?s (ost(artum in )om(arison to 2NTER6ENT2ON: En)ourage rooming@in restri)ted :eeding inter!a's> 4A)?'ey 8 Ladwig< "33N< (, 1LN5, and breast:eeding on demand, 0OAL: %atient wi'' maintain norma' in:ant growth (atterns by dis)harge date 2NTER6ENT2ON: Monitor in:ant res(onses to breast:eeding, 0OAL: Mother wi'' !erba'iIe satis:a)tion with breast:eeding (ro)ess by 1&""&1* 2NTER6ENT2ON: 0i!e en)ouragement&(ositi!e :eedba)? re'ated to breast:eeding mother@in:ant intera)tions, 0OAL: %atient wi'' maintain tem(erature within norma' range by 1&"1&1* 2NTER6ENT2ON: Monitor tem(erature e!ery 1@/ hours or use )ontinuous =Ongoing e!a'uation o: the adeGua)y o: in:ant inta?e su)h as weight< number o: eE)retions 4urine and stoo'5 (er "/ hours< and assessment o: the (resen)e o: Faundi)e is im(ortant to su((ort ongoing e::e)ti!e breast:eeding and :or ear'y dete)tion o: (rob'ems> 4A)?'ey 8 Ladwig< "33N< (, 1LN5, =%ro:essiona's that (ro!ided (ositi!e su((ort were shown to in)rease )on:iden)e 'e!e's whi'e (oor su((ort de)reased their )on:iden)e and )ontributed to )essation o: breast:eeding> 49emirtas< "31"5,

2ne::e)ti!e thermoregu'ation r&t immaturity aeb :'u)tuating aEi''ary tem(eratures

=The )ombination o: a re'ati!e'y 'arger body sur:a)e areas< sma''er body :'uid !o'ume< 'ess we''@de!e'o(ed tem(erature )ontro' me)hanisms< and sma''er amount o: (rote)ti!e body :at 'imits the in:ant;s and )hi'd;s abi'ity to maintain norma' tem(eratures> 4A)?'ey 8 Ladwig< "33N< (, N**5,

NEWBORN ASSESSMENT

tem(erature monitoring as a((ro(riate 0OAL: Mother wi'' eE('ain measures needed to maintain norma' tem(erature by dis)harge date 2NTER6ENT2ON: En)ourage and :a)i'itate :reGuent s?in@to@s?in )onta)t, 0OAL: Mother wi'' !erba'iIe signs and sym(toms o: hy(othermia or hy(erthermia by dis)harge date 2NTER6ENT2ON: Edu)ate mother&:ather regarding !arious signs and sym(toms o: tem(erature :'u)tuations 4hy(o&hy(erthermia5 =2mmediate s?in&to&s?in )onta)t between mother and in:ant and ear'y initiation o: breast:eeding are shown to im(ro!e breast:eeding out)omes> 47eister< Roberts 8 Werner< "33N5,

=Monitoring :or the de:ining )hara)teristi)s o: hy(othermia and hy(erthermia a''ows :or (re!ention and&or ear'y inter!ention> 4A)?'ey 8 Ladwig< "33N< (, N**5,

NEWBORN ASSESSMENT

Re:eren)es A)?'ey< B,< 8 Ladwig< 0, 4"33N5, Nursing diagnosis handbook, 4N ed,5, St, Louis< MO: Mosby E'se!ier, 9emirtas< B, 4"31"5, Strategies to su((ort breast:eeding: A re!iew, International Nursing Review< 594/5< /L/@/N1, doi: 13,1111&F,1/++@ L+-L,"31",3131L,E 7eister< 9,< Roberts< 7,< 8 Werner< S, 4"33N5, Strategies :or breast:eeding su))ess, American Family Physician< 784"5< ""-@"*", Retrie!ed :rom htt(:&&3@web,ebs)ohost,)om,'ib)at,:erris,edu&ehost&detai'O!id$L8sid$:a/bd-ea@-+"N@/+:+@bL*a@ a"be/:1b-b**Psessionmgr11-8hid$13*8bdata$DnN(d0 1QWh!)*Rtb0'"QR==