Newborn Assessment

Newborn Physical Assessment Please use the following code:

Sara Staffen

+ = Present/normal

= Not present

NA = Not applicable

Admission data (This will be obtained from the babys chart!): Temp __36.6____ HR __140___ Resp __48___ Bld glucose __NA___ APGAR Score 1 min __8__ 5 min __9__ Resuscitation measures: _____NA______ ____________________________________________________________________ Ilotycin _11:45_ (time) Vit K __11:45___ (time) Nursed in L&D Y N
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)

Length __19 in___ Wt. ___8 lb 3 oz.___

- Vital signs stable; within normal parameters - Regular respiration rate and pattern, non-labored breathing - Heart sounds strong S1 & S2 audible - Pink color, consistent with race, clear skin - Capillary refill < 3 seconds - Even, round head, minimal caput and molding - Appears to be nursing well 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 __36.7__ HR __130___ Resp __52___ 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 __round, even_ Molding ______ Cephalhematoma _____

Caput succedaneum ___+_minimal___ ISE mark _____ Other ______ Anterior fontanel: Flat __+___ Full ______ Depressed ______ Posterior fontanel: Flat __+___ Full ______ Depressed ______ Sutures Coronal Sagittal Lambdoidal Overriding ________ ________ ________ Separated ________ ________ ________ Approximated _____+_____ _____+_____ _____+_____

Ears: (describe exact location & how you determined if it was normal) Position: Normal __+___ Abnormal ______ Describe normal position _ between the eyes and mouth._____ Skin tags _____ Nose: Symmetry ___+___ Flaring _____ Patent: Left __+__ Right __+__ Eyes: (describe what you found) Right Subconjunctive hemorrhage Nevi on lids Edema Red reflex Other ____ ____ ____ _NA_ _NA_ Left ____ ____ ____ _NA_ _NA_ evenly spaced

Mouth: Mucous membranes: Pink ___+__ Pale ______ Cyanotic ______ Teeth _____ Epsteins pearls _____ Hard palate: Intact ___+___ Abnormal ______________________________ Soft palate: Intact ____+__ Abnormal ______________________________ Lips: Cleft _____ Drooping _____ Symmetry __+___ Anterior chest: Symmetrical __+___ Shape _round_ Clavicles: Intact __+___ Fracture ____________________________ Breasts: Palpable tissue __+____ Engorgement ______ Heart sound: RRR ___+_____ Other ________

Genitals: 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 N Stool Y N Type __NA__

Anterior Abd: Symmetry ___+___ Other _NA___ Cord: # of vessels ___3___ Protruding base _____ Extremities: Right Symmetry Movement Digits (number) Flexion creases Palmar creases Sole creases Hips: Intact Right Left __+ __+ Dislocated/subluxation __ __ __+ __+ __5___ __+ __+ __+ Left __+ __+ __5___ __+ __+ __+ (10 fingers and toes)

Neuro-muscular: Tone: Normal ____+

Lethargic ______ Rigid ______ Tremors ______

What is your overall assessment and prognosis for this infant (do not say good): - Overall all assessment is positive; the newborns Apgar scores were eight and nine. Newborn reflexes present, strong heart and lung sounds with regular rate and rhythms, positive bowel sounds, creases on palms and soles. Newborn is tolerating breast feeding well. - Prognosis: the infant is healthy and should be able to go home with parents two days after delivery.

Reflexes: Reflex: Describe what you observed Rooting: __+

The rooting reflex helps to ensure successful breastfeeding. Lightly touch the corner of the newborns mouth or cheek. Normal newborn babies automatically turn their face toward the stimulus and make sucking (rooting) motions with the mouth when the cheek or lip is touched. Describe the procedures Describe normal responses

Sucking: __+

Touch the roof of the newborn's mouth and they will begin to suck.

Sucking response on finger.

Moro: __+__

Witnessed spontaneously when the newborn was startled by a loud sound or possibly by her own crying.

The infant will have a startled look and the arms will fling out sideways with the palms up and the thumbs flexed.

Stepping: did not assess

NA

Newborn appears to take steps or dance when held upright with his/her feet touching a solid surface.

Grasp/hand: __+__

Stroke newborns hand or just place your finger in their hand.

Stroking the palm of a newborn's hand causes them to close their fingers in a grasp. The newborns toes flex, or curl under and grasp

Grasp/foot: __+__

Stoke up the middle of the newborns foot.

On the basis of your assessment, list at least TWO nursing diagnosis 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
Assess: signs of infections, elevated body temperature, listlessness, difficulty feeding, and irritability. 1. Monitor neonates condition, including vital signs.

Rationale

High risk for infection r/t maternal factors & immune system deficiency

Effective Breastfeeding

Mother tested GBS positive, antibiotics were administered during labor. Mother is not vaccinated against any communicable diseases including Pertussis. Infant was vaccinated against Hep B after delivery. A fever tends to be more clinically relevant in neonates and 2. Provide education to the parents regarding infants younger than three months, because they are observation for signs of infection. immunologically immature and incompletely vaccinated. Including any fever in infants less than (Snyder, Kivlehan, & Collopy, 2011) Studies have shown that three months. infants younger than three months lack innate immunity 3. Ensure that all equipment used for infant therefore are at an increased risk for serious bacterial is sterile, scrupulously clean. infection, bacteremia and occult bacteremia, making the 4. Administer prophylactic antibiotics and/or parental recognition of fever and follow-up actions to seek vaccinations as per Doctors order. medical attention extremely important. (Snyder, Kivlehan, & Collopy, 2011) Assess mothers knowledge and Breastfeeding not only provides essential nutrition, it is also experience with breastfeeding and an important mechanism in the formation of the newborns infants ability to latch on to breast emotional development and building a trusting relationship through correct positioning and assess between the newborn and the mother. (Kailaiselv, 2011). presence of rooting reflex. According to Kailaiselv (2011), breastfeeding has many 1. Monitor infants height and weight to properties that benefit both the mother and newborn. ensure standards of development and Breastfeeding releases Oxytocin which aids in uterine

growth are being met.

2. Educate mother and support person

3.

4.

Ineffective thermoregulation r/t immature compensation for changes in environmental 1. temperature. AEB postpartum axillary temperature of 36.3 C. 2. 3. 4.

about breastfeeding techniques to encourage the success of breastfeeding. Teach mother how to break suction to avoid chaffed nipples and other interventions that decrease engorgement and tenderness. Ensure that infant is nursing every 2-3 hours, stooling 1-6 times and wetting 6-8 diapers daily. Assess temperature frequently, initial rectally, repeating axillary temperature every 15 minutes during rewarming. Desired outcome: axillary temperature within 36.5-37.3 C. Place neonate in radiant heat warmer or skin-to-skin contact with mother. Place hat on neonates head. Utilize heat lamps during any procedures. Ensure neonates clothing and bed linens are dry and warm.

involution, it also encourages strong mother-newborn bonding through skin-to-skin contact and its cost effective. For the newborn, breast milk provides immunologic properties, meets nutritional needs, promotes neurological development, and is easily digested with less allergenic properties.

During a postpartum assessment, the neonates axillary temperature was repeated twice with results of 36.3 C both times. A final rectal temperature reading was 36.4 C; therefore rewarming interventions were performed. Adaptation of the neurological system to extrauterine life may be inadequate, despite being a full-term infant. Hypothermia predisposes infant to cold stress, utilization of nonrenewable brown fat stores, and reduced sensitivity to increased levels of carbon dioxide, hypercapnia, or decreased oxygen levels, hypoxia. (Nurse Care Plan, 2012). Therefore it is important to monitor the neonate for presence of tachypnea or apnea, generalized cyanosis, bradycardia, poor cry, and lethargy. These signs indicate cold stress leading to increased oxygen consumption and possible acidosis. Rewarming the infant too rapidly has been associated with apneic states as well. (Nurse Care Plan, 2012).

References: Kalaiselv, K. (2011). Leifer: Newborn Feeding. Retrieved from http://elsevieradvantage.com/samplechapters/9780323083478/11[1].pdf Ladwig, G.B., & Ackley, B.J. (2011). Mosbys Guide to Nursing Diagnosis. Maryland Heights, MO: Mosby Inc. & Elsevier Inc. Nurse Care Plan. (2012). Ineffective Thermoregulation: Nursing Diagnosis Infant. Retrieved from http://www.nurse-careplan.com/2012/06/ineffective-thermoregulationnursing.html Snyder, S. R., Kivlehan, S., & Collopy, K. (2011). Fever in the Neonate and Young Infant. EMS World, 40(6), 57-61.