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NEW BORN PHYSICAL ASSESSMENT

PATIENTS INITIALS:

NAME OF MOTHER : Asminbanu Nawab Miashi

AGE : 20 years/female DATE OF ADMISSION : 6/12/11

TODAYS DATE : 7/12/11 DATE AND TIME OF BIRTH : 6/12/11 7am

SEX OF BABY: Female GESTATIONAL AGE : 34 weeks

DETERMINED BY : New ballard Scale

NO. OF VESSELS IN CORD : one vein and two arteries

DELIVERY ROOM RESUSCITATION : resuscitation has been done using ambubag &

O2 and Oxygen supplementation is given by oxygen hood.

METHOD OF FEEDING : breast feeding could not be given by mother .

BABYS BLOOD GROUP TYPE AND Rh : O negative

MOTHERS BLOOD GROUP TYPE AND Rh : O positive

CANDIDATE FOR WHICH TYPE OF NEWBORN JAUNDICE : Present

BIRTH WEIGHT : 1KG 775 gm TODAYS WEIGHT : 1kg 700gm

TOTAL WEIGHT LOSS : Present % OF WEIGHT LOSS: 95.77%

TOTAL INCREASE IN WEIGHT : No increase in weight

Apgar score 0 1 2

Heart Rate -_ slow 90 - -Respiratory effort absent - -Muscle tone flaccid - -Reflex - cry -

Colour - Body pink,extremities blue-

-

Total 3IN MY PATIENT : TOTAL SCORE IS 3 INDICATES SEVERE DISTRESS.

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1.VITAL SIGNS :

IN NEWBORN BABY NORMAL INFERRENCE

TEMPERATURE 96.4 F OR 36.2C NORMAL-97.9F TO 36.7C

PULSE 90/MIN NORMAL 100-180

RESPIPRATION 24/MIN NORMAL 30- 50/MIN

BLOOD PRESSURE 68 /40MMHG NORMAL 73/55 MMHG

2.RESPIRATORY EFFORT : RETRACTIONS: present

GRUNTING : present

QUALITY OF CRY: slow and irregular cry present

RESPIRATOY MOVEMENTS: thoracic breathing,unequal motion of chest

3. AUSCULTATE FOR : HEART SOUNDS: 90 beats/min

HEART RHYTHM : Very Irregular in rate & rhythm ,less in volume

4. BOWEL SOUNDS : CHARACTER : Prominent,equally less heard on each side

LOCATION OF ABNORMALITY: Right and left iliac region

5. SKIN : COLOUR : Body pink and extremities blue at birth ,jaundice present

TEXTURE : dryness,flaking,wrinkling

TURGOR :while assessing delay in assuming normal position

RASHES :no rashes present anywhere on the body

OTHER BREAKS OR MARKS : no any one found

LANUGO : not present

Vernix : white cheesy ,oily substance found less on entire body and

Surfaces of the body,equally not spreads on axillary and on Glutealfolds,some amount also left on back and chest,abdomen to prevent hypothermia.

6. MEASUREMENTS: HEAD(FOC) 30 CM CHEST : 26 CMLength 40 cm

7.HEAD : HAIR TEXTURE :dull,brittle and dry

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TENSION: not present

MOULDING :it was flattened as the delivery was vertex

ANTERIOR FONTANELLE : SIZE 1.5 CMS (in width)X 2.5CMS (in length)

POSTERIOR FONTANELLE : SIZE 1 CMSX (in width) X 2 CMS (in length)

CAPUT SUCCEDENUM : Present get disappeared on 3 rd dayCEPHALOHEMATOMA : Present ,on palpation mass was soft,irreducible and fluctua-

ting ,this condition will cleared within few weeks.

8. EYES : POSITION : symmetrical on both sides,slight oedema on lids present

PUPILS : not equally reacting to light as it may take time for 3 weeks

IRIS : no any abrasion,no irregularitySCLERA : clear,no pale,no jaundiced

PRESENCE OF HEMORRHAGE : not present

9.EARS : PLACEMENT :on observation well set (no low set ears)

PINNA : soft and well curved but slow recoil

HEARING :startle reflex present,baby can hear adequately

10. NOSE :SYMMETRY : symmetrical on observation

PATENCY : Patent present of both nostrils.

NASAL CANALS:Flattened

11. MOUTH :COLOUR OF MUCOUS MEMBRANE :Pink in colour

TONGUE : Pale,soft and moist

TEETH : No eruption of teeth

HARD,SOFT PALATE :high arched and narrow

UVULA: Curved in shape

No congenital abnormality,occasional vomiting may persists.

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12. NECK : SHAPE : circular and contour MOBILITY :Adequate

MASSES : no any abnormal mass on palpation

LYMPH NODES :Palpable ,not enlarged

13. CLAVICLE : INTEGRITY : no any abnormality ,normal in size and shape

14. CHEST : SHAPE : circular in shape

BREAST ENGORGEMENT :No engorgemnent present,no

Enlargement of breast ,no milky discharge

NIPPLE SIZE :Flat areola,no bud

15. ABDOMEN :SHAPE :cylindric and erect

# OF CORD VESSELS :one vein and two arteries

UMBILICAL CORD APPEARANCE : less soft granulation tissues at umbilicus

16. FEMORAL PULSES : 90/min with less volume and irregular rate and rhythm

17. GENITALIA : FEMALE : LABIA MAJORA: majora and minora are equally prominent

slightly swollen,prominent clitoris

VAGINA : present ,exudes mucous discharge

VAGINAL DISCHARGE : sometimes mucoid or blood tinged discharge

MALE: POSITION OF URETHRAL OPENING : not applicable as baby is female

PRESENCE OF TESTES : not applicable as baby is female

MATURATION OF SCROTUM : not applicable

18.ELIMINATION : URINE:COLOUR : flow is clear or dilute because of the immaturityOf the kidney to concentrate the urine

# OF TIMES IN LAST 24 HOURS : 3-4 timesSTOOL COLOUR :Dark greenish TYPE : semisolid

# OF TIMES IN LAST 24 HOURS: only once in small amount

19. ANUS : DETERMINE PATENCY :Present in normal anatomical shape

20. HIPS : RANGE OF MOTION :motion present,but not active,flaccid

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Gross abduction of thighs when lying on back found slightly.

21.SPINE : It is straight ,round in shape with no S shaped curve

SCAPULA :Normally present in size and shape GLUTEAL FOLDS :Normal

in symmetry ,no dislocation of hips.OBSERVE PILONIDAL DIMPLE FOR INTACTNESS: Present

22.EXTREMITIES : APPEARANCE OF HANDS :Plump,fingers are short,nails are

Smooth and soft and extend over the finger tips

APPEARANCE OF FEET :small,short,bowed and curved outward

With the feet turned inward and flat because of the presence of the

Planter fat padHANDS # OF DIGITS RT : Five in number

# OF DIGITS IN LT :Five in number

POLYDACTYLY :not present SYNDACTYLY :Not present

FEET # OF DIGITS RT :Five in number

# OF DIGITS IN LT: Five in number

POLYDACTYLY :Not present SYNDACTYLY:Not present

23. REFLEXES : MORO (STARTLE): present

PALMER GRASP : slow response

PLANTER GRASP : slow response

ROOTING : Present

SUCKING : slow response

STEPPING : not present

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JG COLLEGE OFNURSING

AHMEDABAD

SUBJECT : CHILD HEALTH NURSING

TOPIC : NEWBORN ASSESSMENT

SUBMITTED TO:

MR.ARPAN PANDYA SUBMITTED BY:

LECTURER PANCHALSANGITA C.

M.SC.NURSING(PED.NURSING) 2ND YEAR M.SC.NURSING

JGCOLLEGE OF NURSING JGCOLLEGE OFNURSING

AHMEDABADAHMEDABAD

DATE OF SUBMISSION: /1/12

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CONCLUSION:

An important role of the nurse during the physical and behavioral assessments of the newborn is to teach parents about their newborn and involve them in their babyscare. This involvement facilitates the parents identification of their newbornsuniqueness and allays their concerns. We can come to know about Normal ranges for vital signs assessed in the newborn, gestational age of the newborn and normal

measurements. Newborn behavioral abilities include habituation, orientation to visualand auditory stimuli, motor activity, cuddliness, and self-quieting activity.