HIGH RISK NEWBORN ASSESSMENT FORMAT

IDENTIFICATION DATA
Name of the baby -
Age -
Sex -
Date of birth -
Birth weight -
HISTORY COLLECTION
Delivery - singleton/ twins/triplet
Diagnosis -
Cord - Normal/ Prolapsed
Condition at birth - Active/ Asphyxiated
Any birth anomalities - Present/ Absent
Treatment at birth -
Apgar score - at 1mt at 5mt
VITAL SIGNS
Temperature -
Pulse -
Respiration -
ANTHROPOMETRIC MEASUREMENT
Weight -
Length -
Head circumference -
Chest circumference -
Abdominal circumference -
PHYSICAL ASSESSMENT
Activity - Active/ Dull
Body build - Thin / Well built
Skin
Color - Pale/ Pink/ Jaundiced/ Cyanosed
Texture - Smooth/ Dry
Turgor - Normal/ Dry
Vernix caseosa - Present/ Absent
 Lanugo - Present/ Absent
Edema - Present/Absent
Milia - Present/ Absent
Mongolian Spot - Present/ Absent
Head
Size - Normal/ Macrocephaly/ Microcephaly
Shape - Normal/ Abnormal
Anterior fontanels - Palpable/ Depressed/ Bulging
Posterior fontanels - Palpable/ Depressed/ Bulging
Caput succedaneum - Present/ Absent
Cephalohematoma - Present/ Absent

Eyes
Eyelid - Normal/ Edematous
Iris color -
Sclera - White/ Blue/ Yellow
Red reflex - Present/ Absent
Nose
Patent nostrils - Present/ Absent
Nasal discharge - Present/ Absent
Nasal septal deviation - Present/ Absent
Flaring of nostrils - Present/ Absent
Ear
Symmetry -
Appearance -
Pinna in line with eyes -

Mouth
Secretions - Present/ Absent
Intact lips and palate -
Oral trush - Present/ Absent
Neck
Size - Normal/Abnormal
Neck webbing - Present/ Absent
Chest
Shape -
Movement - Symmetry/ Asymmetry
Breath sound -
Heart sound -
Abdomen
Shape - Normal/ Distended
Umbilical cord -
Wharton’s jelly - Present/ Absent
Bowel sounds - Present/ Absent
Female Genitalia
Labia Majora - Normal/ Edematous
Labia Minora - Normal/ Abnormal
Vaginal Discharge - Present/ Absent
Male Genitalia
Urethral opening - Present/ Absent
Testis - Descended/ Undescended
Epispadia - Present/ Absent
Hypospadia - Present/ Absent
Spine
Spine - Intact/ Abnormal
Spina bifida - Present/ Absent
Abnormal curvature - Present/ Absent
Extremities
Shape - Symmetric/ Asymmetric
Range of motion - Active/ Inactive
Nail Buds - Pink/ Cynosised
Muscle tone - Normal/ Abnormal
Polydactylity - Present/ Absent
Syndactylity - Present/ Absent
Neuromuscular
Cry - Weak/ Loud/ High pitched
Lethargic - Present/ Absent
Activity - Active and alert/ Drowsy
Reflexes
o Moro Reflex
o Sucking reflex
o Rooting Reflex
o Tonic neck reflex
o Grasp reflex
o Stepping or walking reflex
o Babinski sign
o Glabellar reflex
o Sneezing reflex
 DAILY OBSERVATION AND CARE OF THE NEWBORN
POSTNATAL DAY 1 2 3
General condition
Temperature
Pulse
Respiration
Eye care
Cord care
Breast feeding
Baby weight
Bladder
Bowel
Sleep
Chief Complaints

Medical treatment

Vaccination

Signature of the care giver :

Signature of the supervisor :