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INITIAL ASSESSMENT (Anthropometric Measurement and Vital Signs Taking) AND Bathing of The Newborn
INITIAL ASSESSMENT (Anthropometric Measurement and Vital Signs Taking) AND Bathing of The Newborn
Purposes
1. To initially assess the newborn with the following:
a. Record the anthropometric measurement
b. Record the vital signs
2. To cleanse the newborn.
Time Frame
Assessment
Nursing Diagnosis
Implementation
Documentation
The following should be noted in the client’s chart:
1. Document response of the newborn to the procedure.
2. Record any pertinent data.
References:
Engstrom, J. (2004).Maternal-Neonatal Nursing, Made Incredibly Easy. Lippincott
Williams & Wilkins.
Pilliteri. A. (2007) Care of the Child Bearing and Child Rearing Family. 5th Edition.
Lippincott Williams & wilkins.
Doenges, H. & M. (2006). Nurses Pocket Guide Diagnoses Prioritized Intervention
and Rationale. 10th Edition.
Smith T., Jean & Johnson, Young,J. ( 2006). Nurses Guide to Clinical Procedures. 5 th
Edition, Philadelphia: Lippincott Williams & Wilkin.
Nettina S.M. (2001). The Lippincott Manual of Nursing Practice. 7 th Edition.
Lippincott: Williams & Wilkins.
Udan Q. J. ( 2004) Mastering Fundamentals of Nursing Concepts and Clinical
Application 2nd Edition. Educational Publishing House.
Woodring,B.C. (2005) Pediatric Nursing Made Incredibly Easy. Lippincott Williams
& Wilkins.
NURSING ACTIONS 1 2 3 4 5
1. Assemble all needed supplies and equipment before starting the
procedure.
2. Wash hands thoroughly before beginning the procedure. Use
individual equipment and a modified isolation technique.
3. Obtain the weight of the newborn.
4. Place the newborn on a safe flat surface.
5. Do not leave the baby unattended for even a moment once you
begin the procedure.
6. Measure the head circumference of the newborn.
7. Measure the chest circumference of the newborn.
8. Measure the abdominal circumference of the newborn.
9. Measure the crown heel length of the newborn.
10. Check the newborn’s respiration rate.
11. Check the newborn’s apical pulse rate.
12. Check the newborn’s body temperature.
13. Wrap the newborn in a towel.
*Note: For normal bathing, undress the newborn before bath, then
wrap in a towel.
14. Keep the baby warm and secure, support during the procedure.
15. Assess the newborn during the bath, note any abnormal color,
blemishes, or rashes on the skin. Observes muscles for abnormal
jerking or twitching. Check the genitals of the female baby for
bleeding or discharges. Observe for any congenital abnormalities.
16. Begin the baby by wiping each eye using a clean cotton balls,
dammed with clear water only. Stroke from the inner to outer corner
of each eye using clean cotton for each eye.
17. Wipe the rest of the face with a soft cloth. Gently wash the face
without soap. Include behind and inside the ears. Pat the face dry.
18. Pick the baby using a football hold and position the baby’s head
over the water basin. Lather the scalp using small amount of mild
soap, massage gently into the scalp. Do not rub vigorously. Comb hair
to loosen and to remove blood. Rinse the hair thoroughly and gently
into the scalp dry the head with a towel and return the newborn to the
radiant warmer.
19. Wash, soap, rinse and dry each arm and hands. Avoid excessive
rubbing. Pay particular attention to the folds of the skin especially the
axilla and dry thoroughly.
20. Wash, soap, rinse and dry baby’s chest, neck, abdomen. Be sure to
remove blood from folds of the neck. Pat dry. Keep baby covered
between washing and rinsing.
21. Roll baby onto his side, wash, rinse and dry his back.
22. Wash, soap, rinse and pat dry baby’s legs and feet. Expose one leg
and feet. Expose one at a time.
NURSING ACTIONS 1 2 3 4 5
Bath the genital region. When cleaning the genital area, assess for
presence of rashes or irritation. Wipe vernix and secretions on the
folds of the thigh.
23. For Female Genital: Clean the vulva and perineum with clean
cotton balls. Then separate the labia and wipe with clean cotton balls
from front to back to remove secretions, as well as to avoid bacterial
contamination from vaginal area and rectum.
24. For Male Genital: For uncircumcised, do not retract the foreskin,
clean the penis and scrotum with clean cotton balls.
25. Bath the buttocks using a gentle motion. Keep area clean and dry
to prevent diaper rash. Grab both baby’s ankles and raise feet to
elevate the buttocks. Wash soap and rinse and dry the area with wash
cloth.
26. Inspect umbilical cord, check for bleeding or foul odor. Clean cord
stump with sterile water/ normal saline or according to hospital policy.
Do not cover the umbilical cord.
27. Dress the newborn, fold the diaper below the cord stump and wrap
in the blanket, place on the crib under a warmer.
28. Return/ Discard all the materials used.
29. Wash hands after the procedureand before touching any other
babies.
30. Document the procedure done and other pertinent findings.
Total : 125 ITEMS
Legend:
5 – Accomplishes the task excellently
4 – Accomplishes the task very satisfactorily
3 – Accomplishes the task satisfactorily
2 – Accomplishes the task fairly
1 – Accomplishes the task poorly
Rating Score