New – Born Assessment Tool

Bio-graphic data:-
Baby of __________________

Sex of the baby: __________________

Date & Time of the birth: __________________

Mode of delivery: Spontaneous vaginal/Assisted

Caesarean section

Gestational age: Term __________________

Preterm __________________

Post term __________________

Occupation of parents: Father: __________________

Mother: __________________

Education of parents: Father: __________________

Mother: __________________

Address:
___________________________________________________________________________
________________________________________________________PIN:_______________

Physical Measurements:
Birth weight: __________________ Length: __________________
Head circumference: __________________
Chest circumference: __________________
Anterior fontanel: - Length: __________________
Width: __________________
Posterior fontanel: - Length: __________________
Width: ___________________

Physical Examination:
General Appearances:
Vital signs: - Temperature: _______________
Pulse: - __________________
Respirations: - ______________
Skin:
Colour: Pink: __________ Pallor: ______________ Cyanosis: ________________

Yellow: _____________Dark red:_______________

Petechiae: ______________ Vernix caseosa:____________

Lanugo: _____________ Ecchymosis:_______________

Acrocyanosis:______________ Mongolian spots:________________

Birth trauma: _________________________

Loose wrinkled skin: ___________________
Others: _____________

Head:-

Hair distribution: _____________ scanty: _________________

Thick: __________________

Colour of hair: Black _________ Brown ____________

If any other specify _______________

Shape : Round __________ Irregular _____________

Moulding ________

Head circumference: _______________

Anterior fontanel: Width ___________ Length _____________

Sutures Closed: Widened __________ Stenosed ____________

Birth trauma Forceps mark Present Absent

Hydrocephalus: Present ____________ Absent ______________

Macrocephalus: Present ____________ Absent ______________

Macrocephalus: Present ____________ Absent ______________

Anencephalous: Present ____________ Absent ______________

Caput succedaneum: Present ____________ Absent ______________

Cephalohematoma: ________________

Plagiocephaly: _______________
Eyes:-

Symmetrical: _____________ Asymmetrical: __________________

Position: Normal____________ Slant ______________

Conjunctiva: Pale ___________ Yellow _____________

Tearing/Watering: ______________________

Pus formation: Present ____________ Absent ____________

Nystagmus: Present ______________ Absent ____________

Strabismus: Present ______________ Absent ____________

Eyelids: Normal/Drooping

Closed: _______________ Open: ______________

Sunset eyes: _____________ Epicanthal folds: ______________

Ulcerations: _____________ Anisocoria: ___________________

Eyelashes :Present________ Absent_______

Ears:-
Symmetrical ______________ Asymmetrical ________________
Position: Normal _______________ Abnormal _______________
Low-set Ears: ________________
Cartilage formation: ________________
Adherent earlobes: ________________
Periauricular skin tags: ________________
Discharge: ________________
If any other specify: ________________
Nose:-
Symmetrical _________________ Asymmetrical __________________
Nostril Patent: _____________ Flaring Narrow: __________________
Obstructed: _____________ Deviated Nasal septum: Present_______ Absent________
Discharge: _________ Nasolabial bridge ____________ Low bridge _______________
If any other specify ___________________
Mouth & Throat:-
Mouth Shape: ________ Lip color: __________ Pink:_______ Dark red:__________
Pale: _________ Cyanosis: ______________
Cleft lip: Present:________ Absent Degree:__________
Grimaces: ____________
Symmetric facial Grimaces: __________________
Gums Bleeding Tongue: _____________________
Palate:_____________________ Hard: _________________
Soft: ___________ Normal: _______________
Cleft Palate: Present: _________ Absent: _________
Tongue Tie _________ Oral thrush: Present_________ Absent__________
Precautions teeth: ________________
Cheeks: Chubby ______________ Hallow__________

Chest:-
Shape: Normal ______ Barrel shaped ________ Pigeon chest ____________
Circumference _____________ Respiratory rate _______________
Rhythm ___________ Expansion & Retraction ________________
Breath sound: Normal____________ Adventitious sound ______________
Grunting _______________ Distress __________________

Thorax:-

Symmetric ___________ Asymmetrical _______________

Anterior-Posterior diameter ________________
Bulging ____________ Rib Flaring _____________
Retraction ________________
Breast :
Nipple point : Symmetric……………..Asymmetry………………….

Aerola …………….

Breast :Swollen………………Flat……………….

Secretion of witche’s milk………………

Abdomen:
Shape :Rounded………………Distended………………..

Hallow Abdomen………………

Shiny Abdomen with prominent vessels…………………

Liver: Palpable…………..Not palpable………………….

Spleen :Palpable…………….Not palpable………………

Peristalisis :Present ……………Absent……………Rate…………..

Cord : Moist………………Dry……………Fallen off……………

Discharge…………….

Any signs of infection : Redness ………….Swollen……………..

Hot feeling locally………………Pus discharge…………….

Omphalocele………………………

Back: Spine……………Normal……………Spinabifida……………
Meningomyelocele…………….Meningocele………………...

Extremities:
Upper extremities :Symmetrical……………..Asymmetrical…………..

Movement………………Position: Flexed…………….Extended…………

Tone……………..

Digits……………….Polydactyly……………….

Syndactyly……………..

Simian crease on plam :present………………

Clubbing of fingers :Present……………Absent…………….

Phantum limb : Present………………...Absent……………..

Short limbs :Present……………………Absent…………….

Lower Extremities:
Symmetric……………….Asymmetric………………

Movement………………..Flexed………………….
Extended…………………Bowed…………………

Muscle tonicity……………….Digits………………

Polydactyly :Present……………..Absent……………..

Talipes Equinovarus………………

Dislocation of hips……………….

Short limbs:……………………

Genitalia:
Female :

Labia majora………………..Labia minora ……………..

Clitoris………………

Vagina : Present …………………Absent………………….

Edematous (swollen)…………………..

Ambiguous Genitalia…………………

Male :

Penis :Normal/Micropenis

Hypospadias : Present ………………Absent………………..

Epispadias :Present ……………….Absent………………….

Phimosis :Present…………………Absent………………..

Scrotum :Present …………………Absent………………

Testis :Descended……………….Undescended………………

Rectum &Anus:
Anal opening :Present………………..Absent…………….

Imperforated anus……………………

Rectal atresia ………………….

Pilonidal dimple………………….Fissures……………….

Stool:
Meconium :Passed …………….Not passed………………

Frequency of stools …………………

Amount…………………….

Transitional stools: Color……………….

Urination :Passed………………….Not passed…………………

Frequency…………………

Amount………………..

Neurological Reflexes:
Neonatal Reflexes:

1.Rooting Reflex: Present……………….Absent………………..

2.Sucking Reflex: Present………………Absent………………..

3.Gagging Reflex: Present………………Absent………………

4.Blink Reflex :Present……………….Absent……………….

5.Startle Reflex :Present……………...Absent………………...

6.Snezing & Coughing Reflex :Present…………………

Absent…………………

7.Moro Reflex :Present…………….Absent………………

8.Dolls Eye Reflex :Present…………Absent……………..

9.Extrusing Reflex :Present …………Absent…………….

10.Palmar &Plantar Grasp Reflex :Present……………….

Absent……………….

11.Babinski Reflex :Present……………Absent………………..

12.Dancing Reflex :Present……………Absent………………

13.Tonic Neck Reflex :Present……………..Absent……………..

Any Danger signs of new born, specify:

Inferences:

Nursing Diagnosis: