ABNORMAL ASSESSMENT OF
NEWBORN
Subject : Child Health Nursing
SUBMITTED TO: SUBMITTED BY:
Mrs. Shivani Thakur Ms. Priya Kumari
Associate Professor, M.Sc. Nursing 1st Year
Dept. Child Health Nursing Dept.Child Health Nursing
NSCN, Palampur Roll No. 08
Submitted On:
IDENTIFICATION DATA
INFORMANT: His Mother
Name of the baby : Isaan
RELIABILITY: Fully Reliable
Date of birth/ age : 20/08/2021/1 day
Gender : Male
Birth Weight : 1.80 Kg
Present Weight : 1.63 Kg
Gestational Age : 36 weeks + 3 days
Final Diagnosis : SGA Male Baby
Date of Surgery : NA
Religion : Hindu
Address : V.P.O Baglamukhi Teh.and Distt. Kangra (H.P)
Duration of Care : 3Days
MOTHERS DATA :
Name : Simran
Age : 22 years
Height : 5’3’’
Weight : 52 kg
Education : Graduation
Occupation : Housewife
Hemoglobin : 11 gm/dl
HISTORY :
Chief Complaints .......
No chief complaints. But Small for gestational age babies may look mature, but they are smaller than other babies of the same
gestational age. They may be small all over, or they may be of normal length and size but have lower weight and body mass. These
babies may be born:
Premature. Before 37 weeks of pregnancy.
Full-term. Between 37 and 38 weeks (early term) through 41 weeks.
Post-term. After 42 weeks of pregnancy.
HISTORY OF PRESENT ILLNESS : No illness or symptoms present. Baby cried immediately after birth.
APGAR score after 1 and 5 minute of birth is 7.
HISTORY OF PAST ILLNESS : NA
BIRTH HISTORY:
Antenatal : G1 P1A0L1. Mother attended 2 Antenatal check-ups during her pregnancy. She was immunized against tetanus in 4 th and
5th month of gestation. According to mother she was having poor nutritional status during the pregnancy. And sometimes she use to
have smoking during her antenatal period nor her health status was also good. No history of LPV/BPV present.
Natal : Full Term Normal Vaginal Delivery. Baby took birth in hospital. No history of episiotomy/epidural or any other
complications during delivery. Baby birth weight is around 1.8 kg. Baby cried immediately after birth.
Postnatal : Baby birth weight is around 1.8 kg. No history of drugs given to the baby immediately after birth. But baby was on
incubator for 2 weeks.
Immunization History : BCG is not given yet.
Any Treatment Given : Inj Vit-K, IM stat.
DIETARY/FEEDING HABITS:
Type of Feeding : Breast feeding
Feeding Pattern: After birth, baby was on incubator so baby was on ryles tube feeding for 2 weeks in between mother’s milk given to
baby.Baby is being given 6 -7 times breast feeding a day, for 10-15 minutes each time and given maximum during night time as baby
remains sleepy during day time mostly.
PHYSICAL ASSESSMENT OF THE NEWBORN :
Anthropometric Measure........
Head circumference : 30cm
Chest circumference : 28cm
Crown to rump length : 26cm
Head to heel length : 48cm
Birth Weight : 1.8kg
Vital Signs.........
Temp. : 37’C
Pulse Rate : 136bpm
Respiration : 48bpm
Blood pressure : 60/38mmhg
General Appearance..........
Posture : Flexion of head and extremities
Skin : Pinkish-red puffy skin, vernix caseosa present on head, milia present on nose, lanugo mostly present on
cheek and back, Mongolian spots are present in the sacral region, edema present on face, around eyes and
scrotum.
Head : Anterior and posterior fontanel, both are palpable.
Eyes : Black in color and lids are edematous.
Reflexes Present : - Blinking or Corneal Reflex
Papillary Reflex
Doll’s Eye
Ears : Pinna flexible and on horizontal line with outer canthus of eye.
Nose : No nasal discharge present
Reflexes Present : - Sneeze reflex
Glabellar reflex
Mouth and Throat : No cleft lip or cleft palate, no epstein pearls or natal teeth present.
Reflexes Present : Absent
Gag reflex, Sucking reflex absent after birth.
Yawn reflex, Rooting reflex absent.
Cough reflex, Extrusion reflex absent.
Neck : Short neck having few skinfolds.
Chest : No chest symmetry present, anteroposterior and lateral diameter are equal, slight retractions are present during
inspiration and no secretion of Witch’s milk from his breast.
Lungs : Equal bronchial breath sounds can be heard bilaterally. Rate and depth of respiration is regular and respiration can
be felt abdominally. No inspiratory stridor or expiratory grunt is present.
Heart : No arrhythmias present, S2 is slightly higher in pitch than S1. No transient cyanosis and cardiomegaly present.
Abdomen : Cylindrical in shape, liver and kidney are palpable, bowel sounds can be heard, umbilicus is bluish white with no
discharge and two arteries and one vein. No abdominal distension present.
Genitalia : Urethral opening is present at the tip of penis. Both the testes are palpable in scrotum. Scrotum is edematous,
pendulous and covered with rugae. Urination occurred within 24 hours of birth, urethral opening is covered by
prepuce. There is no presence of hypospadias, epispadias or hydrocele.
Back and Rectum : Spine is intact, Anal opening is patent. Baby passed meconium within 1st - 24 hours of birth. Absence of
imperforated anus or anal fissures, absence of spina bifida or tuft of hairs along with spine.
Extremities : Ten fingers and toes present with full range of motion. Nail beds are pink with creases on anterior two-third
of flat sole. There is no polydactyl, syndactyly or phocomelia (shortening of long bones of limbs).
Reflexes Present :
Grasp refex
Babinski reflex
Ankle clonus
Neuromuscular System : Extremities usually maintain some degree of flexion, no tremors, hypo or hypertonia. No
opisthotonus (spasticity) or asymmetric posturing present.
OTHER MASS REFLEXES PRESENT:
Moro reflex
Startle reflex
Asymmetric Reflex
HEALTH EDUCATION GIVEN:
Mother was advised to:-
Cover the baby in multiple layers of dry and warm clothes to prevent the hypothermia in baby.
Provide KMC to baby to prevent from hypothermia.
Breast-feed the baby atleast 8-10 times a day and on demand to meet the nutritional needs of baby and to prevent the risk of
hypoglycemia in baby, if baby is enable to suck provide artificial feeding.
Maintain the personal hygiene of baby. Provide daily bath to the baby and avoid if the weather is too cold.
Get the fully immunization of the baby done on time.
Consult physician if any deviation from normal seen in physiology or healthy of the baby.
