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  • Newborn Assessment

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    Daniel Adams
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    This document summarizes a newborn nursing assessment that includes: 1) Demographic information such as birth date, time, sex, weight, and head/chest circumference measurements. 2) Additional assessments of gestational age, breast tissue, plantar creases, ears, and testes to determine if the newborn is preterm or term. 3) A physical exam noting the newborn's appearance, including skin, head, eyes/ears/nose/throat, respiratory, cardiovascular, abdomen, musculoskeletal, genitourinary, and central nervous system.

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    This document summarizes a newborn nursing assessment that includes: 1) Demographic information such as birth date, time, sex, weight, and head/chest circumference measurements. 2) Additional assessments of gestational age, breast tissue, plantar creases, ears, and testes to determine if the newborn is preterm or term. 3) A physical exam noting the newborn's appearance, including skin, head, eyes/ears/nose/throat, respiratory, cardiovascular, abdomen, musculoskeletal, genitourinary, and central nervous system.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    8 views2 pages

    Newborn Assessment

    Uploaded by

    Daniel Adams
    This document summarizes a newborn nursing assessment that includes: 1) Demographic information such as birth date, time, sex, weight, and head/chest circumference measurements. 2) Additional assessments of gestational age, breast tissue, plantar creases, ears, and testes to determine if the newborn is preterm or term. 3) A physical exam noting the newborn's appearance, including skin, head, eyes/ears/nose/throat, respiratory, cardiovascular, abdomen, musculoskeletal, genitourinary, and central nervous system.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Newborn Nursing Assessment

    Birth Date: Birth Time: Sex: Weight: Head Chest Length


    Circumference Circumference: (cm):
    : ________ ______
    _______
    Blood Group Feeding Medications
    Mother____ Breast________ :
    Baby Exclusive______
    Coombs____ Supplement___
    ____Vitamin K
    _
    Formula______ _____EES
    _ ointment

    GESTATIONAL AGE ASSESSMENT


    Gestational Age
    By Dates_________weeks
    By Assessment_____weeks
    <37 weeks (Preterm) >37 weeks (Term)
    BREAST TISSUE ____</= 3mm ____>3mm
    PLANTAR CREASES ____Smooth, Single crease ____Covering Ant. 1/3 or more
    EAR ____Relatively flat, pliable ____Stiff cartilage, Deep crease outer aspect
    TESTES ____In canal ____Well within scrotum
    Normal/Abnormal
    Appearance:
    Skin: ___Bruising ___Petechiae___Meconium Stain___Edema___Peeling
    ___Jaundice___Other___Soft Tissue Wasting___Moderate____Severe
    Head: ___Overriding suture ___Hematoma ___Molding ___Caput ___Other ___
    EENT: ___Cleft Lip/Palate ___Suspected choanal atresia ___Other___Physician
    Assessment
    Respiratory: ___Grunting ___Nasal Flaring ___Retracting ___Decreased Breath Sounds
    RR____ ___Tachypnea ___Other
    CVS: ___Murmur ___Arrythmia ___Tachycardia ___Central Cyanosis ___Ab. Femoral
    Pulses
    HR:____
    Abdomen: ___Scaphoid ___Distended ___Other
    ___Meconium staining ___3 vessels ___2 vessels ___Thin ___Other
    Musculoskeletal: ___Spine ___Hip abnormality ___Clavicle ___ Foot Abnormality
    Genitorectal: ___Hydrocoele ___Hypospadius ___Undescended testes ___Imperforate
    Anus
    CNS: ___Decreased tone ___Abnormal cry ___Increased tone ___Jittery ___Other

    Date:_____________Time__________Signature________________________________
    _

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