CHILD HEALTH NURSING

____________________________

NEWBORN
ASSESSMENT
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SUBMITTED TO SUBMITTED BY
Mrs. Rakhi Ghosh. Pritha Biswas
Senior Lecturer M.Sc (N) 1st yr
C.O.N., M.C.H C.O.N., M.C.H
Kolkata Kolkata

 Date of Assessment: 15/03/2024

  Place of Assessment: SSKM Medical College & Hospital

IDENTIFICATION DATA:
 Name : B/O Chandi Nisha
 Age of mother : 24 years
 Sex : Female
 Religion : Muslim
 Date of Birth : 16/3/24
 Time of Birth : 7:17 Pm
 Birth Weight : 1770 gms
 Mode of Delivery : EmLUCS cause of end diastolic flow absence
 Apgar Score : At 1 min: 5 & At 5 min: 7
 Resuscitation done : Yes [√ ] only initial steps No [ ]
 Registration No. : RG2400067363
 Under Dr. : Dr. S. Mukherjee, Dr. R Mukherjee,
Dr. U. Mondal, Dr. N Naskar
 Ward : SNCU
 Disk no : 479
 Name of Father : Sk Nasiruddin
 Address : DH Road Bodyguard Lane, Alipore
 Previous Obstetrical History : Third Gravida
 History of present pregnancy :G3 P1 + 1
 LMP : 24/07/2023
 EDD : 31/04/2024
 Gestation : 33 weeks
 No. of Checkup : 3 times
 Blood group & Rh : B (+ve)
 Immunization : Injection TT 2 doses taken.

Birth History:
 Antenatal : Iron and folic acid tablets taken & Injection TT 2
doses taken.
o No. of USG : Three times USG done.
o Other medications : Calcium 500 mg 1 Tab daily.
 Natal
: Baby delivered prematurely before 7 weeks. Baby
did not cry immediately after birth.
  Postnatal
Physical examination of the Neonate:
 General Appearance
 Facial expression
 Posture
: Baby not cried immediate after birth. Baby’s condition is stable
at present. Initial steps of resuscitation done and then feeble
cry present but she is hypothermic(33˚c). She developed
central cyanosis. Then she referred at SNCU.
: Good
: Well flexed [ √ ] Asymmetry [ ]

 Activity level : Active [ √ ] Flaccid [ ]

 Personal hygiene
 Type of clothing
 Cry
: Maintained [ √ ] Not Maintained [ ]
: Stuffy [ ] Soiled [ ] Cotton [ √ ]
: Normal [ ] Vigorous but stops on touching &
eye to eye contact [ √ ]
Vigorous and not stopping on touch [ ]

 General condition : Good [ √ ] Asphyxiated [ ] Poor [ ]

 Vital Signs:
 Temperature : 36.2˚ C

 Heart rate : 162 b / minute.

 Respiration : 68 brths / minute.

 Blood Pressure (if required) : NA

 Anthropometry Measurement:
 Length : 48 Cm.
 Weight : 1669 gms.
 Head circumference : 30 Cm.
 Chest circumference : 27 Cm.
 Abdominal circumference : 23 Cm.
 Mid arm Circumference : 8 Cm

 Inspection of Skin:
 Color : Pink Colour [ √ ] Cyanosis [ ] Jaundice [ ]
 Turgor : Good [ ] Poor [√]
 Cleanliness : Clean [ √ ] Dirty [ ]
  Hydration : Normal [ √ ] Dehydrated [ ]
 Vernix Caseosa : Absent or minimal [ ] Excessive [√]
 Lanugo: : Absent [ ] Excessive [√ ]
 Inspection of Hair:
 Hair : Silky & smooth [√ ] Course & rough [ ]
Wooly / Fuzzy [ ]

 Examination of Head:

 Fontanels (Ant and Post)

o Size : Ant. fontanel 2 x 3 Cm & post fontanelle 1x1cm
o Tension :NA
o Shunken :NA
 Sutures : Normal [ √ ] Widely Spaced [ ]
 Moulding : Present [ ] Absent [ √ ]
 Cephal Hematoma : Present [ ] Absent [ √ ]
 Caput Succedaneum : Present [ ] Absent [ √ ]

 Examination of Eyes:

 Eyes : Normal [ √ ] Relation with ear level [ ]

 Alignment : Good [ √ ] Poor [ ]
 Conjunctiva : Normal [ √ ] Infection present [ ]
Sub conjunctival hemorrhage [ ]
 Vision : Normal [√ ] Abnormal [ ]

 Examination of Nose:
 Shape : Shape Normal
 Nasal canal : Patent
 Nasal Septum Deviation : Not Present
 Examination of Mouth:
 Lips : Normal [√] Cleft lip [ ]
 Palate : High arched [√ ] Cleft palate [ ]
 Mouth/ Tongue : Moves freely [√ ] Protruding tongue [ ]
Tongue tie [ ] Coated [ ] Moist [ √]
Epstein pearl [ ] Thrust [ ]
  Size of Chin : Normal [√ ] Micrognathia [ ]
 Examination of Ears:
 Formation of cartilage : Late recoil.
 Shape : Normal [√ ] Abnormal [ ]
 Pinna : Normal in shape [√ ] Smaller in shape [ ]
 Lobule : Fleshy [ ] Thin [√]

 Examination of Neck:

 Neck (Length) : Normal [√ ] Webbing of neck [ ] Torticollis [ ]

 Lymph Nodes : Palpable [ ] Not Palpable [ √ ]

 Inspection of the Chest:

 Chest movement
 Breast size
 Inspection of the Abdomen:
 Abdomen shape
 Bowels sound
 Abdominal Distension
 Umbilical cord
 Liver
 Spleen
: Symmetrical [√ ]
: Normal [ ] Premature size [√]
Abnormality present [ ]
: Dome -shaped [√ ]
: Present [√ ]
: Soft [ √ ]
: Normal [√ ]
Infection present [ ]
: Palpable [ ]
: Palpable [ ]
Asymmetrical [ ]
Concave [ ]
Absent [ ]
Distended [ ]
Bleeding present [ ]
Not palpable [√ ]
Not palpable [ √ ]

 Inspection of Nails:

 Cyanosis : Present [ ] Absent [ √ ]

 Size : Long [ √ ] Ragged [ ]

 Inspection of Extremities:
 Movement : Equal & bilateral [√ ] Unequal & Unilateral [ ]
 Digits : Ten fingers & ten toes [√ ] Fusions of digits [ ]

 Length : Equal [√ ] Unequal [ ]

 Palmar creases : Deep [√ ] Superficial [ ]
  Dislocation of hip : Present [ ] Absent [√ ]
 Club foot : Varus [ ] Vulgus [ ] Absent [√ ]

 Inspection of Back:

 Back spine : Intact [√ ] Not intact [ ]

 Spinal Curve Curvature : Normal [√ ] abnormal [ ]
 Spina bifida : Present [ ] Absent [ √ ]
 Inspection of the Genitalia:
 Genitalia (Girl)
o Girl : Normal [ √ ] Presence of abnormality [ ]
o Labia majora covers minora : Yes [√] No [ ]
o Discharge : Yes [ ] No [√]
o Type of discharge : White [ ] Mucoid [ ] Blood [ ] No discharge[√]
o Clitoris : Prominent [√] Covered [ ]
 Observation of feeding behavior:

 Breast feeding : Yes [√ ] K/S or OG feed No [ ]

 If No, the reasons : The baby is early preterm.
 Aritifical feeding : NA
 Vomiting : No vomiting [ √ ] Vomiting < 2 times [ ]
Persistent vomiting [ ]
 Neuromuscular Observation:

 State of alertness : Active & Alert [ ] Sleepy [√] Restless [ ]

 Muscle tone : Normal [ ] Hypotonia [√] Hypertonia [ ]
 Reflexes
o Sucking reflex : Normal [ ] Weak [√] Absent [ ]
o Rooting reflex : Normal [ ] Weak [√] Absent [ ]
o Moros reflex : Normal [ ] Weak [√] Absent [ ]
o Dancing reflex : Normal [ ] Weak [√] Absent [ ]
o Grasping reflex : Normal [ √ ] Weak [ ] Absent [ ]
o Tonic neck reflex :Normal [ ] Weak [√] Absent [ ]
o Babinski sign :Normal [√ ] Weak [ ] Absent [ ]
o Glabellar tap : Normal [√ ] Weak [ ] Absent [ ]
Remarks / Impression:
Baby not cried immediate after birth. Baby’s condition is stable at present. Initial steps of resuscitation done and
then feeble cry present but she is hypothermic(33˚c). She developed central cyanosis. Then she referred at
SNCU.
At present general condition is somehow stable and moderately satisfied of this baby. Baby is on EBM with
katori-spoon or OG as per her condition. Baby also passes urine and stool normally. Her mother gives normal
care such as napkin changing, feeding, oro-motor stimulation. mother follows all the instructions given by
doctors and nurses.