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Ferris State University NURS 342 Summer 2010 Newborn Assessment

Newborn Physical Assessment Please use the following code:

+ = Present/normal = Not present NA = Not applicable Admission data (This will be obtained from the babys chart!): Temp 37.0 HR 148 Resp 56 Bld glucose NA Resuscitation measures: Delayed cord clamping, Length 52.1 cm Wt. 3735 g APGAR Score 1 min 8 5 min 9

suction bulb, tactile stimulation, neo present at delivery___________________________ Ilotycin 22.15 (time) Vit K 22.15 (time) Nursed in L&D: Yes After you have read the infants chart and gathered the information, give your assessment of this infants status when it was 1 hour after birth (give details, not good) Vital signs were stable and within normal limits. Heart Rate: 148, 132, 128. Temperature: 37.0, 36.8, 36.0. Respirations: 56, 52, 50. Respiratory, cardiovascular, neuro, and skin assessments revealed no positive findings. No bowel movements or voids were recorded in the first hour.

NOW YOU ARE READY TO DO A PHYSICAL ASSESSMEDNT ON THIS BABY (to be completed by you the day you are caring for the baby): Temp 36.9 Color: Pink Jaundice + HR 112 Resp 59 + Pale Mottles Plethoric Retracting Dry +

Stained

Acrocyanosis

Skin: Clear Ecchymosis Rash

Pressure marks Petechiae

Abrasions Milia

Nevi

Lanugo

Vernix +

Mongolian spots Abdominal

Respirations: Regular

Grunting

Shallow

Nasal flaring Weak

Shrill

Sighing

Other

Cry: Lusty

Head: Symmetry/shape Bilateral symmetrical/elongated Molding Cephalhematoma ISE mark Full Full + Abnormal Other

Caput succedaneum

Anterior fontanel: Flat + Posterior fontanel: Flat Sutures Coronal Sagittal Lambdoidal +

Depressed Depressed

Overriding

Separated

Approximated +_____ +_____ +_____

Ears: (describe exact location & how you determined if it was normal) Position: Normal Skin tags _____ + Flaring Patent: Left + Right Subconjunctive hemorrhage Nevi on lids Edema Red reflex Other NA + Pale Right +__ Left ___ ___ ___ NA_ ___ Cyanotic Describe normal position Top of ears

align with eyes and are symmetrical

Nose: Symmetry

Eyes: (describe what you found) Align with top of ears. Symmetrical.

Mouth: Mucous membranes: Pink Teeth Epsteins pearls + +

Hard palate: Intact Soft palate: Intact

Abnormal Abnormal

Lips: Cleft

Drooping

Symmetry

Anterior chest: Symmetrical Clavicles: Intact +

Shape Round

Fracture +

Breasts: Palpable tissue Heart sound: RRR +

Engorgement NA +

Other

Genitals: Voided: Date NA

Time

Color of urine

NA

Male: Urethral orifice: Normal position

Abnormal (describe) + Other NA NA Hymenal tag NA

Testes (#/location) 2/Descended in in scrotum Scrotum + Pendulous Rugated

Female: Labia majora: Completely covers minora NA Partially covers minora Labia minora protruding NA Vaginal discharge + + Truft of hair Intact Type Other Left + + 5/5 + + + Dislocated/subluxation + Meconium Posterior: Pilonidal dimple Spinal column: Symmetry Anal patency Yes Anterior Abd: Symmetry Cord: # of vessels Extremities: Right Symmetry Movement Digits (number) Flexion creases Palmar creases Sole creases Hips: Intact Right Left + + + + 5/5 + + + 3

Stool Yes

Protruding base

Neuro-muscular: Tone: Normal Rigid

Lethargic Tremors

Reflexes: Reflex: Describe what you observed Rooting: Turn head towards light touch on cheek Sucking: Sucking movement of mouth Moro: Rapid abduction & extension of arms/embracing motion Stepping: Stepping motion of legs Grasp/hand: Curls fingers Grasp/foot: Curls toes Describe the procedures Stoke cheek Place finger in mouth Pick up baby and carefully drop back onto hands/surface Pick up baby vertically and place feet on surface Put finger in palm of hand Put finger on bottom of foot What is your overall assessment and prognosis for this infant (do not say good): Overall this baby seems to be in good health. He has normal vital signs and his reflexes are appropriate for his developmental age. No abnormalities were discovered on this assessment. This infant should continue to grow and thrive, based on assessment results. Describe normal responses Turn head towards stimulus Suck on finger Rapid abduction & extension of arms & embracing motion Pick up legs and make stepping motion Curl fingers around finger Curl toes around finger

On the basis of your assessment, list at least TWO nursing diagnosis for this baby and all the teaching interventions you would use for each nursing diagnosis. Please include the rationale for your actions. You must have at least two references besides your textbooks for your rationales. Be sure your assessment and interventions correspond to your Nursing Diagnosis.

Nursing Diagnosis Risk for imbalanced nutrition less than requirements r/t ineffective breastfeeding

Necessary Assessments/Interventions Assist parents in identifying infant arousal cues as opportunities to practice breastfeeding Monitor voids and stools Measure daily infant weights Refer mother to lactation consultant as appropriate

Rationale It is important for newborns to receive adequate nutrition soon after birth and throughout life. Breast milk contains everything that a newborn needs. According to the School of Nursing and Midewifery at the University of Western Sidney, a womans breast milk has a unique composition of nutrients, enzymes, growth factors, hormones, and immunological and antiinflammatory properties that can reduce the risk of a wide range of illnesses for a child well beyond infancy. Essentially, it is like liquid gold for a growing baby (Burns, Schmied, Fenwick, & Sheehan, 2012, pp. 1737). Ineffective breastfeeding could cause delayed growth and other complications for newborns.

Potential complication of adjustment to extrauterine life r/t transition

Apply cap to prevent heat loss Keep umbilical cord dry by exposing to air and diapering newborn below cord Respond to newborns cues for care to facilitate development of trust Keep infant with parents after birth when possible

Newborns must go through a transition period after birth where they rapidly make physiological changes to adapt to the environment. According to the American Journal of Nursing, there are six stages of transition. It is important for nurses to assure that steps 3-6 occur. These include the initiation of air breathing and respiration, the change from fetal to neonatal circulation, alterations of hepatic and renal functions, the passage of meconium, induction of enzymes, changes in blood oxygen saturation, and recovery of neural tissues (Arnold, Putnam, Barnard, Desmond, & Rudolph, 1965, pp. 77).

Risk of urinary retention r/t urethral obstruction secondary to post-circumcision edema

Provide comfort measures postprocedure

Circumcisions are a relatively safe procedure, however, complications can occur and it is important to monitor the infant during and after the procedure. According to Monitor bleeding. Refer to Stanford School of Medicine, while not a complication bleeding post-circumcision of circumcision itself, the application of a tight circular protocol if appropriate bandage may create an obstruction to urine flow and cause urinary retention. Removal of the bandage is Apply petroleum jelly dressing to curative. In most cases, a circumcision site is circumcision adequately dressed when covered with a petroleum jelly coated gauze pad without any taping or circumferential

Medicate for pain pre-procedure per physician order

pressure (Stanford School of Medicine, 2013).

Resources Arnold, H., Putnam, N., Barnard, B., Desmond, M., & Rudolph A. (1965). Transition to extra-uterine life. The American Journal of Nursing, 65(10), 77-80. Retrieved from http://0-www.jstor.org.libcat.ferris.edu/stable/3419548. Burns E., Schmied V., Fenwick J., & Sheehan A. (2012). Liquid gold from the milk bar: constructions of breastmilk and breastfeeding women in the language and practices of midwives. Social Science & Medicine, 75(10), 1737-1745. Retrieved from www.elsevier.com/locate/socscimed. Stanford School of Medicine. (2013). Complications of circumcision. Retrieved from http://newborns.stanford.edu/CircComplications.html#top.

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GRADING RUBRIC FOR OB OR NEWBORN ASSESSMENT Below Expectations

A. Assessment (15 points) Assessment has >12 blank spaces, has poor analysis (0 points) Does not complete the care plan (0 points) Does not have any interventions (0 points) Does not have any rationales for interventions (2 points) >10 errors in grammar or spelling; ideas are not clearly presented

Needs Improvement
(20 points) Assessment has 9-12 blanks (15 points) Chooses inappropriate nursing diagnoses based on the assessment (15 points) Has chosen inappropriate nursing interventions (15 points) Stated inappropriate rationales for nursing interventions (5 points) <10 errors in grammar or spelling; ideas are almost always clearly presented

Meets Expectations
(25 points) Assessment has 5-8 blank spaces, analysis need to be more in depth (17 points) Chooses 1-2 appropriate nursing diagnoses based on the assessment (17 points) Chooses 2-3 appropriate nursing interventions for each diagnosis (17 points) Stated appropriate rationales for nursing interventions for each diagnosis (7 points) <5 errors in grammar or spelling; ideas are clearly presented

Exceptional
(30 points) Assessment has no blank spaces and exceptional analysis (20 points) Chooses 3 appropriate nursing diagnoses based on the assessment (20 points) Chooses 4 or more appropriate nursing interventions for each nursing diagnosis (20 points) In-depth discussion of the nursing interventions for each diagnosis with evidence-based support outside of textbooks (10 points) APA format is excellent; no errors in grammar or spelling; ideas are clearly presented

B. Nursing diagnosis

C. Interventions

D. Rationale for interventions

E. Grammar, spelling, & clarity of ideas