Ferris State University School of Nursing NURS 341

Newborn Physical Assessment Please use the following code:

Dana L Knoll 9/18/2013 ! = Not present Resp 42 NA = Not applicable Bld glucose N/A

+ = Present/normal Admission data: Temp 37.2 HR 159

APGAR Score: 1 min - 8 5 min - 9 Resuscitation measures: Delayed cord clamping, prewarmed infant warmer, tactile stimulation Ilotycin 2316 (time) Vit K 2318 (time) Length 48.3 cm Wt. 3305 g Nursed in L&D No

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.

-Regular heart rate and rhythm, murmur noted. Regular pulmonary rate; clear lung sounds bil, no rales, wheezes or rhonchi noted. No active bowel sounds noted, no urine voided; GI and GU closely observed. Infant alert and quiet, easily arousable. Skin is dry and intact, pink, slight jaundice. !"#$%"&$'()$()'*%$+"$*"$'$,-%./0'1$'..)..2)*!+$"!$+-/.$3'3%$ Temp 36.7 HR 122 Resp 48 Jaundice + Stained ! Acrocyanosis ! Dry + Ecchymosis ! Petechiae ! Mongolian spots ! Retracting ! Shallow ! Cry: Lusty + Weak ! Shrill !

Color: Pink + Pale ! Mottles ! Plethoric ! Skin: Clear + Nevi ! Milia ! Nasal flaring ! mark ! Other ! Anterior fontanel: Flat + Posterior fontanel: Flat + Sutures Overriding Coronal ! Sagittal + Lambdoidal ! Ears: Position: Normal + Full ! Full ! Depressed ! Depressed ! Pressure marks + Rash ! Lanugo ! Vernix ! Sighing ! Other !

Abrasions +

Respirations: Regular + Grunting ! Abdominal !

Head: Symmerty/shape + Molding + Cephalhematoma ! Caput succedaneum ! ISE

Separated Approximated ! + ! ! ! + Abnormal ! Skin tags ! Patent: Left + Right +

Describe normal position: upper ear attachment aligned with corners of eyes Nose: Symmetry + Flaring !

Eyes: Right Left Subconjunctive hemorrhage ! ! Nevi on lids ! ! Edema ! ! Red reflex + + Other ! ! Mouth: Mucous membranes: Pink + Pale ! Cyanotic ! Teeth ! Hard palate: Intact + Abnormal ! Symmetry ! Shape + Clavicles: Intact + Fracture ! Heart sound: RRR + Other ! Color of urine light yellow Partially covers minora ! Engorgement ! Time 0900 Lips: Cleft ! Drooping ! Breasts: Palpable tissue + Female: Labia majora:

Epsteins pearls !

Soft palate: Intact + Abnormal !

Anterior chest: Symmetrical +

Genitals: Voided: Date 9/14/13

Completely covers minora !

Labia minora protruding + Vaginal discharge ! Hymenal tag ! Posterior: Pilonidal dimple ! Tuft of hair ! Anal patency: Y N Stool Y N Extremities: Symmetry Movement Digits (number) Flexion creases Palmar creases Sole creases Hips: Right Left Intact + + Dislocated/subluxation ! ! Lethargic ! Rigid ! Tremors ! Right + + + + + + Left + + + + + + Anterior Abd: Symmetry + Other ! Spinal column: Symmetry + Intact + Type meconium Cord: # of vessels 3 Protruding base +

Neuro-muscular: Tone: Normal +

Reflexes:

Reflex: Describe what you observed

Rooting: Babys mouth moved toward my finger when placed on her cheek Sucking: Baby able to feed from bottle; baby able to suck when object, such as finger, is placed in her mouth Moro: When I placed my stethoscope on babys chest she raised her arms up, made Cs with her hands Stepping: Flexes and extends legs when held upright over a surface; looks as though she is stepping Grasp/hand: Baby closes fingers over mine when my finger is placed in her palm Grasp/foot: Baby curls her toes towards my finger when placed underneath them

Describe the procedures

Gently stroke the infant from the lips to the cheek Place finger or nipple into infants mouth

Describe normal responses

Infant should turn his/her head toward the stimulated side with mouth opening Rhythmical sucking of object

Support the infants head and shoulders with one hand; allow the neck to drop back to allow the anterior neck muscles to stretch Support the infant upright with the feet touching a hard surface.

The shoulders abducts, elbows, wrists and fingers extend Alternating, rhythmical and coordinated stepping motions Infants fingers will flex around the finger Plantar flexion of all of the toes

Place a finger in infants hand from the ulnar to the palmar surface Apply firm pressure to the plantar surface of infants foot

What is your overall assessment and prognosis for this infant (do not say good): Infant at 48 hours old is alert and responsive to environment, with lusty/vigorous cry. Currently bottle-feeding approximately every 4 5 hours, 10-15 mls at a time. Normal skin turgor, pink color with slight jaundice and abrasion is noted on left forehead. Regular cardiac rate and rhythm, no murmurs, cyanosis or edema noted. Respirations unlabored with clear breath sounds bilaterally. Active bowel sounds, no masses palpable and no distention noted. Infant has demonstrated normal bowel and voiding patterns. Prognosis is positive; physical assessment raises no cause for concern. Mother may require education regarding normal infant feedings and should make note of how much infant eats and how often.

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 Sudden Infant Death Syndrome r/t inexperienced parent performance

Necessary Assessments/Interventions
Consider offering a pacifier during sleep times Lightly clothe the infant for sleep; avoid over bundling and overheating the infant Position infant supine to sleep; do not position prone or sidelying Use an electronic thermometer in the axilla of infants under 4 weeks for routine temperature checks Keep head covered Keep infant covered during procedures, transport and diagnostic testing

Rationale
Use of pacifier was associated with decreased incidence of SIDS (Moon et al, 2012) Overheating the infant has been associated with increased risk of SIDS (Mitchell et al, 2008). More than 70% of incidences happened when infant was prone or side-lying position (Ostfeld et al, 2010). Combination of smaller body surface area, smaller body fluid volume, immature temperature control mechanisms and small amount of body fat limits infants ability to maintain normal temperatures (NICE, 2007).

Ineffective thermoregulation r/t immaturity of neuroendocrine system aeb warm to touch

Mitchell, E., et al. (2008). Head covering and the risk for SIDS: Findings from the New Zealand and German SIDS case-controlled studies. Pediatrics, 121(6), 1478-1483. Moon, R., et al. (2012). Pacifier use and SIDS: Evidence for a consistently reduced risk. Journal of Maternal Child Health, 16(3), 609-612. National Institute for Health and Clinical Excellence (NICE). (2007). Feverish illness in children. Retrieved from: http:/www.nice.org.uk/cg047 Ostfeld, B., et al. (2010). Concurrent risks in sudden infant death syndrome. Pediatrics, 125(3), 447-453.