Newborn Assessment

BP: ________ T ______ P______ R____

BP: ________ T ______ P______ R____
Heart: Regular irregular
Tachycardic
Bradycardic (normal 110-160)
Respi: Labored regular unlabored tachyneic dyspneic (normal 30-60cpm)
With O2 inhalation? Yes No _____LPM via _______ NGT? _____________
Lung sound: clear diminished crackles wheeze Bowel Sounds:_______
Head (fontanel):____________ Ears:_______________ Eyes:__________
Mouth:_______ Chest:________ Skin color:_________ patho phys jaundice
Umbilicus (cord): clamped unclamped dry intact wet odor drainage_______
Circumcised? Yes No describe:______________________________________

Patient Initials: _____________ Room #: _______

DOB: ________ Age: ____ Status: ____ Religion: _________
Height: __________ Weight: ________ Blood Type: ______
Allergies: ____________________________________________
Diet: ______________ Activity: ______________________________
Restriction/precaution:_____________________________________
Admission
Date: ______________
AP/0B: _______________ PED: ____________ NB: ______________
Reason for Admission: _____________________________________
________________________________________________________
________________________________________________________
Health History:
________________________________________________________
________________________________________________________
Maternal Data
G __ P__ ( AB __ Pt __ T __ L __ )
Obstetrical History: GDM PIH Hypotension Clotting problems
________________________________________________________
________________________________________________________
Complications during pregnancy? Yes No What: _______________
Complications during labor? Yes No
What: ________________
Induction of Labor? Yes or No Medicine Used: _________________
Delivery Date: ___________ Time: _____ AOG:____ Gender:_____
CS type: ________________ NSVD (Epis,lacera) ________________
NB: Voided: ____ Stool: ___ Apgar 1___ 5____ Ht:______ Wt: ____
Feeding: ____________
With anesthesia? Yes No Type used: _________________________
EBL: _______ Additional Surgery:_____________________________
Assessment
Maternal time__:__
BP: ________ T ______ P______ R____ O2 Sat: ___
BP: ________ T ______ P______ R____ O2 Sat: ___
Heart: Regular irregular
Tachycardic
Bradycardic
Resp: Labored regular unlabored tachyneic dyspneic
With O2 inhalation? Yes No _____LPM via ____________________
Lung sound: clear diminished crackles wheeze
Cough: present productive non productive
Breast: Soft Filling Engorged other:__________________________
Nipple: norm flat evert invert flat sore cracked other: _________
Abdomen: firm tense distended tender
Bowel sounds: normoactive hypo hyper absent BM:____ Flatus?____
Fundus: firm massaged to firm boggy Location:________________
What used for incision closure? Staples steri strips glue ___________
Dressing: dry intact removed wet describe:___________________
Incision: R E E D A other:___________________________________
How many times changed pads? __ Scant Moderate Heavy ________
Done with first 2 voids? Yes No Amount/ Charac: _______________
Catheter Amount/ Charac: _________________________________
Varicosities? Yes No Loca/descrptn:___________________________
Edema? Yes No Loca/descrptn: _______________________________
DTR: absent 1+sluggish,dull 2+active/normal 3+brisk 4+briskw/clonus
Clonus? Yes No Homans sign: Yes No Anus:____________________

Labs
Test
Hgb/ Hct
ABO
Rh
Hep B
Rubella
GBS
RPR/VDRL
PPD
Blood
other

Date Taken:
Patient Value

Normal Range

Significance

Labs
Test
Rh
RPR
Coombs
Hgb/Hct
others

3hr

Normal Range

NURSING ACTIONS
Time

Assessment

Medications
Ordered date
Name

Intervention

Freq/dosage/
route

Ordered date
Name

Freq/dosage/
route

Newborns I&O
Time

1hr

Date Taken:
Patient Value

Void

Stool

Feeding

Amount

L (time)

R (time)