Emily Kosmicki

Ferris State University School of Nursing NURS 341

Newborn Assessment

Newborn Physical Assessment Please use the following code: + = Present/normal 0= Not present NA = Not applicable

Admission data (This will be obtained from the babys chart!): Temp 37.4 HR 150 Resp 50 Bld glucose 56 APGAR Score 1 min-8 5 min-9 Resuscitation measures: towel stimulation, suction bulb Ilotycin 15:05 (time) Vit K 15:05 (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). 1 hour post-delivery infant vitals stable: HR 150, Resp 40, temp 37.1. Skin color pink throughout trunk and extremities. Cries noted as loud and strong. Infant currently skin-to-skin with mom, breast-feed attempted 1x on left nipple. Educated mom on breastfeeding, verbalized understanding. Length 21.5 inches Wt. 9lbs 14 ounces

Emily Kosmicki

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 37.2

HR 140 Pale 0

Resp 50 Mottles 0 Acrocyanosis 0 Abrasions + Milia 0 Dry + Plethoric 0

Color: Pink + Jaundice 0

Stained 0

Skin: Clear + Pressure marks + Ecchymosis 0 Rash 0 Petechiae 0 Vernix 0

Nevi 0

Lanugo 0

Mongolian spots 0 Abdominal 0 Other NA Retracting 0

Respirations: Regular + Shallow 0

Grunting 0 Sighing 0

Nasal flaring 0

Cry: Lusty + Weak 0

Shrill 0

Head: Symmerty/shape + Molding + Cephalhematoma 0 Caput succedaneum 0 ISE mark 0 Other NA

Anterior fontanel: Flat + Full 0 Depressed 0 Posterior fontanel: Flat + Full 0 Sutures Coronal Sagittal Overriding 0 + Depressed 0 Separated 0 0 Approximated + 0

Emily Kosmicki

Lambdoidal

Ears: (describe exact location & how you determined if it was normal) Position: Normal + Abnormal 0 Describe normal position: Bilat symmetry noted in ears, shape and color consistent throughout bilat Skin tags 0 Nose: Symmetry + Flaring 0 Patent: Left + Right + Eyes: No edema or discharge noted. Symmetric bilat. Blue sclera noted bilat with red reflex present. Right Subconjunctive hemorrhage Nevi on lids Edema Red reflex Other 0 0 0 0 NA Left 0 0 0 0 NA

Mouth: Mucous membranes: Pink + Pale 0 Cyanotic 0 Teeth 0 Epsteins pearls 0

Hard palate: Intact + Abnormal NA Soft palate: Intact + Abnormal NA

Emily Kosmicki

Lips: Cleft 0 Drooping 0 Symmetry + Anterior chest: Symmetrical + Shape: No barrel chest noted Clavicles: Intact + Fracture 0 Breasts: Palpable tissue + Engorgement 0 Heart sound: RRR 0 Other NA

Genitals: Voided: Date NA Time NA Color of urine NA Male: Urethral orifice: Normal position NA Abnormal (describe) NA Testes (#/location) NA Scrotum NA Pendulous NA Rugated NA Other NA Female: Labia majora: Completely covers minora + Partially covers minora 0 Labia minora protruding 0 Vaginal discharge 0 Hymenal tag 0 Posterior: Pilonidal dimple 0 Truft of hair0 Spinal column: Symmetry + Intact 0 Anal patency: unknown, no BM yet Anterior Abd: Symmetry + Other NA Cord: # of vessels 2 arteries, 1 vein Protruding base 0 Stool No Type NA

Emily Kosmicki

Extremities: Right Symmetry Movement Digits (number) Flexion creases Palmar creases Sole creases Hips: Intact Right Left + + Dislocated/subluxation 0 0 + + 5 + + + Left + + 5 + + +

Neuro-muscular: Tone: Normal + Lethargic 0 Rigid 0 Tremors 0

Emily Kosmicki

Reflexes: Reflex: Rooting: Baby made kissing face/made an oval mouth Sucking: Baby began sucking on gloved finger Moro: Baby stretched out hands above head making C shape with hands Stepping: I did not observe this reflex being tested Grasp/hand: Baby was able to grasp an adult finger when placed in palm of hand Grasp/foot: Toes fanned apart and footprint(s) were obtained Describe the procedures Touch cheek to prompt head turn Describe normal responses Baby will turn toward cheek that was touched and begin to make sucking face Baby will open mouth and began sucking on gloved finger Baby will move arms outward and flexes knees while making a C shape with hands Baby will make a walking motion while being fully supported at chest Baby will close fingers around adults finger when placed in palm

Nurse will stick clean, gloved hand inside babys mouth Lay baby on back, move arms above head to arch back then release babys arms Hold the baby upright and forward so that feet touch a flat surface Place finger in palm of babys hand- left and right

Stroked lateral sole of foot from heel to ball of foot

Toes fan out when stimulus applied from heel to ball of foot

What is your overall assessment and prognosis for this infant (do not say good): Since birth, babys vital signs have remained WNL. Heart and lung sounds clear with no variables noted. Mom has attempted breastfeeding x2, with successful latch at each attempt after several minutes of nipple stimulation and education and encouragement from nurse. Cries continue to be lusty. Color remains pink throughout trunk and extremities. Baby currently sleeping in basinet with hat and swaddled in blanket. Expected to d/c from hospital 48 hours post-delivery.

Emily Kosmicki

Nursing Diagnosis

Necessary Assessments/Interventions Nurse will:

Assess coordination of infants suck, swallow, and gag reflex Provide opportunities for skin to skin care Implement pacing for infants having difficulty coordinating breathing with sucking and swallowing Help to properly position infant for optimal feeding (Ladwig, 2011)

Rationale
An article by Dewey, Nommsen-Rivers, Heinig, & Cohen (2003) discusses the complications that are often associated with infant feeding patterns (breast-feeding), Early lactation success is strongly influenced by parity, but may also be affected by potentially modifiable factors such as delivery mode, duration of labor, labor medications, use of nonbreast milk fluids and/or pacifiers, and maternal overweight (p. 607) The role of the nurse is to educate and provide the mother support so that she may breast-feed her baby if she chooses to do so. Grover, Berkowitz, Lewis, Thompson, Berry, & Seidel (1994) reported in a study that the infants immature autonomic thermoregulatory responses, larger body surface area to mass ratio, immature sweating, and limited ability to move away from or modify adverse environments all limit thermoregulation ability (p. 672).

Ineffective infant feeding pattern r/t oral hypersensitivity (breastfeeding)

(Ladwig, 2011)

Nurse will: Ineffective thermoregulation r/t immaturity (Ladwig, 2011) Measure and record patients axillary temperate q4 or as needed Use same site for temperature assessment to assess accurately Recognize that pediatric clients have decreased ability to adapt to temperature changes Keep head covered and use blankets to keep baby warm (Ladwig, 2011)

Nurse will: Follow meticulous hand hygiene when working with newborns Encourage early enteral feeding with breast milk Carefully wash and pat dry skin, including skin folds Educate and encourage all that interact with newborn on proper hand hygiene (Ladwig, 2011)

Risk for infection r/t inadequate acquired immunity

(Ladwig, 2011)

Although research by Pessoa-Silva et al (2007) can not directly prove that increase in education in hand washing alone decreased the rate of infection among NICU patients, they believe that, this study disclosed that hand hygiene promotion was independently associated with a significant decrease in infection risk among the most fragile pediatric population, VLBW neonates, and represents a step forward toward improved neonatal care (p. e388).

Emily Kosmicki

References Dewey, K., Nommsen-Rivers, L., Heinig, M., & Cohen, R. (2003). Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics, 112(3), 607-619. Grover, G., Berkowitz, C., Lewis, R., Thompson, M., Berry, L., & Seidel, J. (1994). The effects of bundling on infant temperature. Pediatrics, 94(5), 669-673. Ladwig, G., & Ackley, B. (2011). Mosbys guide to nursing diagnosis. (3rd ed.). Maryland Heights, MS: Mosby Elsevier. Pessoa-Silva, C., Hugonnet, S., Pfister, R., Touveneau, S., Dharan, S., Posfay-Barbe, K., & Pittet, D. (2007). Reduction of health care associated infection risk in neonates by successful hand hygiene promotion. Pediatrics, 120(2), e382-90.

Emily Kosmicki

GRADING RUBRIC FOR OB OR NEWBORN ASSESSMENT

Below Expectations
A. Assessment (15 points) Assessment has >12 blank spaces, has poor analysis B. Nursing diagnosis (0 points) Does not complete the care plan

Needs Improvement
(20 points) Assessment has 9-12 blanks

Meets Expectations
(25 points) Assessment has 5-8 blank spaces, analysis need to be more in depth (15 points) Chooses 1-2 appropriate nursing diagnoses based on the assessment (17 points) Chooses 2-3 appropriate nursing interventions for each diagnosis (15 points) Stated appropriate rationales for nursing interventions for each diagnosis with citation from websites or textbook. (7 points) <5 errors in APA, 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 from nursing journals (10 points) APA format is excellent; no errors in grammar or spelling; ideas are clearly presented

(10 points) Chooses inappropriate nursing diagnoses based on the assessment (15 points) Has chosen inappropriate nursing interventions (15 points) Stated inappropriate rationales for nursing interventions

C. Interventions

(0 points) Does not have any interventions

D. Rationale for interventions

(0 points) Does not have any rationales for interventions

E. Grammar, spelling, & clarity of ideas

(2 points) >10 errors in APA, grammar or spelling; ideas are not clearly presented

(5 points) <10 errors in APA, grammar or spelling; ideas are almost always clearly presented