West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City

Nursing Process

NEWBORN ASSESSMENT
i. Vital Information

Name: __________________ Date of Delivery: ___________________ Time of Delivery: _____________ Sex: ________ Address: _______________________________________________ Ordinal Position in the Family: _________ Parents: Mother: _________________ Father: __________________ OB AOG (based on LMP): Clinical AOG (Based ion the new Ballard Scoring): Type of Delivery: _____________________ Newborn Screening: ( )done ( ) not done
ii. Physical assessment

A. Measurements:

Birth weight: _________ Length: _________ Head circumference: _________ Chest Circumference: _________ Temperature: _________ APGAR Score: _________ Respiratory Rate: _________ Pulse Rate: _________

B. Clinical Inspection General Appearance:

a. Skin, Hair, Nails

b. Head, Face, Neck, Lymphatics

c. Eyes, Ears, Nose, Mouth & Throat

d. Chest, Breast, and Axilla

e. Thorax and lungs/ Respiratory System

f. Heart and Cardiovascular System

g. Abdomen/ Gastrointestinal System

h. Genitalia/ Genito-urinary System/ Anal Area

i. Upper/Lower Extremities/ Musculoskeletal System

j. Neurological Assessment

C. REFLEXES HOW ELICITED EVALUATION

REFLEXES

HOW ELICITED

EVALUATION

iii.Discharge plans and instructions a. Cord Care

b. Baby bath

c. Care of the eyes, ears, nose and mouth

d. Sunlight exposure

e. Babys Diet

f. Babys visit to the pediatrician

g. Clothing

h. Immunization

i. Newborn Screening Exam

j. Others

iv. Beliefs and Fallacies Nursing implication

Vi. Problem List