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    Newborn Assessment OBG

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    Anish Veettiyankal
    This document outlines the format for a newborn case study and care plan. It includes sections for identification data, reason for hospitalization, family and medical history, assessments of the newborn including anthropometric measurements, a head-to-toe examination, immunization schedule, disease conditions, nursing care process, and conclusions. The case study format aims to provide a comprehensive overview of the newborn's condition, care needs, and family context.

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    Newborn Assessment OBG

    Uploaded by

    Anish Veettiyankal
    1K views6 pages
    This document outlines the format for a newborn case study and care plan. It includes sections for identification data, reason for hospitalization, family and medical history, assessments of the newborn including anthropometric measurements, a head-to-toe examination, immunization schedule, disease conditions, nursing care process, and conclusions. The case study format aims to provide a comprehensive overview of the newborn's condition, care needs, and family context.

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    Newborn Assessment OBG

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    This document outlines the format for a newborn case study and care plan. It includes sections for identification data, reason for hospitalization, family and medical history, assessments of the newborn including anthropometric measurements, a head-to-toe examination, immunization schedule, disease conditions, nursing care process, and conclusions. The case study format aims to provide a comprehensive overview of the newborn's condition, care needs, and family context.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views6 pages

    Newborn Assessment OBG

    Uploaded by

    Anish Veettiyankal
    This document outlines the format for a newborn case study and care plan. It includes sections for identification data, reason for hospitalization, family and medical history, assessments of the newborn including anthropometric measurements, a head-to-toe examination, immunization schedule, disease conditions, nursing care process, and conclusions. The case study format aims to provide a comprehensive overview of the newborn's condition, care needs, and family context.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 6

    UNITY ACADEMY OF EDUCATION

    College of nursing, manglaore



    Dept. of OBG

    Newborn Case study /Care Plan format

    I. Introduction
    II. Identification data
    Name :
    Age :
    Sex :
    I.P No. :
    Ward :
    Name of Mother :
    Age :
    Name of Father :
    Occupation :
    Religion :
    Date of Admission :
    Date of Delivery :
    Date of care started :
    Date of care ended :
    Diagnosis :
    Address :


    III. Reason for Hospitalization
    Admission
    Complaints

    IV. Socio economic History


    V. Family History
    1. Family Characteristics
    2. Family tree
    3. Family Medical History

    VI. Present Medical History
    VII. Present Surgical History
    VIII. Obstetrical History of Mother
    Past obstetrical History
    Present obstetrical History
    1
    st
    Trimester
    2
    nd
    Trimester
    3
    rd
    Trimester

    IX. Intranatal History
    Labour notes
    Time of onset of labour
    Membranes ruptured at
    Character of amniotic fluid
    Expulsive contraction started at
    Type of Labour
    Mode of Delivery

    Length of labour
    1
    st
    Stage
    2
    nd
    Stage
    3
    rd
    Stage
    Placental expulsion

    Condition of Baby
    Sex
    Weight
    Head circumference
    Chest circumference
    Length

    Apgar Score
    Sign Normal Value Baby value in
    1
    st
    minute
    Baby value in
    5
    th
    Minute
    Remark





    X. Immunization Scheduled
    Sl. No. Name of
    vaccine
    Dosage Route Book
    Picture
    Patient
    Picture







    XI. Newborn Assessment

    Anthropometric Measurement
    Head Circumference
    Chest Circumference
    Weight
    Length

    General Appearance
    Nourishment : Well Nourished/Malnourished
    Body Build : Normal /Thin Built
    Activity : Active /Lathargic/Sicky/Restless

    Posture: Normal /Extended posture/ flexion of head or extremities which rest
    on chest or abdomen.

    Skin: Colour : Pink/Jaundice/Cyanosis/Pallor Erythmatous/
    Acrocyanosis
    Vernix caseosa : Present/Absent
    Lanugo : Present/Absent

    Lesions :Mangolian spots/Milia/Erythma toxucum/Harlequin
    colour changes/ jaundic/harmonohogic
    rashes, pustules blisters.

    Texture : Tough/Smooth and soft
    Turgor : Loss of turgor
    Temperature : Warm/Hyperthermic/Chilled /Cool
    Moisture : Dry/Moist

    A) Head to Foot Examination:
    Head :
    Size and Shape : Normal /Cephal
    Haematoma/Assymetry/Microcephly/
    Hydrocephalus/Caput succedaneum
    Fontanelle :
    Anterior fontanelle : Normal/Buiging fantanelle/premature closure
    Posterior fantanelle depressed/Widely separated
    Hair : Normal /lack of lusture/smooth/thin and spares
    Face: : Normal appearance/moon face/asymmetrical facial
    features. Diffuse pigmentation/puffy face

    Eyes: Observation : Normal /Perirbital oedema.colour/exophthalmus /
    squint/nystagmus

    Conjunctiva : Normal/Dry/Wrinkeld/pale/ discharge
    Cornea : Normal /Dryness
    Sclera : White/lateness/redness
    Pupil : PEARLA

    Ears Position : Normal /Low set ears/ deformities
    Size and shape : Small/Large size
    Pinna : Flexible
    Drainage : Present or Absent

    Nose Appearance: : Nasal patency/flat nasal bridege/deviated
    nasal
    septum/nasal polyps/discharge/ flarring

    Mouth and throat Lips : Cleft lip/Normal /Dry/Cracked/Cyanosed
    Tongue : Normal /pale and flabby/tongue tie/short tongue
    Teeth : Natal Teeth
    Gums : Normal/ spongy/bleeding/swelling
    Palate : Cleft palate/epstien pearls

    Neck : Short Neck/Thick Neck
    Excess skin folds resistance to
    flex/Torticolis/webbing of neck

    Thorax and chest
    Inspection : Depressed sterum, wide spaced nipples
    Breast engorgement, witchs milk
    Shape :Stenal retractions intercostals/symmetrical
    retractions

    Chest wall movement : Symmetrical or Asymmetrical
    Respiratory rate.
    Depth of Respiration : Deep/Shallow
    Auscultation
    Breath sounds : Crackles, wheezing
    Persistent irregular periodic breath
    Apex beat: S1 S2 transient ajanesis on trying, dextro cardiac murmurs

    Abdomen
    Inspection :
    Size and shape : distended/flat/scaphoid
    Umblicus :
    Position of umbilical cord/ Colours/Small cord/cord bleeding/signs of infection
    Bowel sounds : Hyper peristalsis/ Paralyticilues

    Genitalia

    Male:
    Penis: Urethral opening, urination, epispadiasis, hypospadiasis
    Testis: Undescended testis, hydrocele, presence of rugae in the scrotum.
    Meconium from scrotum, torsion of testis, Ambigious genitalia, phimosis

    Female:
    Vaginal opening: Absent vagina
    Discharge/ Pseudomenstration
    Labia/clitoris : oedematous
    Urination
    Meconium from vagina
    Mass in labia
    Ambigious genitalia

    Anus and reetum

    Patency of anus, fissures or fistulas
    Rectal prolapse/perianal dermatis/ napkin rashes

    Extremities

    Deformities/fractures
    Limitation motion
    Knock knees/ Bowed legs
    Epiphyseal enlargement
    ROM, dislocation hip

    Fingers, Toes and Nails

    Ten fingures, Ten toes
    Nail: Pink/cyanosis/Capillary refilling
    Kolionychias/Syndactaly/Polydactaly/ Oslir nodes:
    Creases in the palms and soles

    Back and Spine

    Normal/Abnormal curvature/Neural tube defects/Lepemal tufts of hair/
    Dimples/Swelling or tenderness

    Reflexes

    Sucking, Rooting, Swallowing
    Pupillary, Corneal, Sneezing, Tonic neck, Startle Mord, palmar grasping, Glabellar,
    Dolls eye.

    XII. Anatomy & Physiology
    XIII. Disease condition
    XIV. Lab investigation & Medications
    XV. Nursing process
    XVI. Health Education
    XVII. Conclusion & bibliography

    *******************

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