Newborn Assessment

Perinatal History: Collection of background information about the newborn's condition before birth.
Prenatal Records: Documentation of the mother’s health and medical history during pregnancy.
Birth Records: Official documents that provide details regarding the delivery and newborn specifics.
Physical Examination: Detailed inspection of the newborn's body systems.
Apgar Score: A standardized scoring system used to evaluate a newborn's physical condition at 1 and 5 minutes after birth.
Vital Signs/Pain Assessment:
- Measurement of blood pressure, temperature, pulse, respiratory rate, and pulse oximetry.
- Assessment of pain levels.
Measurements: Includes birth weight, current weight, length, and chest circumference.
Head to Toe Assessment: Comprehensive physical assessment performed at admission, as well as ongoing shift interval assessments.
Gestational Age Determination: Assessment of the newborn's maturity level based on specific criteria.

Date of Assessment: [To be filled out]
Physical Assessment Parameters: Criteria used in the assessment
- Relevant Labs: Results of laboratory tests that are either pending or complete.
- Vital Signs:
- Blood Pressure
- Temperature
- Pulse
- Respiratory rate
- Pain levels
- Behavioral State and Posture: Observations regarding the newborn's level of consciousness, comfort, and muscle tone.
- Measurements:
- Birth weight, current weight
- Length
- Chest circumference
- Skin Assessment: Inspection for color, texture, and turgor.
- Head and Neck Examination: Assessment of facial structures and clavicles.
- Chest Examination: Auscultation of heart and lung sounds.
- Abdomen Examination: Inspection for distension or other abnormalities.
- Extremities:
- Upper and lower extremities assessment.
- Genitals: Evaluation of external genitalia.
- Back and Buttocks: Checking for any abnormalities.
- Neuromuscular/Reflexes: Assessment of reflex responses.
- Feeding: Documentation of feeding type and frequency.
- Voids and Stools: Recording information regarding urination and bowel movements.
Findings: Record any normal or abnormal findings in the narrative nursing note section.

General Survey: Assessment includes:
- State of Alertness
- Color
- Muscle Tone (Flaccid, Flexed?)
- Signs of Respiratory Distress (Grunting, Flaring, Retracting)

Normal Score: 7-10
Criteria Breakdown:
- Heart Rate:
- 0: Absent
- 1: <100 beats/min
- 2: >100 beats/min
- Respirations:
- 0: Absent
- 1: Weak cry
- 2: Strong cry
- Muscle Tone:
- 0: Limp
- 1: Some bending
- 2: Active motion
- Reflex Irritability:
- 0: No response
- 1: Grimace
- 2: Cry
- Color:
- 0: Blue or pale
- 1: Body pink, arms and legs blue
- 2: Completely pink

Temperature: Measured either axillary or rectally; normal range:
- 36.5-37.5 °C (97.7-99.5 °F).
Pulse:
- Measured apically for 1 minute; normal rate: 110-160 bpm (rate and rhythm should be noted).
Respirations:
- Measured for 1 minute; normal range: 30-60 breaths per minute.
Blood Pressure: Measured only as necessary; typically:
- Birth: 65-95/30-60.
Pulse Oximetry: Should be above 95% after the first 15 minutes of life; checked if resuscitation was needed or if indicated.
Pain: Assess using pain scales such as NIPS or PIPP.

Color: Normal skin tones should be noted and variations.
Texture: Assessment of smoothness, dryness, or rash.
Turgor: To assess hydration.
Variations:
- Vernix Caseosa: A protective coating present at birth.
- Acrocyanosis: Bluish discoloration of extremities.
- Central Cyanosis: Look for discoloration, especially inside the mouth.
- Birthmarks:
- Milia: Small, white cysts.
- Jaundice: Yellowing of the skin.
- Lanugo: Fine hair present at birth.
- Erythema Toxicum: Common rash in newborns.
Birthmarks and Lesions:
- Slate Grey Patches (Mongolian Spots): Fade over 3-5 years.
- Hemangiomas: Types include superficial or deep varieties, with different characteristics and implications for treatment.

General Head Assessment:
- Inspection of head shape, fontanelles, and molding.
Features Examined:
- Eyes: Placement, color, discharge, etc.
- Ears: Placement, shape, firmness, skin tags noted.
- Nose: Patency and structure.
- Mouth: Inspection for clefts, Epstein's pearls, and feeding capabilities.
Neck: Assessment of range of motion (ROM) and any abnormalities.

Symmetry: Evaluation for equality of limb lengths and movement capabilities.
Flexion: Assess the ability to bend joints appropriately.
Neurological Assessments: including reflex testing.
Genitalia: Inspection for normal anatomy and any abnormalities (e.g., epispadias, hypospadias).

Rooting Reflex: Newborn turns towards the stimulus on the cheek to suck.
Sucking Reflex: Sucking action when the mouth roof is touched.
Tonic Neck Reflex: Positioning in response to neck turning, resembling a fencing position.
Grasping Reflex: Firmly grasping an object placed in the palm.
Babinski Reflex: Toes fan out when the sole is stroked.
Moro Reflex (Startle): Symmetric extension of arms in response to noise/movement.
Stepping Reflex: A little walking motion when the feet touch a surface.

Criteria used include:
- Neuromuscular Characteristics: Assessment of posture, square window sign, recoil ability, popliteal angle, scarf sign, heel-to-ear extension.
- Physical Characteristics: Evaluation of skin, lanugo, plantar creases, breast bud development, and ear/genitalia formation.