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  • In Consortium With N. Bacalso Ave. Cor Panganiban ST., 6000 Cebu City, Cebu, Philippines Tel. Nos. (032) 316-5128/ (032) 4186105 Email Address

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    Carl Jayson Leyson
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    This document contains an assessment tool for newborns with various sections: 1. Demographic data and chief complaints 2. History and exam including genogram, lab results, physical assessment of various body systems 3. Sections on anatomy, physiology, pathophysiology, nursing diagnoses, medications, and care plan The physical assessment section includes an extensive list of aspects to examine on the newborn including general appearance, growth, skin, head, face, neck, extremities, respiratory, cardiac, abdomen, genitals, back, and neurologic assessment.

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    ASSESSMENT-TOOL-nursery-1

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    This document contains an assessment tool for newborns with various sections: 1. Demographic data and chief complaints 2. History and exam including genogram, lab results, physical assessment of various body systems 3. Sections on anatomy, physiology, pathophysiology, nursing diagnoses, medications, and care plan The physical assessment section includes an extensive list of aspects to examine on the newborn including general appearance, growth, skin, head, face, neck, extremities, respiratory, cardiac, abdomen, genitals, back, and neurologic assessment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    22 views5 pages

    In Consortium With N. Bacalso Ave. Cor Panganiban ST., 6000 Cebu City, Cebu, Philippines Tel. Nos. (032) 316-5128/ (032) 4186105 Email Address

    Uploaded by

    Carl Jayson Leyson
    This document contains an assessment tool for newborns with various sections: 1. Demographic data and chief complaints 2. History and exam including genogram, lab results, physical assessment of various body systems 3. Sections on anatomy, physiology, pathophysiology, nursing diagnoses, medications, and care plan The physical assessment section includes an extensive list of aspects to examine on the newborn including general appearance, growth, skin, head, face, neck, extremities, respiratory, cardiac, abdomen, genitals, back, and neurologic assessment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 5

    CEBU TECHNOLOGICAL UNIVERSITY

    In consortium with
    CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING
    N. Bacalso Ave. cor Panganiban St., 6000 Cebu City, Cebu, Philippines
    Tel. Nos. (032)316-5128/(032) 4186105
    Email address: ctuccmc_cn@ymail.com

    ASSESSMENT TOOL

    I. DEMOGRAPHIC DATA
    a. Name
    b. Age
    c. Sex
    d. Civil Status
    e. Educational Attainment
    f. Address
    g. Significant Other
    h. Medical Diagnosis

    II. CHIEF COMPLAINTS

    III. HISTORY OF PRESENT ILLNESS

    IV. GENOGRAM

    V. LABORATORY/DIAGNOSTIC STUDIES

    Diagnostic Test

    Date of Examination

    Laboratory Normal Value Result Nursing Significance


    VI. ASSESSMENT

    NEWBORN ASSESSMENT TOOL

    Physical Examination

    ASPECT CLINICAL ASSESSMENT FINDINGS


    General Appearance  While the newborn is quiet, alert, not hungry or
    crying observe:
    o Skin color/warmth/perfusion
    o State of
    o alertness/responsiveness
    o Activity
    o Range of spontaneous
    o Movement
    o Posture
    o Muscle tone
    Growth status Weight
    and feeding Length
    Head Circumference
    Abdominal Girth
    Skin  Color
     Trauma
     Congenital or subcutaneous skin lesions
     Edema
    Head  Shape and symmetry
     Scalp
     Anterior and posterior fontanelle
     Sutures
     Scalp lacerations/lesions
    Face  Symmetry of structures, features and movement
     Eyes
    o Size and structure
    o Position in relation to the nasal bridge
    o Red eye reflex
     Nose
    o Position and symmetry of the nares and
    septum
     Mouth
    o Size, symmetry and movement
    o Shape and structure
     Gums
     Lips
     Palate (hard/soft)
     Tongue/frenulum
     Ears
    o Position
    o Structure including patency of the external
    auditory meatus
    o Well-formed cartilage
     Jaw size
    Neck  Structure and symmetry
     Range of movement
    ASPECT CLINICAL ASSESSMENT FINDINGS
     Thyroid and other masses
    Shoulders, arms and  Length
    hands  Proportions
     Symmetry
     Structure an number of digits
    Chest, cardio-respiratory  Chest
    o Chest size, shape and symmetry
    o Breast tissue
    o Number and position of nipples
     Respiratory
    o Chest movement and effort with
    respiration
    o Respiratory rate
    o Breath sounds
     Cardiac
    o Pulse – brachial and femoral
    o Skin color/perfusion
    o Heart rate
    o Heart rhythm
    o Heart sounds
    Abdomen  Shape and symmetry
     Palpate for enlargement of liver, spleen, kidneys
    and bladder
     Bowel sounds
     Umbilicus including number of arteries and vein
     Tenderness
    Genitourinary  Has the newborn passed urine?
     Male Genital
    o Penis including foreskin
    o Testes (confirm present bilaterally and
    position of testes) including any
    discoloration
    o Scrotal size and color
    o Other masses such as hydrocele
     Female Genital
    o Clitoris
    o Labia
    o Hymen
    Anus  Has the newborn passed meconium?
     Anal position
     Anal patency
    Back  Spinal column
     Scapulae and buttocks for symmetry
     Skin
    Neurologic  Moro reflex
     Suck reflex
     Grasp reflex
     Tonic neck reflex
    ASPECT CLINICAL ASSESSMENT FINDINGS
     Babinski
     Step reflex
     Rooting reflex
     Truncal incurvation reflex

    VII. ANATOMY AND PHYSIOLOGY


    a. Macro Anatomy

    b. Micro Anatomy

    c. Physiology

    VIII. PATHOPHYSIOLOGY
    a. Definition
    b. Risk Factors
    c. Diagnostic Studies and Its Possible Results
    d. Medical-Surgical Management
    e. Pharmacologic Management
    f. Diagram/Concept Map

    IX. SUMMARY OF FINDINGS

    LEGEND CUES
    ROS

    ASSESSMENT

    LABORATORY FINDINGS

    ACTUAL NSG DX RISK/POTENTIAL NSG DX WELLNESS NSG DX


    1. 1. 1.
    2. 2. 2.
    3. 3. 3.
    4. 4. 4.
    5. 5. 5.

    X. DRUG STUDY

    Dosage, Route Contra- Mechanism of Drug-to-Drug Adverse Nursing


    Name of Drug Indication
    and Frequency indication Action Interaction Effects Responsibility
    Generic Name:

    Brand Name:

    Therapeutic
    Classification:

    MEDICATION
    TICKET

    XI. NURSING CARE PLAN

    NURSING GOAL OF NURSING


    DATE CUES SCIENTIFIC BASIS RATIONALE EVALUATION
    DIAGNOSIS CARE INTERVENTION
    ROS Definition Of The INDEPENDENT
    Nursing Dx

    Assessment DEPENDENT
    Pathophysiological
    Basis

    COLLABORATIVE
    Diagnostic
    Studies Rationale

    XII. DISCHARGE PLAN

    a. Demographic Data

    b. General Objective

    c. Specific Objectives

    d. Medications

    NAME OF THERAPEUTIC SIDE HEALTH


    DOSAGE FREQUENCY
    DRUG USE EFFECTS EDUCATION

    e. Environment

    f. Treatment

    g. Health Teaching

    h. Observable Signs And Symptoms

    i. Diet

    j. Spiritual Care

    __________________________________

    Signature

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