Newborn Assessment

NEW BORN ASSESSMENT FORMAT

I      Identification date:

            a. Name:

            b. Age:

            c. Date of Birth:                                             Time:

            d. Sex:

            e. Hospital Number:

            f. Date of Admission:

            g. Birth Weight:

            h. Father name:

            i. Mother’s Name:

II    History:

a. Antenatal History:

            b. Intranatal History:

            c. Postnatal History:

            d. Family History (if significant):

III  Physical Assessment :

a. Biological Assessment :

Length:  …………………      Weight:  ………………….

Head circumference:  ……………………… Chest circumference:  ………

Mid arm circumference: …………………

Abdominal circumference:  …………….

Skin co lour

Vital Signs

       - Temp

       - Heart rate

       - Respiration

Activity

Spontaneous Activity:

Working State (Active, alert, crying):

Sleep State:

Cry:

Brest feeding

b. Head to foot examination:

Area	Findings of Baby	Normal Result
Head Appearance: Over riding of suture Moulding: Fontanelles: Hair texture: Presence of caput: Face Appearance: Eyes: Any hemorrhage: Presence of Tears Size & reaction of pupils: Cornea & Sclera: Visual response: Ears: Size and shape: Hearing: Nose: Nares Presence of Milia Mouth & Throat: Any congenital deformity: Chest Symmetry of Chest: Chest abdominal Movements: Apical pulse Normur Location Pulse (peripheral) Abdomin Appearance (soft, distended) Liver Umbilical cord Extremeties Length (Equal/ Unequal) Number of fingers Number of toes Palmar creases Sole creases Muscle tone Spine Normal curvature Any deformity Genitatia Male Testis descended/not Any congenital deformity Time of first voiding Female Labia minora Labia majora Any discharge Reflexes More reflex Palmar grasp Plantar reflex Stepping reflex Sucking & Swallowing Reflex Traction reflex Blinking reflex

III Investigations

IV Treatment

V Remarks