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    Patient Initials: - Room #: - : Newborn Assessment

    Uploaded by

    hjr
    This document contains a newborn assessment form with sections to record the newborn's vital signs, physical exam findings, feeding and elimination, maternal and delivery history, laboratory tests and results, nursing actions, medications, and intake and output. Key details include the newborn's heart rate, respiratory rate and effort, skin appearance, muscle tone, reflexes, feeding amount and frequency, and initial laboratory tests including blood type, glucose, and screening tests.

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    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd

    Patient Initials: - Room #: - : Newborn Assessment

    Uploaded by

    hjr
    3K views1 page
    This document contains a newborn assessment form with sections to record the newborn's vital signs, physical exam findings, feeding and elimination, maternal and delivery history, laboratory tests and results, nursing actions, medications, and intake and output. Key details include the newborn's heart rate, respiratory rate and effort, skin appearance, muscle tone, reflexes, feeding amount and frequency, and initial laboratory tests including blood type, glucose, and screening tests.

    Original Description:

    Postpartum Assessment Sheet

    Original Title

    Cheat Sheet

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    © Attribution Non-Commercial (BY-NC)

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    This document contains a newborn assessment form with sections to record the newborn's vital signs, physical exam findings, feeding and elimination, maternal and delivery history, laboratory tests and results, nursing actions, medications, and intake and output. Key details include the newborn's heart rate, respiratory rate and effort, skin appearance, muscle tone, reflexes, feeding amount and frequency, and initial laboratory tests including blood type, glucose, and screening tests.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    3K views1 page

    Patient Initials: - Room #: - : Newborn Assessment

    Uploaded by

    hjr
    This document contains a newborn assessment form with sections to record the newborn's vital signs, physical exam findings, feeding and elimination, maternal and delivery history, laboratory tests and results, nursing actions, medications, and intake and output. Key details include the newborn's heart rate, respiratory rate and effort, skin appearance, muscle tone, reflexes, feeding amount and frequency, and initial laboratory tests including blood type, glucose, and screening tests.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    Newborn Assessment

    BP: ________ T ______ P______ R____


    BP: ________ T ______ P______ R____
    Heart: Regular irregular
    Tachycardic
    Bradycardic (normal 110-160)
    Respi: Labored regular unlabored tachyneic dyspneic (normal 30-60cpm)
    With O2 inhalation? Yes No _____LPM via _______ NGT? _____________
    Lung sound: clear diminished crackles wheeze Bowel Sounds:_______
    Head (fontanel):____________ Ears:_______________ Eyes:__________
    Mouth:_______ Chest:________ Skin color:_________ patho phys jaundice
    Umbilicus (cord): clamped unclamped dry intact wet odor drainage_______
    Circumcised? Yes No describe:______________________________________

    Patient Initials: _____________ Room #: _______


    DOB: ________ Age: ____ Status: ____ Religion: _________
    Height: __________ Weight: ________ Blood Type: ______
    Allergies: ____________________________________________
    Diet: ______________ Activity: ______________________________
    Restriction/precaution:_____________________________________
    Admission
    Date: ______________
    AP/0B: _______________ PED: ____________ NB: ______________
    Reason for Admission: _____________________________________
    ________________________________________________________
    ________________________________________________________
    Health History:
    ________________________________________________________
    ________________________________________________________
    Maternal Data
    G __ P__ ( AB __ Pt __ T __ L __ )
    Obstetrical History: GDM PIH Hypotension Clotting problems
    ________________________________________________________
    ________________________________________________________
    Complications during pregnancy? Yes No What: _______________
    Complications during labor? Yes No
    What: ________________
    Induction of Labor? Yes or No Medicine Used: _________________
    Delivery Date: ___________ Time: _____ AOG:____ Gender:_____
    CS type: ________________ NSVD (Epis,lacera) ________________
    NB: Voided: ____ Stool: ___ Apgar 1___ 5____ Ht:______ Wt: ____
    Feeding: ____________
    With anesthesia? Yes No Type used: _________________________
    EBL: _______ Additional Surgery:_____________________________
    Assessment
    Maternal time__:__
    BP: ________ T ______ P______ R____ O2 Sat: ___
    BP: ________ T ______ P______ R____ O2 Sat: ___
    Heart: Regular irregular
    Tachycardic
    Bradycardic
    Resp: Labored regular unlabored tachyneic dyspneic
    With O2 inhalation? Yes No _____LPM via ____________________
    Lung sound: clear diminished crackles wheeze
    Cough: present productive non productive
    Breast: Soft Filling Engorged other:__________________________
    Nipple: norm flat evert invert flat sore cracked other: _________
    Abdomen: firm tense distended tender
    Bowel sounds: normoactive hypo hyper absent BM:____ Flatus?____
    Fundus: firm massaged to firm boggy Location:________________
    What used for incision closure? Staples steri strips glue ___________
    Dressing: dry intact removed wet describe:___________________
    Incision: R E E D A other:___________________________________
    How many times changed pads? __ Scant Moderate Heavy ________
    Done with first 2 voids? Yes No Amount/ Charac: _______________
    Catheter Amount/ Charac: _________________________________
    Varicosities? Yes No Loca/descrptn:___________________________
    Edema? Yes No Loca/descrptn: _______________________________
    DTR: absent 1+sluggish,dull 2+active/normal 3+brisk 4+briskw/clonus
    Clonus? Yes No Homans sign: Yes No Anus:____________________

    Labs
    Test
    Hgb/ Hct
    ABO
    Rh
    Hep B
    Rubella
    GBS
    RPR/VDRL
    PPD
    Blood
    other

    Date Taken:
    Patient Value

    Normal Range

    Significance

    Labs
    Test
    Rh
    RPR
    Coombs
    Hgb/Hct
    others

    3hr

    Normal Range

    NURSING ACTIONS
    Time

    Assessment

    Medications
    Ordered date
    Name

    Intervention

    Freq/dosage/
    route

    Ordered date
    Name

    Freq/dosage/
    route

    Newborns I&O
    Time

    1hr

    Date Taken:
    Patient Value

    Void

    Stool

    Feeding

    Amount

    L (time)

    R (time)

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