INITIAL ASSESSMENT (Anthropometric Measurement and Vital Signs Taking) AND

BATHING OF THE NEWBORN

Purposes
1. To initially assess the newborn with the following:
a. Record the anthropometric measurement
b. Record the vital signs
2. To cleanse the newborn.

Materials/ Equipment Needed

1. Weighing Scale 8. Clean crib linens used in the hospital
2. Tape Measure 9. Trash bag
3. Stethoscope 10. Baby soap
4. Thermometer 11. Fine comb or brush
5. Pan of warm (98.6 o F or 37 o C) water 12. Cotton balls and swab
6. Clean clothes and diaper 13. Watch or clock with second hand
7. Soft cloth, or other clean materials 14. Sterile water or normal saline

Time Frame

At the end of 10 minutes, the students can demonstrate

Assessment

1. Assess the newborn anthropometry and vital signs.

2. Assess the initial condition of the newborn skin, and note the presence of vernix
caseosa.
3. Assess for the room temperature, approximately 75 o F (24 oC) to prevent chilling.
4. Assess for the presence of meconium , and if anus is patent.
5. Assess for any deviation from normal.
6. Assess for the presence of mucus and secretions.

Nursing Diagnosis

1. Risk for infection related to cross-contamination of equipment, poor hygienic practices

and poor hand washing
2. Risk for impaired skin, integrity, related to too much rubbing of the skin
3. Risk for injury
4. Risk for Hypothermia

Outcome Identification and Planning

1. Proper hand washing remains the mainstay of infection control.

2. Strict medical aseptic technique should be employed since newborn have few defense
mechanism to combat microorganism.
3. Items and other equipment should be placed out of the newborn’s reach or premises.
4. The room should be warm, appropriately 24 o C (75 o F).
5. Use mild soap when bathing the newborn.
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 6. Each body area should be dried, and after washing before proceeding to the next area
to prevent heat loss from evaporation.
Desired Outcomes

1. The newborn will maintain normal body temperature.

2. The newborn will be free from any signs and symptoms of infection.
3. The newborn will maintain normal skin integrity.
4. The newborn will be free from any injury.

Implementation

Nursing Action Rationale

1. Assemble all needed supplies and equipment
before starting the procedure.
2. Wash hands thoroughly before beginning the  Minimize transmission of bacteria.
procedure. Use individual equipment and a
modified isolation technique.
3. Obtain the weight of the newborn.  Infant may lose 5% - 10% of birth
weight because of minimal intake of
nutrients and fluids and loss of
excess fluid from urine/meconium.
4. Place the newborn on a safe flat surface.
5. Do not leave the baby unattended for even a  To prevent falling and avoid any
moment once you begin the procedure. possible injury.
6. Measure the newborn anthropometry with the
following:
a. Head Circumference
b. Chest Circumference
c. Abdominal Circumference
d. Crown Heel Length
7. Check the newborn’svital signs which include:  The use of rectal thermometer
a. respiration predisposes to irritation of rectal
b. apical pulse mucosa.
c. body temperature.
8. Wrap the newborn in a towel.
*Note: For normal bathing, undress the newborn
before bath, then wrap in a towel.
9. Keep the baby warm and secure, support
during the procedure.
10. Assess the newborn during the bath, note any
abnormal color, blemishes, or rashes on the skin.
Observes muscles for abnormal jerking or
twitching. Check the genitals of the female baby
for bleeding or discharges. Observes for any
congenital abnormalities.
11. Begin the bath by wiping each eye using a  Start from cleanest area to most
clean cotton balls, dammed with a clear water soiled.
only. Stroke from the inner to outer corner of

35
each eye using a clean cotton for each eye.
12. Wipe the rest of the face with a soft cloth.  Face is sensitive to soap and can
Gently wash the face without soap. Include irritate the skin.
behind and inside the ears. Pat the face dry.
13. Pick the baby using a football hold and  Prevent cradle cap from forming
position the baby’s head over the water basin. especially over the frontal areas.
Lather the scalp using small amount of mild  To loose and remove blood.
soap, massage gently into the scalp. Do not rub
vigorously. Comb hair to loosen and to remove
blood. Rinse the hair thoroughly and gently into
the scalp dry the head with a towel and return the
newborn to the radiant warmer.
14. Wash, soap and rinse and dry each arm and  Exposes folds for more thorough
hands. Avoid excessive rubbing. Pay particular cleansing.
attention to the folds of the skin especially the
axilla and dry thoroughly.
15. Wash, soap, rinse and dry baby’s chest, neck,  Excessive rubbing can cause skin
abdomen. Be sure to remove blood from folds of irritation and moisture can cause
the neck. Pat dry. Keep baby covered between excoriation of the skin. Air current
washing and rinsing. increases loss of heat.
16. Roll baby onto his side, wash, rinse and dry
his back.
17. Wash, soap, rinse and pat dry baby’s legs and
feet. Expose one leg and feet. Expose one at a
time.
Bath the genital region. When cleaning the genital area, assess for presence of rashes or
irritation. Wipe vernix and secretions on the folds of the thigh.
18. For Female Genital: Clean the vulva and  Always start from cleanest areas to
perineum with clean cotton balls. Then separate the most soiled minimizes
the labia and wipe with clean cotton balls from colonization of bacteria. Cleansing
front to back to remove secretions, as well as to from front to back prevents bacterial
avoid bacterial contamination from vaginal area contamination.
and rectum.
19. For Male Genital: For uncircumcised, do  Foreskin in newborn is tight for
not retract the foreskin, clean the penis and retraction, may cause edema and
scrotum with clean cotton balls. constriction.
20. Bath the buttocks using a gentle motion.
Keep area clean & dry to prevent diaper rash.
Grab both baby’s ankles and raise feet to elevate
the buttocks. Wash, soap and rinse and dry the
area with wash cloth.
21. Inspect umbilical cord, check for bleeding or  Area is susceptible to skin
foul odor. Clean cord stump with sterile water/ breakdown because of acid reaction
normal saline or according to hospital policy. Do of urine and feces.
not cover the umbilical cord.
22. Dress the newborn, fold the diaper below the  To prevent contamination from urine
cord stump and wrap in the blanket, place on the and feces.
crib under a warmer.

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 23. Return/ Discard all the materials used.
24. Wash hands after the procedure and before  To prevent cross contamination.
touching any other babies.
25. Document the procedure done amd other
pertinent findings. (e.g. anthropometric
measurement, vital signs and any other deviation
from normal)
Evaluation
1. Newborn’s vital signs are within normal.
2. Newborn is free from infection.
3. Newborn’s skin is normal.
4. Newborn is free from injury.

Documentation
The following should be noted in the client’s chart:
1. Document response of the newborn to the procedure.
2. Record any pertinent data.

References:
 Engstrom, J. (2004).Maternal-Neonatal Nursing, Made Incredibly Easy. Lippincott
Williams & Wilkins.
 Pilliteri. A. (2007) Care of the Child Bearing and Child Rearing Family. 5th Edition.
Lippincott Williams & wilkins.
 Doenges, H. & M. (2006). Nurses Pocket Guide Diagnoses Prioritized Intervention
and Rationale. 10th Edition.
 Smith T., Jean & Johnson, Young,J. ( 2006). Nurses Guide to Clinical Procedures. 5 th
Edition, Philadelphia: Lippincott Williams & Wilkin.
 Nettina S.M. (2001). The Lippincott Manual of Nursing Practice. 7 th Edition.
Lippincott: Williams & Wilkins.
 Udan Q. J. ( 2004) Mastering Fundamentals of Nursing Concepts and Clinical
Application 2nd Edition. Educational Publishing House.
 Woodring,B.C. (2005) Pediatric Nursing Made Incredibly Easy. Lippincott Williams
& Wilkins.

INITIAL ASSESSMENT (Anthropometric Measurement and Vital Signs Taking) AND

BATHING OF THE NEWBORN

37
 NURSING ACTIONS YES NO REMARKS
1. Assemble all needed supplies and equipment before starting
the procedure.
2. Wash hands thoroughly before beginning the procedure. Use
individual equipment and a modified isolation technique.
3. Obtain the weight of the newborn. Normal Weight is 2,500
grams to 4,000 grams.
4. Place the newborn on a safe flat surface.
5. Do not leave the baby unattended for even a moment once
you begin the procedure.
6. Measure the head circumference of the newborn. Ave. 33-
35cm
7. Measure the chest circumference of the newborn. Ave. 30-33
cm
8. Measure the abdominal circumference of the newborn.
9. Measure the crown heel length of the newborn. Ave. 46-56
cm.
10. Check the newborn’s respiration rate. 30- 60 respirations /
min
11. Check the newborn’s apical pulse rate. 120-160 bpm
12. Check the newborn’s body temperature.. 36.5 - 37.5 °C
13. Wrap the newborn in a towel.

*Note: For normal bathing, undress the newborn before bath,

then wrap in a towel.
14. Keep the baby warm and secure, support during the
procedure.
15. Assess the newborn during the bath, note any abnormal
color, blemishes, or rashes on the skin. Observes muscles for
abnormal jerking or twitching. Check the genitals of the female
baby for bleeding or discharges. Observe for any congenital
abnormalities.
16. Begin the baby by wiping each eye using a clean cotton
balls, dammed with clear water only. Stroke from the inner to
outer corner of each eye using clean cotton for each eye.
17. Wipe the rest of the face with a soft cloth. Gently wash the
face without soap. Include behind and inside the ears. Pat the
face dry.
18. Pick the baby using a football hold and position the baby’s
head over the water basin. Lather the scalp using small amount
of mild soap, massage gently into the scalp. Do not rub
vigorously. Comb hair to loosen and to remove blood. Rinse
the hair thoroughly and gently into the scalp dry the head with a
towel and return the newborn to the radiant warmer.
19. Wash, soap, rinse and dry each arm and hands. Avoid
excessive rubbing. Pay particular attention to the folds of the

38
skin especially the axilla and dry thoroughly.
20. Wash, soap, rinse and dry baby’s chest, neck, abdomen. Be
sure to remove blood from folds of the neck. Pat dry. Keep baby
covered between washing and rinsing.
21. Roll baby onto his side, wash, rinse and dry his back.
22. Wash, soap, rinse and pat dry baby’s legs and feet. Expose
one leg and feet. Expose one at a time.
Bath the genital region. When cleaning the genital area, assess
for presence of rashes or irritation. Wipe vernix and secretions
on the folds of the thigh.
23. For Female Genital: Clean the vulva and perineum with
clean cotton balls. Then separate the labia and wipe with clean
cotton balls from front to back to remove secretions, as well as
to avoid bacterial contamination from vaginal area and rectum.
24. For Male Genital: For uncircumcised, do not retract the
foreskin, clean the penis and scrotum with clean cotton balls.
25. Bath the buttocks using a gentle motion. Keep area clean
and dry to prevent diaper rash. Grab both baby’s ankles and
raise feet to elevate the buttocks. Wash soap and rinse and dry
the area with wash cloth.
26. Inspect umbilical cord, check for bleeding or foul odor.
Clean cord stump with sterile water/ normal saline or according
to hospital policy. Do not cover the umbilical cord.
27. Dress the newborn, fold the diaper below the cord stump
and wrap in the blanket, place on the crib under a warmer.
28. Return/ Discard all the materials used.
29. Wash hands after the procedureand before touching any
other babies.
30. Document the procedure done and other pertinent findings.
Total : 30 ITEMS

30= 1.0
29= 1.25
Total Score :_________________
27-28= 1.5
25- 25= 1.75
23-24= 2.0 Rating: _____________________
21-22= 2.25
20= 2.5 Student Signature : ____________
19= 2.75
18= 3.0 C.I. Signature : _________________
17- 16= 3.25
15 = 5.0 Date : _____________________

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