CEBU TECHNOLOGICAL UNIVERSITY

In consortium with
CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING
N. Bacalso Ave. corPanganiban 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: J.D
b. Age 4 days
c. Sex M
d. Civil Status
e. Educational Attainment
f. Address
g. Significant Other J.D , M.D
h. Medical Diagnosis
N/A

II. CHIEF COMPLAINTS

Alive and well, female neonate

III. HISTORY OF PRESENT ILLNESS

IV. GENOGRAM

V. LABORATORY/DIAGNOSTIC STUDIES

Diagnostic Test

Date of Examination: August 27, 2019

Laboratory Normal Value Result Nursing Significance

WBC 10.0-20.0 L 9.0
Hemoglobin 136-196 190
Hematocrit 50-58% 0.57
Platelet 84-478 216
Differential Count
Segmenters 0.55-0.65% L 0.51
Lymphocytes 0.30-0.35% H 0.36
Monocytes 0.03-0.06% H 0.08
Eosinophil 0.02-0.04% 0.04
Basophil 0.00-0.01 0.01

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 -pale & yellowish, warm & dry
o State of -Non-responsive to unpleasant external stimuli and
o alertness/responsiveness internal stimuli
ASPECT CLINICAL ASSESSMENT FINDINGS
o Activity -abnormal sleeping pattern; not being breastfeed every
2 hours
o Range of spontaneous
o Movement
o Posture
o Muscle tone -Flimsy muscle tone
Growth status Weight -2800 grams
and feeding Length -48cm
Head Circumference -31cm
Abdominal Girth -29cm
Skin  Color -pale & yellowish
 Trauma -no signs of trauma

 Congenital or subcutaneous skin lesions -no lesions on congenital and subcutaneous skin

 Edema -no signs of edema

Head  Shape and symmetry Molding
 Scalp Molding

 Anterior and posterior fontanelle Soft

 Sutures Normal growth

No scalp lacerations/lesions
 Scalp lacerations/lesions
Face  Symmetry of structures, features and movement Face symmetrical, no involuntary movement
 Eyes
o Size and structure Round and symmetrical
o Position in relation to the nasal bridge Midline

o Red eye reflex Positive red eye reflex

 Nose
o Position and symmetry of the nares and Nares symmetrical and septum in the middle
septum
 Mouth
o Size, symmetry and movement Symmetrical, no involuntary movement
o Shape and structure
 Gums Pinkish

 Lips Pinkish

 Palate (hard/soft) Pinkish

 Tongue/frenulum Pinkish
 Ears
o Position Upper pinna same level of the canthus of the eye
o Structure including patency of the external No bony external meatus

auditory meatus
o Well-formed cartilage yes
 Jaw size Recessed chin
Neck  Structure and symmetry Neck is short and symmetrical
 Range of movement Able to turn head

 Thyroid and other masses No masses

Shoulders, arms and  Length Bilaterally equal
hands  Proportions Proportionally equal

 Symmetry Symmetrical

 Structure an number of digits Symmetrical structure and complete number of digits

Chest, cardio-respiratory  Chest
o Chest size, shape and symmetry
Enlarged and engorged breasts
o Breast tissue Breast tissue equally distributed
ASPECT CLINICAL ASSESSMENT FINDINGS
o Number and position of nipples Two nipples and are bilaterally symmetrical
 Respiratory
o Chest movement and effort with respiration Bilaterally synchronous chest movement
6:00 AM: 50 cpm
o Respiratory rate
8:00 AM: 48 cpm
12:00 NN: 47 cpm
No abnormal breath sounds
o Breath sounds
 Cardiac 6:00 AM: 125 bpm
8:00 am: 126 bpm
o Pulse – brachial and femoral
12 nn: 120 bpm

Yellowish
6:00 AM: 125 bpm
o Skin color/perfusion 8:00 am: 126 bpm
o Heart rate 12 nn: 120 bpm

Lubdub
Clicked hyper-resonance sound

o Heart rhythm
o Heart sounds
Abdomen  Shape and symmetry Prominent in supine position
 Palpate for enlargement of liver, spleen, kidneys and Soft; no masses
bladder
 Bowel sounds Normal bowel sounds

 Umbilicus including number of arteries and vein Pink; no discharges, odor/ redness; AVA

 Tenderness No tenderness
Genitourinary  Has the newborn passed urine? -Yes
 Male Genital
o Penis including foreskin -Intact, Fair to brown in color

o Testes (confirm present bilaterally and position -Intact, dark brown in color, no discoloration

of testes) including any discoloration

o Scrotal size and color -Dark brown in color
-No masses present
o Other masses such as hydrocele
 Female Genital
o Clitoris
o Labia
o Hymen
Anus  Has the newborn passed meconium? -Yes
 Anal position -At midline, below spine

 Anal patency -No obstruction and patent

Back  Spinal column -At midline
 Scapulae and buttocks for symmetry -Same in size , bilaterally symmetrical, no deformation

 Skin -fair
Neurologic  Moro reflex -Good
 Suck reflex -Poor

 Grasp reflex -Good

 Tonic neck reflex -Good

-Good
 Babinski
-Not applicable
 Step reflex
-Poor
 Rooting reflex
-Good
 Truncalincurvation reflex
VII. ANATOMY AND PHYSIOLOGY
a. Macro Anatomy

b. Micro Anatomy

c. Physiology
The liver is classed as a gland and associated with many functions. The major functions of the liver include:
 Bile production: Bile helps the small intestine break down and absorb fats, cholesterol, and some vitamins. Bile consists of bile salts,
cholesterol, bilirubin, electrolytes, and water.
 Absorbing and metabolizing bilirubin: Bilirubin is formed by the breakdown of hemoglobin. The iron released from hemoglobin is stored in
the liver or bone marrow and used to make the next generation of blood cells.
 Supporting blood clots: Vitamin K is necessary for the creation of certain coagulants that help clot the blood. Bile is essential for vitamin K
absorption and is created in the liver. If the liver does not produce enough bile, clotting factors cannot be produced.
 Fat metabolization: Bile breaks down fats and makes them easier to digest.
 Metabolizing carbohydrates: Carbohydrates are stored in the liver, where they are broken down into glucose and siphoned into the
bloodstream to maintain normal glucose levels. They are stored as glycogen and released whenever a quick burst of energy is needed.
 Vitamin and mineral storage: The liver stores vitamins A, D, E, K, and B12. It keeps significant amounts of these vitamins stored. In some
cases, several years' worth of vitamins is held as a backup. The liver stores iron from hemoglobin in the form of ferritin, ready to make new red
blood cells. The liver also stores and releases copper.
 Helps metabolize proteins: Bile helps break down proteins for digestion.
 Filters the blood: The liver filters and removes compounds from the body, including hormones, such as estrogen and aldosterone, and
compounds from outside the body, including alcohol and other drugs.
 Immunological function: The liver is part of the mononuclear phagocyte system. It contains high numbers of Kupffer cells that are involved
in immune activity. These cells destroy any disease-causing agents that might enter the liver through the gut.
 Production of albumin: Albumin is the most common protein in blood serum. It transports fatty acids and steroid hormones to help maintain
the correct pressure and prevent the leaking of blood vessels.
 Synthesis of angiotensinogen: This hormone raises blood pressure by narrowing the blood vessels when alerted by production of an
enzyme called renin in the kidneys.
 VIII. PATHOPHYSIOLOGY
a. Definition

JAUNDICE
Definition
a medical condition with yellowing of the skin or whites of the eyes, arising from excess of the pigment bilirubin and typically caused by
obstruction of the bile duct, by liver disease, or by excessive breakdown of red blood cells.

Risk factors
Major risk factors for jaundice, particularly severe jaundice that can cause complications, include:
 Premature birth.
 A baby born before 38 weeks of gestation may not be able to process bilirubin as quickly as full-term babies do.
 Significant bruising during birth.
 Blood type.
 Breast-feeding.
 Diagnostic studies and Possible results.

d. Medical-Surgical Management

Medical Surgical and Pharmalogic Management

PHOTOTHERAPY
 The Newborns are generally scheduled for phototherapy when the total serum bilirubin rises to 15 mg/dL at 25-28 hours of age.
 Continuous exposure to bright lights this way may be harmful to the newborns retina , so the infants eyes must always be covered while
under bilirubin lights. Eye dressings or cotton bolls can firmly secure in place by an infant mask.
 Phototherapy is treatment with a special type of light (not sunlight). It's sometimes used to treat newborn jaundice by lowering the bilirubin
levels in your baby's blood through a process called photo-oxidation.This makes it easier for your baby's liver to break down and remove
the bilirubin from their blood.

Risk factors for Phototherapy:

 Damaging of infants retina if not properly covered
 Causing of brown skin

e. Pharmacologic Management
f. Diagram/Concept Map

Diagram
 g. 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.

h. 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

i. DISCHARGE PLAN

b. Demographic Data
Name: J.D
Age: 4days old
Sex: M
Address: C.Padilla, Duljo
Significant Other: J.D , M.D
Medical Diagnosis: Alive baby male neonate delivered via NSVD

c. General Objective
After 45 minutes of nurse- client interaction, the client will be able to acquire the knowledge, attitude, and skills towards
maintaining health.

d. Specific Objectives
After 45 minutes of nurse-client interaction, the client will be able to:
i. Identify signs and symptoms of jaundice
ii. Know that breastfeeding causes less stomach upset, diarrhea, and constipation than formula.
iii. Have adequate knowledge on breastfeeding

e. Medications

NAME OF THERAPEUTIC SIDE HEALTH

DOSAGE FREQUENCY
DRUG USE EFFECTS EDUCATION
 f. Environment
Should provide spaces that are safe, clean, and stimulating. Soft, thick floor coverings, such as vinyl mats, will help mobile
infants feel comfortable moving on the floor. Adding features such as tunnels to the environment will encourage further
development of motor skills and exploration.
g. Treatment
 Expose the baby’s skin to as much light as possible (phototherapy).

h. Health Teaching
 Watch your newborn for signs that jaundice is getting worse. Undress your baby and look at his or her skin closely two
times a day. For dark-skinned babies, look at the white part of the eyes to check for jaundice. If you think that your
baby's skin or the whites of the eyes are getting more yellow, call your doctor or nurse call line.
 Breastfeed your baby frequently (about 8 to 12 times or more in a 24-hour period). Extra fluids will help your baby's
liver get rid of the extra bilirubin.
 If you are using phototherapy to treat your baby at home, it is important that you understand how to use all the
equipment. Ask your health professional for help if you have questions

i. Observable Signs And Symptoms

Symptoms:
 A yellow tinge to the skin and the whites of the eyes, normally starting at the head and spreading down the body
 Itchiness
j. Diet
 Exclusive breastfeeding every 2 hours

k. Spiritual Care
 Encourage the family members to always put God first in everything and to trust in him.
 To pray and always ask for God’s guidance

__________________________________

Signature

Best for babies

Reduces incidence of allergies
Economical
Antibodies
Stool-inoffensive
Temperature always correct and constant
Fresh
Emotional bonding
Easy once established
Digested easily
Immediately available
Nutritionally balanced
Gastroenteritis greatly reduced