LORMA COLLEGES CON TEMPLATE

PHYSICAL EXAMINATION
RELATED LEARNING EXPERIENCE

STUDENT NAME: BALLON, Karlo C. ROTATION:  7th Rotation AREA: Neonatal Intensive Care Unit (NICU)
YR LEVEL AND CLINICAL
SEC:  BSN 2-BETTY NEUMAN DATES:  July 5, 6, 7, 8, 9 12, 13, 14 INSTRUCTOR:  Marina Jumalon

A. GENERAL ASSESSMENT

Baby girl Wency was delivered. She did not cry

immediately after delivery. Based from the initial
assessment, the neonate appeared pale and
bluish, with weak pulses, poor perfusion with O2
Sat of 75, decreased capillary refill, and persistent
bradycardia with CR of 55. She has also minimal
response to stimuli and muscle tone and
respiration is absent. Because of the cord prolapse,
the newborn developed hypovolemic shock
secondary to acute blood loss. APGAR score was
checked which is interpreted by Nurse Guerly as
“Severely Depressed”.

B. SKIN, HAIR AND NAILS

- The neonate appeared pale and bluish. Skin
warm, dry, with low good turgor. Lanugo is seen
of fine hair, which is barely visible and
characteristic of the newborn period.

C. HEAD AND NECK

-Neonate’s has no scars, masses,
glandular or nodal enlargement. The
trachea, no deviation. Thyroid gland as
the patient swallows, no enlargement.

D. EYES AND EARS

- Conjunctivae is pink, sclerae white,
without jaundice. Ears and nose without
deformity, external tenderness or
discharge .Hearing intact bilaterally by
rough testing.

E. MOUTH, THROAT, NOSE AND SINUSES

-Patient’s lips are normally symmetrical, pink,

smooth, and moist. There are no growths, lumps, or
discoloration of the tissue. Teeth present, good
dental hygiene. Gums and mucous membranes pink
without bleeding, lesions or inflammation. Tongue
normal size and papillation, midline protrusion.
Tonsils not enlarged .
Palate elevates symmetrically, gag intac.

F. HEART AND NECK VESSELS

- Her Heart sounds were weak, and there were no
signs suggestive of congestive heart failure. Neck
supple with full range of motion (ROM). No masses
or tenderness.
G. ABDOMINAL ASSESSMENT
- No any masses or hernias.

H. EXTREMITIES

- Minimal response to
stimuli and muscle tone
No asymmetry or muscle
atrophy. No edema, or
superficial varicosities.
Plantar creases. These
are creases on the soles
of the feet. They can
range from absent to
covering the entire foot.

J. GENITALIA

- The size of the clitoris and

the labia were normal.

I. NEUROLOGIC
- A comprehensive
neurologic assessment
should be performed in any
newborn suspected to have
central or peripheral
nervous system dysfunction,
either based upon history.