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    Newborn Assessment: GEN Activity Skin Head Resp GI Neuro

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    Raj Paul
    This document contains a newborn assessment form with various sections to document vital signs, measurements, and assessments of general appearance and activity, skin, head and neck, chest and respiratory, gastrointestinal, neurological, muscoskeletal systems, and areas for patient teaching and nursing notes. The form includes fields to document information such as temperature, heart rate, skin color, muscle tone, respiratory effort, bowel sounds, spinal alignment, range of motion, and reflexes.

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    Newborn Assessment: GEN Activity Skin Head Resp GI Neuro

    Uploaded by

    Raj Paul
    25 views36 pages
    This document contains a newborn assessment form with various sections to document vital signs, measurements, and assessments of general appearance and activity, skin, head and neck, chest and respiratory, gastrointestinal, neurological, muscoskeletal systems, and areas for patient teaching and nursing notes. The form includes fields to document information such as temperature, heart rate, skin color, muscle tone, respiratory effort, bowel sounds, spinal alignment, range of motion, and reflexes.

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    Original Title

    NEWBORN

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    This document contains a newborn assessment form with various sections to document vital signs, measurements, and assessments of general appearance and activity, skin, head and neck, chest and respiratory, gastrointestinal, neurological, muscoskeletal systems, and areas for patient teaching and nursing notes. The form includes fields to document information such as temperature, heart rate, skin color, muscle tone, respiratory effort, bowel sounds, spinal alignment, range of motion, and reflexes.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
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    25 views36 pages

    Newborn Assessment: GEN Activity Skin Head Resp GI Neuro

    Uploaded by

    Raj Paul
    This document contains a newborn assessment form with various sections to document vital signs, measurements, and assessments of general appearance and activity, skin, head and neck, chest and respiratory, gastrointestinal, neurological, muscoskeletal systems, and areas for patient teaching and nursing notes. The form includes fields to document information such as temperature, heart rate, skin color, muscle tone, respiratory effort, bowel sounds, spinal alignment, range of motion, and reflexes.

    Copyright:

    © All Rights Reserved
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    of 36

    NEWBORN ASSESSMENT

    GEN ACTIVITY SKIN HEAD RESP GI NEURO

    See nursing notes


    NEWBORN ASSESSMENT : See nursing notes

    GENERAL ASSESSMENT :

    VITAL SIGNS : TEMP HR RR B/P

    MEASUREMENTS :

    WEIGHT : lb oz

    LENGTH : in cm

    GESTATIONAL AGE :

    GENERAL ASSESSMENT NOTES :


    MSK TEACHING

    No assessment required at this time See


    nursing notes

    HEAD CIRCUMFERENCE : cm

    CHEST CIRCUMFERENCE : cm
    GENERAL ACTIVITY

    GEN ACTIVITY SKIN HEAD RESP GI NEURO

    GENERAL ACTIVITY : See nursing notes


    See nursing notes

    MOVEMENT : Active Alert

    TONE : Flexed Poor

    CRY : Lusty Weak

    SLEEP : Alert Asleep

    GENERAL ACTIVITY NOTES :


    MSK TEACHING

    No assessment required at this time See


    nursing notes

    Symmetric

    Flaccid Jittery `

    Absent High-pitched
    SKIN ASSESSMENT

    GEN ACTIVITY SKIN HEAD RESP GI NEURO

    SKIN ASSESSMENT : See nursing notes


    See nursing notes

    COLOR: Pink Pale Rash

    TURGOR: Good Loose Tenting `

    TEMP: Warm Hot Cool Cold core

    CHARACTERISTICS: Lanugo Vernix

    BIRTHMARKS : Present Not Present

    MONGOLIAN SPOTS : Present Not Present

    SKIN NOTES :
    MSK TEACHING

    No assessment required at this time See


    nursing notes

    Jaundiced Cyanotic Acrocyanosis Other

    Cold core
    HEAD & NECK

    GEN ACTIVITY SKIN HEAD RESP GI NEURO

    HEAD & NECK : See nursing notes


    See nursing notes

    HEAD : Molding Forceps marks

    FACIAL MOVEMENT : Asymmetri


    Symmetric
    c

    EYES :

    POSITION/SPACING : Even Wide-set

    PUPILS : Round Equal in size Other

    DISCHARGE : No tears Tears Yellow

    POSITION OF EARS : Even Low-set

    NARES : Patent Not-Patent

    MOUTH : Patent Other


    Patent Other

    MUCOUS MEMBRANES : Pink Moist Dry

    HEAD & NECK NOTES :


    MSK TEACHING

    No assessment required at this time See


    nursing notes

    Other Lesions

    Closely-set

    Other

    Yellow
    Dry Sticky Pale
    CHEST/RESPIRATORY

    GEN ACTIVITY SKIN HEAD RESP GI NEURO

    CHEST/RESPIRATORY: See nursing notes


    See nursing notes

    SHAPE : Asymmetri
    Symmetric
    c

    NIPPLES : Two Supranumerary

    HEART RHYTHM : Regular Irregular

    RESPIRATORY EFFORT: Easy Retractions

    RESPIRATORY CARE NOTES:


    MSK TEACHING

    No assessment required at this time See


    nursing notes

    Breat tissue Discharge

    Murmur Extra Sounds Other

    Nasal flaring Grunting Periods of apnea


    GASTROINTESTINAL

    GEN ACTIVITY SKIN HEAD RESP GI NEURO

    GASTROINTESTINAL : See nursing notes


    See nursing notes

    SHAPE : Asymmetri
    Symmetric
    c

    UMBILLICAL CORD : 3 vessels Other

    BOWEL SOUNDS : Present Absent

    GASTROINTESTINAL CARE NOTES:


    MSK TEACHING

    No assessment required at this time See


    nursing notes

    Round Scaphoid

    Clamp Drainage
    NEUROLOGICAL:

    GEN ACTIVITY SKIN HEAD RESP GI NEURO

    NEUROLOGICAL : See nursing notes


    See nursing notes

    SPINE : Intact Straight

    NEUROLOGICAL CARE NOTES :


    MSK TEACHING

    No assessment required at this time See


    nursing notes

    Curved Other
    MUSCULOSKELETAL

    GEN ACTIVITY SKIN HEAD RESP GI NEURO

    MUSCULOSKELETAL : See nursing notes


    See nursing notes

    UPPER EXTREMITIES :

    RANGE OF MOTION (ROM) : Full ROM Limited ROM

    DIGITS : 5 Right 5 Left

    LOWER EXTREMITIES :

    RANGE OF MOTION (ROM) : Full ROM Limited ROM

    DIGITS : 5 Right 5 Left

    CLAVICLES : Intact Crepitus

    HIPS : No Click Right hip clicks

    REFLEXES : Gag Rooting


    Rooting

    MUSCULOSKELETAL CARE NOTES :


    MSK TEACHING

    No assessment required at this time See


    nursing notes

    Limited ROM

    5 Left Other

    Limited ROM

    5 Left Other

    Crepitus

    Right hip clicks Left hip clicks Both hips click

    Sucking Grasp Babinski


    Sucking Grasp Babinski
    PATIENT TEACHING

    GEN ACTIVITY SKIN HEAD RESP GI NEURO

    PATIENT TEACHING :
    MSK TEACHING

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