CHILD HEALTH NURSING

____________________________

NEWBORN
ASSESSMENT
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SUBMITTED TO SUBMITTED BY
Mrs. Rakhi Ghosh. Pritha Biswas
Senior Lecturer M.Sc (N) 1st yr
C.O.N., M.C.H C.O.N., M.C.H
Kolkata Kolkata
  Date of Assessment: 20/03/2024
 Place of Assessment: SSKM Medical College & Hospital

IDENTIFICATION DATA:
 Name : Mehjabeen Khatun
 Age of mother : 28 years
 Sex : Male
 Religion : Muslim
 Date of Birth : 16/3/24
 Time of Birth : 5:18 Pm
 Birth Weight : 2750 gms.
 Mode of Delivery : EmLUCS cause of oligohydramnios
 Apgar Score : At 1 min: 6 & At 5 min: 7
 Resuscitation done : Only initial steps done
 Registration No. : RG2400551184
 Under Dr. : Dr. S. Mukherjee, Dr. R Mukherjee,
Dr. U. Mondal, Dr. N Naskar
 Ward : SNCU
 Disk no : 450
 Name of Father : Md. Sahid
 Address : Santoshpur Padirhati Sekh Para,
P.S.- Rabindranagar, P.O.- Bidhangarh,
Dist.- South 24 Pargana
 Previous Obstetrical History : First Gravida
 History of present pregnancy : G1 P0 + 0
 LMP : 20/06/2023
 EDD : 27/03/2024
 Gestation : 39 weeks
 No. of Checkup : 4 times
 Blood group & Rh : B (+ve)
 Immunization : Injection TT 2 doses taken

Birth History:
 Antenatal : Iron and folic acid tablets taken & Injection TT
2 doses taken.
o No. of USG : Four times USG done.
o Other medications : Calcium 500 mg 1 Tab daily.
 : Baby delivered as a late preterm before 1 week.
 Natal

 Postnatal : Baby didn’t cry immediately after birth. After initial steps baby
cried. He had persistent labored breathing and hypothermia.
Oxygen was given to him and referred to SNCU.
On 2nd day of life, he had 4 episodes of vomiting. After that
IVF D10 6.8 ml/hr and IVF NS bolus 28 ml/hr given. After
that he was stable and on 3rd day OG feeding started.
Physical examination of the Neonate: (20/3/24)
 General Appearance
 Facial expression : Good
 Posture : Well flexed [ √ ] Asymmetry [ ]

 Activity level : Active [ √ ] Flaccid [ ]

 Personal hygiene
 Type of clothing
 Cry
: Maintained [ √ ] Not Maintained [ ]
: Stuffy [ ] Soiled [ ] Cotton [ √ ]
: Normal [√] Vigorous but stops on touching &
eye to eye contact [ ]
Vigorous and not stopping on touch [ ]

 General condition : Good [ √ ] Asphyxiated [ ] Poor [ ]

 Vital Signs:
 Temperature : 36.7˚ C

 Heart rate : 142 b / minute.

 Respiration : 66 breaths / minute.

 Blood Pressure (if required) : NA

 Anthropometry Measurement:
 Length : 48 Cm.
 Weight : 2695 gms.
 Head circumference : 34 Cm.
 Chest circumference : 30 Cm.
 Abdominal circumference : 28 Cm.
 Mid arm Circumference : 9 Cm
 Inspection of Skin:
 Color : Pink Colour [ √ ] Cyanosis [ ] Jaundice [ ]
 Turgor : Good [ √ ] Poor [ ]
 Cleanliness : Clean [ √ ] Dirty [ ]
 Hydration : Normal [ √ ] Dehydrated [ ]
 Vernex Caseosa : Absent or minimal [√ ] Excessive [ ]
 Lanugo: : Absent [ √ ] Excessive [ ]
 Inspection of Hair:
 Hair : Silky & smooth [ ] Course & rough [√ ]

Wooly / Fuzzy [ ]

 Examination of Head:

 Fontanels (Ant and Post)

o Size : Ant. fontanel - 2.5 x 3.5 Cm & Post fontanelle – 1.5 x 1.5cm
o Tension :NA
o Shunken :NA
 Sutures : Normal [ √ ] Widely Spaced [ ]
 Moulding : Present [ ] Absent [ √ ]
 Cephal Hematoma : Present [ ] Absent [ √ ]
 Caput Succedaneum : Present [ ] Absent [ √ ]

 Examination of Eyes:

 Eyes : Normal [ √ ] Relation with ear level [ ]

 Alignment : Good [ √ ] Poor [ ]
 Conjunctiva : Normal [ √ ] Infection present [ ]
Sub conjunctival hemorrhage [ ]
 Vision : Normal [√ ] Abnormal [ ]

 Examination of Nose:
 Shape : Shape Normal
 Nasal canal : Patent
 Nasal Septum Deviation : Not Present
 Examination of Mouth:
 Lips
 Palate
 Mouth/ Tongue
 Size of Chin
: Normal [√] Cleft lip [ ]
: High arched [√ ] Cleft palate [ ]
: Moves freely [√ ] Protruding tongue [ ]
Tongue tie [ ] Coated [ ] Moist [ √]
Epstein pearl [ ] Thrust [ ]
: Normal [√ ] Micrognathia [ ]

 Examination of Ears:
 Formation of cartilage : Good, easily recoil.
 Shape : Normal [√ ] Abnormal [ ]
 Pinna : Normal in shape [√ ] Smaller in shape [ ]
 Lobule : Fleshy [√] Thin [ ]

 Examination of Neck:

 Neck (Length) : Normal [√ ] Webbing of neck [ ] Torticollis [ ]

 Lymph Nodes : Palpable [ ] Not Palpable [ √ ]

 Inspection of the Chest:

 Chest movement : Symmetrical [√ ] Asymmetrical [ ]
 Breast size : Normal [ √ ] Premature size [ ]
Abnormality present [ ]
 Inspection of the Abdomen:
 Abdomen shape : Dome -shaped [√ ] Concave [ ]
 Bowels sound : Present [√ ] Absent [ ]
 Abdominal Distension : Soft [ √ ] Distended [ ]
 Umbilical cord : Normal [√ ] Bleeding present [ ]
Infection present [ ]
 Liver
: Palpable [ ] Not palpable [√ ]
 Spleen : Palpable [ ] Not palpable [ √ ]

 Inspection of Nails:

 Cyanosis : Present [ ] Absent [ √ ]

  Size : Long [ √ ] Ragged [ ]

 Dislocation of hip : Present [ ] Absent [√ ]

 Club foot : Varus [ ] Vulgus [ ] Absent [√ ]

 Inspection of Extremities:
 Movement : Equal & bilateral [√ ] Unequal & Unilateral [ ]
 Digits : Ten fingers & ten toes [√ ] Fusions of digits [ ]

 Length : Equal [√ ] Unequal [ ]

 Inspection of Back:

 Back spine : Intact [√ ] Not intact [ ]

 Spinal Curve Curvature : Normal [√ ] abnormal [ ]

 Spina bifida : Present [ ] Absent [ √ ]

 Inspection of the Genitalia:

 Genitalia (Boy)
o Boy : Normal [ √ ] Presence of abnormality [ ]
o Testes descending : Yes [√] No [ ]
o Rugae present : Yes [√] No [ ]
o Type of Rugae : Deep [√] Good [ ] Few [ ] No [ ]
o Scrotum : Normal [√] Empty [ ] Flat, smooth [ ]

 Observation of feeding behavior:

 Breast feeding : Yes [√ ] but EBM 35ml/ 2 hrly, No [ ]
 If No, the reasons : -
 Artificial feeding : NA
 Vomiting : No vomiting [ √ ] Vomiting < 2 times [ ]
Persistent vomiting [ ]
 Neuromuscular Observation:

 State of alertness : Active & Alert [ √ ] Lethargic [ ] Restless [ ]

 Muscle tone : Normal [√ ] Hypotonia [ ] Hypertonia [ ]
 Reflexes
o Sucking reflex : Normal [√ ] Weak [ ] Absent [ ]
o Rooting reflex : Normal [√ ] Weak [ ] Absent [ ]
o Moros reflex : Normal [ √ ] Weak [ ] Absent [ ]
o Dancing reflex : Normal [√ ] Weak [ ] Absent [ ]
o Grasping reflex : Normal [ √ ] Weak [ ] Absent [ ]
o Tonic neck reflex :Normal [ √ ] Weak [ ] Absent [ ]
o Babinski sign :Normal [ √ ] Weak [ ] Absent [ ]
o Glabellar tap : Normal [√ ] Weak [ ] Absent [ ]
Remarks / Impression:
Baby didn’t cry immediately after birth. After initial steps baby cried. He had persistent labored breathing
and hypothermia. Oxygen was given to him and referred to SNCU. On 2nd day of life, he had 4 episodes of
vomiting. After IVF D10 6.8 ml/hr and IVF NS bolus 28 ml/hr given. After that he was stable and on 3rd day
OG feeding started.

At present general condition is stable and moderately satisfied of this baby. Baby takes the breast feed
through EBM through katori-spoon. Baby also passes urine and stool normally. Her mother gives normal
care such as napkin changing, feeding, skin care. Mother follows all the instructions given by doctors and
nurses.