Document Sample
NEWBORN EXAM Powered By Docstoc
					                                               University of Washington
School of Nursing                                                                      Nurse-Midwifery Program

                                     NEWBORN EXAM: EXTENDED

                                             Newborn History Worksheet

Date of Exam:________________________

Student:_______________________________             Preceptor:_________________________________________

Maternal Hx: G:___ P:_________ Age:_____

Birth Date:_____________ Hour__________             Sex:_____ Wt:___________ Gestational Age:__________

Abnormalities of previous pregnancies (describe):

Significant medical, surgical gyn history:

AP course:

Medication during pregnancy:

Maternal Labs: Type & Rh______ HbsAG______ HIV______ Rubella_____ Serology______ TB screening_____


DELIVERY: Delivery Type______          Duration of 1st Stage_______ 2nd Stage_______

        Fluid color:_________       Membranes ruptured _____ hours prior to delivery

        Significant labor events:

        Medication/Anesthesia in labor:



APGAR____1 min ___5 min             Resuscitation:______________________________________________________

Cord gases: Arterial pH________ Venous pH___________ Meds given:_________________________________

Other lab:_____________________________________________________________________

Length_____________ HC_______________               Vital Signs: Temp._____Ax/Rect     Pulse____ Resp.______

Age at exam:___________ Posture & state:__________________________________________________________

D:\Docstoc\Working\pdf\293ecdaf-49ec-4df6-9b23-90bf89cd80eb.doc Page 1 of 4
                                                               Newborn Physical Examination
           Red         Acrocyanosis                               Milia
           Pink        Cyanosis_____________________________      Vernix ______________________________
           Pale        Jaundiced____________________________      Peeling______________________________
              Turgur:  Good         Fair     Poor___________________________________________________
           Mongolian Spots____________________________      Birth Marks_______________________________
             Breasts:  WNL          Engorged     Supernumery Nipples__________________________________
          Other: _______________________________________________________________________________________
Variations: Erythema Toxicum, telangiectasias, forcep marks Abnormality: Hemangiomas, circumoral/circumorbital cyanosis, pustules, many petechiae, plethora

          Head and Neck:
                  Face:        Symmetrical                Asymmetrical
                  Head:        WNL                        Molding                    Caput                   Hematoma
              Fontanels:       Flat                       Bulging                    Depressed               Posterior Closed
                Sutures:       Approximated               Overriding                 Wide Split
                  Neck:        WNL                        Webbing                    Mass                    Lymph Node Enlarged
Abnormalities: Cephalahematoma, microcephaly, hydrocephaly, craniotabes Face: prominent, narrow, flat forehead, micrognathia, paralysis. Neck: webbing
torticollis, lymph node enlargement

          Eyes: (Check symmetry, Iris, Sclera, PERRLA, Red Reflex)
           WNL                Other:
Variation: Strabismus, chemical conjunctivitis, subconjunctival hemorrhage. Abnormality: epicanthal fold, cataracts, bushy eyebrows, very long eyelashes, exudate,
setting-sun sign, jaundice, Brushfield’s spots:

          Ears:      (Check symmetry, Shape, Pinna formation, Hearing)
           WNL                Other:
          Variation: Periauricular sinus, overly prominent ears, Darwin’s tubercle, absent anthelix. Abnormality: large flabby ear; abnormal attachment

           Nares present & Patent                   Other:

          Mouth:       (Check symmetry, palate, lips/gums, tongue)
           WNL                Palate Intact            
          Variation: Epstein’s pearls, sucking tubercle, premature dentition. Abnormality: cleft palate, high palate arch, profuse saliva, tongue sores or thrush

                    Chest:         Symmetrical expansion                       Symmetrical breast placement
            Breath Sounds:         Bilateral   Clear                          Even        Easy                              Other:
                                   Grunting  Flaring                          Retracting
           Notes

                  Rhythm:                Regular                      Irregular                    Murmur:
            Femoral Pulses:              Right Present                Left Present                 Other:
           Notes

           Abdomen  Soft           Distended                        Firm             Scaphoid                Bowel sounds present
                   Umbilical Cord: ___Vessels                                         Anus Parent                   Meconium passed
           Other:
          Variation: Diastasis recti, umbilicus hernia. Abnormality: distention, ascites, umbilical discharge/odor.

          D:\Docstoc\Working\pdf\293ecdaf-49ec-4df6-9b23-90bf89cd80eb.doc Page 2 of 4
Genitourinary:           (Check scrotal size, testes, urethral opening, clitoral size, hymen)
   Male Genitalia:         WNL               NA              Other
 Female Genitalia:         WNL               NA              Other
 Voided                   Other:
Variation: Mucoid vaginal discharge, priapism, adherent foreskin. Abnormalities: epispadius, hypospadius, hydrocele.

Musculoskeletal:            (Check spinal curve, integrity, gluteal folds, trunk incurvation, leg length, movement, hip movement, finger movement, length,
number. Clavicles)
 Extremities WNL                                 Clavicles Intact                                Spinal Column WNL
 Symmetrical Gluteal Folds                       No Hip Click
 Other:
Variation: Bowed legs, pretibial edema. Abnormality: simian creases, syndactyly, polydactyly, fisted hands. Cysts, dimples, hair tufts, pilonidal sinus,
nevus flammeus, nevus pilosus, Dislocated hip, pes cavus, pes valgus, varus, rocker bottom feet.

                       State:          Crying                 Active & alert                                Quiet & Alert
                                      Lethargic              Jittery                                       Irritable
                 Tone:                WNL                    Hypotonic                                     Hypertonic
     Tonic Neck Reflex:               Present            Absent      Palmar Grasp Reflex:                   Present               Absent
          Moro Reflex:                Present            Absent             Rooting Reflex:                 Present               Absent
        Sucking Reflex:               Present            Absent           Babinski Reflex:                  Present               Absent
           Movements:                 All Well           Diminished          Plantar Grasp:                 Present               Absent

D:\Docstoc\Working\pdf\293ecdaf-49ec-4df6-9b23-90bf89cd80eb.doc Page 3 of 4
Physical                                                                                    SCORE   Record
Maturity           -1              0           1            2          3           4          5     Score
Sign                                                                                                Here
            Sticky friable    gelatinous smooth                  cracking
                                                       superficial          parchment leathery
SKIN        transparent       red                                pale areas deep
                                          pink visible peeling &/or                      cracked
                              translucent veins        rash, few rare veins cracking     wrinkled
                                                       veins                no vessels
Lanugo      none              sparse      abundant thinning      bald areas mostly
Plantar     heel-toe          >50 mm      no crease faint red    anterior   creases
Creases     40-50mm:-1                                marks      transverse over entire
            <40 mm: -2                                           crease     sole
Breast      imperceptible     barely      flat areola stippled   raised     full areola
                              perceptible no bud      areola 1-2 areola 3-4 5-10 mm
                                                      mm bud     mm bud     bud
EYE/ EAR Lids fused           lids open sl curved well-curved formed        thick
            loosely: -1       pinna flat pinna; soft pinna; soft and firm   cartilage
            tightly: -2       stays       slow recoil but ready  instant    ear stuff
                              folded                  recoil     recoil
Genitals    scrotum flat,     scrotum     testes in   testes     testes     testes
Male        smooth            empty faint upper       descending down good pendulous
                              rugae       canal rare few rugae   rugae      deep
                                          rugae                             rugae
Genitals    clitoris          prominent prominent majora &       majora     majora
Female      prominent &       clitoris &  clitoris &  minora     large      cover
            labia flat        small labia enlarging equally      minora     clitoris and
                              minora      minora      prominent  small      minora
                                                                           Total Physical
                                                                           Maturity Score

Score      -10      -5       0          5    10       15        20    25      30       35    40     45       50
Weeks       20      22       24        26    28       30        32    34      36       38    40     42       44

Gestational Age    By dates:_________ By Ultrasound:_________ By Exam:________

      Essentially normal term newborn

      Other


      Follows standard care and teaching

      Other

                   Observe for:

                                                           Student Signature:_________________________________
                                                           Preceptor Signature:_______________________________

D:\Docstoc\Working\pdf\293ecdaf-49ec-4df6-9b23-90bf89cd80eb.doc Page 4 of 4

Shared By: