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N CLINICAL COMPETENCY EVALUATION

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					                  N263 CLINICAL COMPETENCY EVALUATION
                   HEAD TO TOE ASSESSMENT NEWBORN

Student Name: _______________________ Pt: ______Days old

General
      3 minute scrub, prevention of hypothermia.
      Check name band.
      Comments: ______________________________________________
Neurological
      Signs of ICP _____.
      Myotone: hypotonia, hypertonia, flexed, flaccid, rigid.
      Reflexes: sucking/rooting, palmar grasp, Moro, Babinski, plantar grasp,
      tonic neck, stepping.
      Pupils: equal, round, reactive to light & accommodation, pupil size _____.
      Cry: lusty_____, weak _____, other _____.
      Comments: _________________________________________________
Head
      Shape: molding, round.
      Fontanels: anterior, posterior, flat, buldging.
      Sutures: approximated, overriding, separated.
      Caput succedaneum, cephalohematoma.
      Facial shape: symmetry eyes, ears, nose.
      Mouth: palate intact_____, lips intact_____.
      Comments: ________________________________________________
Respiratory
      Respirations: rate _____ (30-60), quiet, regular & symmetrical.
      Work of breathing: grunting, flaring, retracting location _____.
      Sounds: anterior & posterior, clear, coarse, diminished, crackles, wheeze.
      Nailbeds color _____, mucous membranes color _____, moist, dry.
      Oxygen: cannula/mask _____L/min. None_____.
      Comments: ________________________________________________
Cardiovascular
      Auscultation: rate_____ (100-180), regular, irregular, mumur.
      Peripheral pulses: palpable, regular, strength.
      Skin: color _____, temperature _____, moisture, CRT____seconds.
      Comments: ________________________________________________
Gastrointestinal
      Bowel sounds: hypoactive, hyperactive, absent.
      Abdomen: soft, firm, flat, round, distended.
      Umbilicus: cord care _____, 3 vessel cord _____.
      Diet: breast _____, bottle _____, both _____.
      BM _____, color _____, consistency _____.
      Comments: ______________________________________________


8-4-09 DV file: N263OBclinical
Genitalia
      Female: swollen, vaginal discharge, white mucus, pink/bloody.
      Male: swollen, hydrocele, hypospadias, testes descended.
      Comments: _______________________________________________
Genitourinary
      Urine: void _____, color _____.
      Comments: ________________________________________________
Musculoskeletal
      Extremities: symmetrical, spontaneous movement. Palmar crease, club
      foot.
      Clavicle fracture.
      Hips: click_____, symmetrical gluteal & thig h creases_____.
      Pilonidal dimple _____.
      Toes & fingers: polydactyly, syndactyly.
      Activity: active ____, jittery ____, lethargic _____, sleeping ______.
      Comments: _______________________________________________
Integumentary
      Skin: color _______( pink, pale, acrocyanotic, cyanotic, mottled, plethoric,
      jaundice), temperature ______, moisture ______, turgor _____, intact,
      vernix, lanugo, meconium stained, peeling, bruising_____, edema_____.
      Marks/lesions: forceps, scalp electrode, petechaie ____, café au lait____,
      Mongolian spots ____, erythema toxicum _____, milia____.
      Comments: _______________________________________________
Psychosocial
      Evidence of bonding.
      Adoption.
      Social services needs.
      Comments: ________________________________________________
Pain
      NIPS: ______


          Observed all Overriding Concerns: Accountability, Therapeutic
          Communication, Physical Jeopardy, Emotional Jeopardy, Asepsis.

Instructor Comments:
________________________________________________________________
________________________________________________________________
________________________________________________________________

Results of Competency Examination: Passed               Did not Pass

Student’s Signature: ___________________________ Date: ____________

Instructor’s Signature: __________________________ Date: ____________


8-4-09 DV file: N263OBclinical

				
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