Newborn Assessment.docx - RN Program CLINICAL PHYSICAL...

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RN Program CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN NURSERY STUDENT NAME: Christopher Ralph Bataoil CLINICAL SITE/UNIT: FWB 2 South CLINICAL DATE: 12/13/17 PATIENT INTIALS: PC AGE: 32 Sex: Female RELIGION/CULTURE: NONE MATERNAL AND LABOR HISTORY: Maternal health history: Sickle Cell Anemia, Epilepsy, Gestational Diabetes, Polyhydramnios, Premature, Early onset of delivery. Growth/ Development Erickson: Piaget: LMP: Unknown EDC: 3/22/17 Labor onset: date & time: 12/12/17 at 1244 ROM date & time: Color: African American Delivery date & time & type: 12/12/17 @ 1257 Maternal health history: Sickle Cell Anemia, Epilepsy, Gestational Diabetes, Polyhydramnios, Premature Birth, Early onset of delivery Labor complications: Seizure during Labor, Other Exercise Bleeding, Fetal Intolerance, Anesthetic Complications, Dysfunctional Labor, Seizure during Labor, Abruptio Placenta,
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Placenta Previa, Cephalopelvic Disproportion, Shoulder Dystocia, Chrorioamniosnitis, Failure to progress in the first stage, Other excessive bleeding, Maternal Fever, Mild Preeclampsia, Severe Preeclampsia, HELLP, Eclampsia, Precipitous Labor, Incompetent Cervix, Premature rupture membranes, Uterine Dehiscence, Uterine inversion, Uterine rupture, Tachysystole, Prolong second stage >2 hours, Prolonged labor >20 hours, Hemorrhage, Maternal Exhaustion, Placental Infarction, Abnormal cord length, Suspected uterine rapture, Embolus, Cord Prolapse Maternal medications: Colace 100mg, Humalog 6units, Lantus CURRENT ORDERS: Circle all that apply Diet: breast, bottle, NPO Treatments: Vitamin K injection, Hep. B vaccine, Erythomycin eye ointment, Triple Dye to Cord CBC, Blood type & RH, Direct and Indirect Combs Other: NEWBORN ASSESSMENT at time of Admission: Birth date & time: 12/12/17 Delivery type: Caesarian Apgar: 8, 9, 9 Birth weight: 8 lbs. and 14 oz. Today’s weight: 9lb and 2.4 oz % age +/-: 1 day Length: 53.3cm Head circ: 35.6cm Chest circumference: Mother’s blood type: A+ Infant’s blood type: A+ GBS status: Positive NEWBORN PHYSICAL EXAM (HEAD TO TOE)
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Blood pressure: Temperature: 98.8ax Pulse: 113 Respirations: 58 Crying: Yes Posture: straight no deformities Skin: warm, dry, pink and intact, Mongolian spots on buttocks per gestational age. Head: symmetrical, fontanel present and soft, sutures palpable and unjoined, stork spot at the back of her scalp, Hair: coarse and thick, variations in amount. Face: round, symmetrical, newborn rash bilateral cheeks, well placed. Eyes: bright eyes, left eyelid stork, blink reflex present, no discharge, sclera is white, symmetrical in shape and both present and equal in size, epicanthus folds normal. Nose: midline, symmetrical, millia, no flaring, no drainage noted Mouth: symmetry of lip movement intact, dry and moist buccal mucosa, pink gums, tongue not protruding and freely movable, sucking present, soft and hard palate intact, mouth is moist. Ears: Correct placement: Line drawn through inner and outer canthi of eyes reaching the top notch of ears, well formed, firm cartilage, correct placement, respond to voice and other sound.
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