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NEWBORN CLINICAL PATIENT ASSESSMENT

 

Gestational Age at Birth: ________ Gestational Age Now: ________

Mothers History: Gravida ________ Para ________ Abortions ________ Live Births ________

Miscarriages ________ Blood Type ________ ROM ________ VDRL ________ Rubella ________ 

HIV ________

Maternal History of Pregnancy: ____________________________________________________________ 

________________________________________________________________________________________  

Newborn Admitting Diagnosis:

Delivery Date & Time: ________ Type of Delivery: ________

Apgar: ________ 

Image transcription text

Apgar Score Gestational age weeks Sign O 2 1
minute 5 minute 10 minute 15 minute 20 minute
Color Blue or Pale Acrocyanotic Comp… Show more

Complications of Delivery: _________________

Head: ________ inches,     Chest: ________ inches,     Length: ________ inches

Vital signs:

 

 

Neurological: 

 

 

Respiratory:

 

 

 

 

Cardiovascular:

 

 

 

 

Gastrointestinal:

 

 

 

 

Genitourinary:

 

 

 

 

Musculoskeletal: 

 

 

 

Skin:

 

 

 

Endocrine (Include Blood Sugars):

 

 

 

Pain/Sensory: 

 

Indicate Pain Scale used and rating:

Head, Eyes, Ears and Neck: 

 

 

 

 

Psychosocial:

 

 

 

 

Erickson’s Stage:

 

 

 

 

Patient Teaching: (Brief description of what you taught and patient’s response)

 

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING VNSG 2460

 

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