Printable Newborn Physical Exam Template
Facial sensation is intact to pinprick in all 3 divisions bilaterally.
Printable newborn physical exam template. Has all baby needs including. This is part i of a two part article on the newborn examination. Parenting tips help your baby learn by playing and talking with him. Mother primary care physician.
Well nourished ambulatory child brought into clinic today for routine examination and scheduled immunizations. Verbalize impressions during exam o evaluate the students performance according to the checklist i. Cortez is a 21 day old african american male infant who presented. Baby has been doing well since birth breastfed x3 stool x 1 and void x 1 vss.
Keep your baby away from crowds and people who have colds and coughs. O obtain verbal consent from family to use their baby for osce examination o instruct student to. Lewis md dwight d. Visual acuity is 20 20 bilaterally.
Mom states that feeding are going well but she complains of sore nipples. The rash in his diaper area is getting worse history of present illness. Nursing assessment is an important step of the whole nursing process. Newborn baby born to a yo g p at and weeks ega who presented in labor with without srom at.
Eisenhower army medical center fort gordon georgia. Cn iii iv vi. With a weak or incorrect assessment nurses can create an incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation. Color posture tone activity size maturity and quality of cry.
Face is symmetric with normal eye. She was not induced augmented and progressed well to complete over about hours. History of present illness. Assessment can be called the base or foundation of the nursing process.
Call your baby s doctor or nurse before your next visit if you have any questions or worries about your baby. Make sure that people who hold or care for your baby wash their hands often. Eomi no nystagmus no ptosis. Sample pediatric history and physical exam date and time of h p.
Pupils are 4 mm and briskly reactive to light. Sibling under bili lights for 2 days in newborn nursery negative for congenital diseases childhood deaths or atopic diseases. This infant has a normal pink color normal flexed posture and strength good activity and resposiveness to the exam relatively large size over 9 pounds physical findings consistent with term gestational age skin ears etc and a nice strong cry. Visual fields are full to confrontation.
Patient then began to push and at this time of 2nd stage of labor had complications. Only assign a score if the exam has been done correctly i e. Perform a full newborn exam ii. The history was obtained from both the patient s mother and grandmother who are both considered to be reliable historians.
Fundoscopic exam is normal with sharp discs. Total time with ruptured membranes was. Before even touching the infant notice the following. Intact family 3 yo sib.
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