-
Mother assessment strategy
- General Impression
- wash hands/glove up
- VS
- Head
- Chest
- Abdomen & Bladder
- Fundus
- Perineum/Lochia
- Lower Extremities
- Psyche
- Education
- Discharge Plan
-
Mother General Impression
- appearance
- General color
- non-verbal expression
- Clear speech
- CHECK ID
- pain/effectiveness of tx
- priority needs/concerns
-
Mother VS
- skin Characteristics,
- color
- nail bed
- capillary refill
- Turger
- T/BP/P/RR/Pain
-
Mother Head
- H/A or VisualChanges
- Hair clean and “done”
- Features symmetrical
- unusual features
- Eyes are clear
- Lips/mucus membranes moist
- Neck full ROM
-
mother Chest
- Hx of SOB/cough?
- Characteristics of Respiration
- Symmetrical Anatomy
- Upper Extremities full ROM
- Heart sounds (pt lift breast PRN)
- Lung sounds (not through clothing)
- Breasts/Nipples Density/Skin Integrity, colostrum/milk
-
Mother Abdomen & Bladder
- Assess for constipation & voiding
- Visual appearance
- Auscultate BS
- Palpate abdomen/bladder
- Abd Dressing PRN
-
Mother Fundus
- Orientation to umbilicus
- Midline, L/R to midline, above or below umbilicus in cm
- (ex U -2 M/L)
- Consistency: firm, firm w/massage, boggy, full bladder effect assessment
- Massage fundus prn
-
Mother Perineum/Lochia
- Visual appearance of Perineum
- swelling, redness, bleeding
- skin/sutures intact
- Assess amount/characteristic of lochia
- Assess for hematoma
- Turns pt to fully examine Perineum
- Assess for hemorrhoids
- Epidural insertion site prn
- lung sounds
- back of legs color/temp/viens
-
Mother Lower Extremities
- Assess color, skin temperature, veins
- Edema
- Pedal Pulses/capillary refill
- Assess for pain when pt dorsiflexes foot,stands or walks
-
Mother Psyche
- Assess Mood
- Assess parent/infant bonding
-
Mother Education
- Readiness to learn
- Prior teaching/understanding
- Learning priorities for patient/family
-
Mother Discharge Plan
- Patient needs/expectation
- Maternal Plan of care
- Newborn Plan of care
-
Newborn Assessment strategy
- General Impression
- wash hands/glove up
- VS
- Skin FRONT/BACK
- Head
- Chest & CV system
- Abdomen
- Genitalia
- Musculo-Skeletal
- Neuro
- Safety
- Discharge Plan
-
Newborn General Impression
ID/SECURITY DISK
- Knowledge prenatal/delivery history
- obvious anomalies
- skin color
- tone
- Posture
- alertness
-
Newborn VS
- Take HR/RR before Temp/physical
- -lung/heart sounds/murmurs
- -femoral/brachial pulses
-
Newborn
Skin FRONT/BACK
Color
- Deviations: bruising,
- petechiae, milia, Mongolian
- spot, port wine stain, rash, meconium staining, “birth marks”, Jaundice
Newborn rash
texture: smooth, peeling, dry
Lanugo
Spinal column/vertebral closing, dimple or tuft of hair along spine (Pilonidal dimple, Nevus pilosis (hairy nevus))
Planter creases
-
Newborn Head
- Shape: Hematoma or Caput?
- puncture from FSE,
- Fontanels
Eyes
Ears: Skin tags/Hearing test completed?
Nose: Symmetrical/midline
Nares: Patent, w/o flaring
ROM of Neck
- ROOTING REFLEX (cheek is touched or stroked
- along the side of the mouth to turn the head toward the stimulated side and
- begin to suck.)
Mouth, (usually left until last)Midline, symmetrical lip movement,
Mucus membranes: color/dryness Palate inspected for cleft
-
Newborn Chest & CV system
Shape/Symmetry
Respiratory Rate
Retractions, nasal flaring, Grunting
Breath sounds
Acrocyanosis/cyanosis
-
Newborn Abdomen
Shape/Symmetry
Hernias
Bowel sounds
Soft to palpate
Stool pattern
- Umbilical cord: 2 arteries/
- 1 vein/Clamp?
-
Newborn Musculo-Skeletal
ROM
Tone
“Jittery”
clavical
Symmetry – brachial plexus?
Polydactyl
Fused digits
symmetry of gluteal folds
Clubbing of feet
-
Newborn Genitalia
Normal for GA
Voiding?
Testes (male)
Urethral meatus (male)
Hydrocele (male)
-
Newborn Neuro
Reflexes:
- Moro: elicited sudden loud noise or raising the head slightly and allowing it to drop. response consists of flexion of the legs, an embracing posture of the
- arms, and usually a brief cry.
Wink: automatic closure of the eyelids inresponse to an appropriate stimulus.
Rooting
- Grasp: stroking the palm or sole with the
- result that the fingers or toes flex in a grasping motion
Babinski: dorsiflexion of the big toe with extension and fanning of the other toes elicited by firmly stroking the lateral aspect of the sole of the foot
Plantar: firmly stroking the outer surface of the sole from heel to toes, characterized by flexion of the toes
Cry
-
Newborn Safety
ID Band
Security Disc
Bulb syringe in crib
“Back to sleep”
Bonding
-
Newborn Discharge Plan
Maternal/Family readiness to learn
Procedures/Follow-up
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