Newborn Assessment Guide

Under supervision

- Prof. Dr. Mohamed Latif, CEO of the Egyptian Health Council

 Dr. Kawthar Mahmoud, Head of the Egyptian Nursing Syndicate - Member of the Senate

Prepared by 

• Identify the nursing needs of each sick child to develop an appropriate nursing plan based on those needs.

Procedures:

A. Patient Admission by the Nursing Staff:

1. The responsible nurse introduces herself to the child's guardians and greets them.
2. The nurse verifies the patient's information (full name, mother's full name, age, gender, nationality, and medical record number).
3. The nurse prepares an identification bracelet for the newborn, including:
• Full name if a birth certificate is available.
• Mother's full name and medical record number if a birth certificate is not available.
• The bracelet should indicate "Son/Daughter of [Mother’s Name]."
4. Conduct a comprehensive physical assessment.

B. Nursing Assessment:

1. The responsible nurse or an accredited assistant nurse conducts the initial nursing assessment for newborns upon admission.
2. The newborn assessment includes:
• Vital signs measurement
• Length, weight, head circumference, and abdominal circumference
• Pain assessment using the CRIES scale
• Vaccination status
• Neurological condition
• Nutritional assessment
• Skin condition screening
• Examination for congenital anomalies
• Sleep pattern
• Medical history (obtained from the guardians)
• Discharge planning

C. Reassessment:

1. The responsible nurse re-evaluates the child's condition whenever there is a change in treatment, care stage, or diagnosis, documenting it in the nursing notes.
2. The nurse conducts reassessments as follows:
• Vital Signs Reassessment:
• Every 3 hours for preterm infants in incubators or as per the doctor's instructions.
• Every hour for post-open-heart surgery cases and isolation unit patients.
• Documented in the vital signs chart.
• Skin Condition Reassessment (Bedsores):
• Every 24 hours, documented in the Newborn Skin Risk Assessment (NSRA) form.
• Pain Reassessment:
• Every 12 hours.
• In case of pain occurrence.
• Before and after surgeries.
• One hour after pain relief treatment.
• As per doctor's orders.
• Documented in the pain assessment form.
• Blood Sugar Reassessment:
• Every 6 hours (or as per the doctor's orders), documented in the blood sugar monitoring form.

D. Nursing Care Plan:

• The nurse develops a nursing care plan based on the newborn’s needs and updates it in case of any medical interventions or complications.

E. Documentation:

1. The nurse completes the initial newborn assessment within 12 hours of admission to the neonatal unit or as per hospital policy.

5. Responsible Personnel:

• The responsible nurse overseeing the case.

6. Attachments:

• Newborn Initial Assessment Form
• CRIES Pain Assessment Form
• Newborn Skin Risk Assessment (NSRA) Form
• Blood Sugar Monitoring Form

• Develop a care plan for each patient in the hospital across different specialties under the supervision of the responsible physician, ensuring comprehensive, evidence-based, and standardized care.
• Documenting the care plan ensures that medical staff, nursing staff, and other healthcare professionals achieve integrated and consistent patient outcomes.
• Promote collaborative teamwork based on a shared understanding of the best approach to managing the patient’s condition.

Steps:

The nursing team shall:

1. Conduct a nursing assessment upon the child's admission to identify the patient’s problems.
2. Record the child's nursing issues in the nursing care plan according to NANDA (North American Nursing Diagnosis Association).
3. Document the necessary interventions to help resolve the identified nursing problems.
4. Set a specific timeframe for reassessment based on each issue.
5. Reassess the patient to determine their response to nursing interventions.
6. Engage the child’s guardians in their care plan to ensure effective participation in the recovery process.

Responsible Personnel:

• Nursing staff in the department.

Attachments:

• Nursing Care Plan Template.

• Establish guidelines and procedures for caring for at-risk patients by preventing unintentional or thoughtless actions that could cause injury or harm.
• Provide support and guidance to all medical team members in managing patients who may be at risk.
• Ensure respect for the rights, privacy, and dignity of vulnerable patients, particularly those with special needs.

Patients with Special Needs Who Are at Risk of Abuse and Neglect

Types of Abuse:

1.     Mental Abuse (Psychological or Emotional Harm):

• Physical or verbal threats
• Intimidation
• Isolation
• Insults
• Humiliation
• Deprivation

2.     Physical Abuse:

• Infliction of harm on the child’s body through (hitting, slapping, kicking)

Signs of Physical Abuse:

• Child falling or unexplained injuries
• Bedsores
• Untreated wounds
• Unexplained bruises or cuts
• Pain when touched
• Bite marks, scratches, abrasions, or bruises
• Signs of dehydration, malnutrition, sunken eyes, or eye injuries

3.     Financial Abuse:

• Theft
• Misuse of money or property
• Extortion of the child’s guardians
• Fraudulent activities
• Unusual transactions in the child’s guardians’ bank accounts
• Reckless or irresponsible financial management

4.     Neglect:

• Failure to provide necessary care without a valid medical reason by a responsible person during the child’s hospital stay.

Definition of a Vulnerable Patient:

• A person requiring assistance due to (intellectual disability, young age, brain atrophy, or functional impairment) that hinders their ability to protect themselves or provide self-care.

Potential Types of Neglect:

• Failure to provide adequate medical or nursing care
• Neglect in administering prescribed treatments
• Failure to meet social and psychological needs
• Lack of sufficient food and water
• Placing the patient in an unsafe environment without supervision

Procedures:

1. The physician and nursing staff assess the child’s condition and determine their treatment needs.
2. The physician and nursing staff inform the child’s guardians about the treatment plan and how it will be implemented.
3. The ward supervisor conducts daily rounds to detect any signs of neglect or abuse, reporting them to hospital administration for appropriate action.
4. If a case of abuse or neglect is identified:
• The attending physician evaluates the child’s condition, documents any signs of abuse or neglect, and ensures appropriate medical and psychological treatment.
• The physician encourages the guardians to submit a formal complaint if they choose, with or without their signature.
• The head of the medical team assigns the Patient Satisfaction Department to investigate the complaint and submit the findings for appropriate action.

Responsible Personnel:

• Physician
• Nursing staff
• Patient Satisfaction Department

Attachments:

• Abuse and Neglect Assessment Form

• To establish a system for assessing the skin condition and safety of neonates upon hospital admission to determine their risk level for developing pressure ulcers.
• To identify neonates most at risk of pressure ulcers and take necessary preventive measures.
• To help heal existing pressure ulcers in affected neonates.

Definitions:

• Pressure Ulcer: A skin injury caused by impaired blood circulation and continuous friction against a bony area of the body, occurring when the skin is under prolonged pressure from a firm surface, such as a bed.

Procedures:

A. Risk Assessment at Admission, Including Skin Evaluation:

1. The nurse conducts a pressure ulcer risk assessment and records it in the neonatal nursing assessment form.
2. The nurse examines the skin over bony prominences such as the heels, ankle joints, pelvis bones, coccyx, ears, shoulders, and elbows.
3. The nurse checks for areas of redness that persist for more than 30 minutes. For dark-skinned neonates, skin warmth in affected areas should be assessed.
4. The nurse classifies the neonate's skin condition as:
• Low risk
• Moderate risk
• High risk
• Severe risk

B. Timeframe for Pressure Ulcer Screening Completion:

• The nurse must complete the screening within two hours of the neonate’s admission to the neonatal intensive care unit (NICU) and record the findings in the neonatal nursing assessment form.

C. Frequency of Pressure Ulcer Risk Reassessment:

1. If no pressure ulcers are present at admission, the nurse reassesses the neonate within 24 hours using the Neonatal Skin Risk Assessment (NSRA) Scale:
• Score ≥ 8: Low risk
• Score 9-16: Moderate risk
• Score 17-24: High risk
• Score 25-32: Severe risk
2. The nurse performs a daily reassessment every 24 hours using the NSRA scale.
3. If a pressure ulcer is present at admission, the nurse documents:
• The number, location, and severity of the ulcers
• The presence of any discharge

Stages of Pressure Ulcers:

• Stage 1: Red or pink area that does not disappear within 30 minutes, similar to a mild sunburn. Skin may feel painful or itchy.
• Stage 2: Red, swollen, and painful skin. Blisters may be present, and the upper skin layers begin to deteriorate.
• Stage 3: The ulcer extends deeper into the skin layers, forming a crater-like wound.
• Stage 4: The ulcer extends into the fat, muscle, or even bones.

D. Actions in Case of Existing Pressure Ulcers:

1. The nurse informs the neonate's family about the ulcer's location, severity, and presence of discharge, obtaining written acknowledgment.
2. The attending physician is notified to create a treatment plan, which may include consultation with a dermatologist or surgeon.
3. For high-risk neonates, the nurse reassesses the skin every two hours to check for redness or dryness and records it in the patient repositioning log.

E. Preventive Measures:

1. Regular Repositioning:
• The nurse repositions the neonate every two hours and documents it in the repositioning log.
• The neonate's head should be elevated at a 30-degree angle, except during feeding, per physician instructions.
2. Skin Protection:
• Use prescribed emollients to reduce friction injuries.
• Avoid massaging over bony prominences.
• Keep the skin clean and dry.

F. Individualized Care Plans Based on Risk Assessment:

1. Following the skin assessment, the nurse:
• Reports findings to the physician.
• Develops a care plan to minimize pressure on bony areas, reduce friction, and prevent moisture-related skin damage.
• Establishes a patient repositioning schedule (every two hours or as prescribed by the physician).
• Educates the family on pressure ulcer prevention, documenting it in the health education form and nursing care plan.

Responsibility:

• Attending physician
• Ward nurses
• Nutrition specialist

Attachments:

• Patient Repositioning Log
• Neonatal Skin Risk Assessment (NSRA) Form
• Pressure Ulcer Staging Guide
• Incident Reporting Form

1. Injured Party Information:

• Name: ................................................
• File/Card Number: ..................
• Age: ...........
• Gender: ..................
• Department: ...............................................
• Admission Date (for patients): ............................
• Category:
• □ Patient
• □ Employee
• □ Visitor
• □ Other (Specify): ........................

2. Type of Incident:

• □ Error
• □ Accident
• □ Significant Unexpected Event
• (Specify) ..................................................

3. Incident Details:

• Date: ....../....../20......
• Time: .......... (AM / PM)
• Exact Location: ..................................................

4. Incident Description and Contributing Factors:

..................................................

5. Corrective Actions Taken:

..................................................

6. Reporter’s Information:

• Name: ..................................................
• Department: ...............................................
• Physician Notified: ...............................................
• Time Report Initiated: ........................
• Witness (if any): ..................................................
• Contact Number: ............................

7. Supervisor’s Information:

• Name: .........................................
• Position: ............................
• Date: ....../....../20......
• Time: .......... (AM / PM)
• Signature: ..........................

8. Medical Supervision (If Injury Occurred):

(Include patient examination, required tests, results, and diagnosis)
..................................................

• Name: .........................................
• Date: ....../....../20......
• Signature: ..........................

9. Medical Follow-up Information:

..................................................

• Name: .........................................
• Date: ....../....../20......
• Signature: ..........................

10. Department Head’s Instructions (Verification of Report Details):

..................................................

• Name: .........................................
• Date: ....../....../20......
• Signature: ..........................

11. Hospital Director’s Instructions:

..................................................

The report is submitted to the Hospital Quality Improvement Committee Coordinator for recommendations, implementation, and filing.

• Hospital Director’s Signature: ..................................................
• Date: ....../....../20......