Newborn Assessment Guide

• 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