AdventHealth University
Department of Nursing - NURS 330
Newborn Clinical Document
Student Information
Student Name:
Date:
Basic Patient Information
Baby Gender:
Room #:
Patient Name:
OB Provider:
Delivery Date & Time:
Type of Delivery:
Gestational Age:
Size Classification:
Accuchecks:
Initial Assessments
Time of 1st Void:
Notes (e.g., "0" if documented as zero, not yet occurred, unable to assess):
Time of 1st Stool:
Notes (e.g., "0" if documented as zero, not yet occurred, unable to assess):
Time of Bath:
Notes (e.g., "0" if documented as zero, delayed, not yet given):
Feeding Information
Feeding Method:
Feeding Times:
Weight Measurements
Birth Weight:
Today's Weight (grams):
% Changed +/-:
APGAR Scores
1 Minute:
5 Minutes:
10 Minutes:
Birth Information
Resuscitation, Medication, etc:
Blood Type and Rh Factor:
Coombs Test:
ROM (Rupture of Membranes) Time:
Notes:
Maternal Labs Affecting Newborn
GBS:
Type & Rh Factor:
Hepatitis B:
Rubella:
RPR:
HIV:
Chlamydia:
Gonorrhea:
COVID:
Other:
Maternal Conditions Affecting Newborn
Conditions:
Allergies:
Gravida/Para:
Blood Loss:
Epidural:
Laceration:
Baby Medications
Antibiotics:
Ampicillin:
Gentamycin:
Eyes/Thighs Treatment:
Screening Results
Hearing Screen:
Cardiac Test:
Car Seat Test:
PKU:
Circumcision:
Hepatitis B Vaccine:
HUGS Tag:
Laboratory Values
Glucose Levels (mg/dL):
Family Interaction
Observed:
Limited PNC 43 visits (Limited prenatal care with 3 visits) Mother present 12-7pm shift on 7/6/25
Describe the interaction of the infant and the family:
NEWBORN FOCUSED ASSESSMENT
Assessment
8 AM
12 Noon
Extra
MISC:
bulb syringe in crib, supine positioning, bands verified, wrapped, cap on
SKIN:
pink/pale/cyanotic/jaundiced, dry/peeling/moist, skin integrity & turgor, mucous membrane color & description, presence of rash, nevi, Mongolian spot, milia, etc.
HEAD:
symmetrical, molding, caput, cephalhematoma
FONTANELS:
soft/flat/bulging
FACE:
symmetrical, movement, mouth & palate intact, ear/eye discharge, sclera color
CARDIAC:
heart rhythm/rate reg or irreg, murmur, pulses present/equal
PULMONARY:
breath sounds present all lobes, respiratory rate reg/irreg, retractions present, grunting
CHEST:
breasts symmetrical, buds
ABDOMEN:
bowel sounds present, distended/non-distended/soft
UMBILICAL CORD:
drying/moist
GENITALIA:
Female: labia majora covers minora/equal size of both, vaginal discharge
NEURO REFLEXES:
grasp, rooting, moro, Babinski, suck
ACTIVITY:
awake & alert, quiet, lethargic, jittery
CRY:
weak/excessive
Education Provided to Parents/Caregivers
Case Study
(A) Assessment: Focused Observations
a. Subjective Data:
Objective Data:
b. Recognizing Deviations from Expected Patterns:
c. Patterns to be Recognized as Potential Problems:
d. Additional Information Needed:
(D/O) Nursing Diagnosis and Outcome
e. Prioritized Problems with Supporting Data:
(P/I) Plan and Interventions
f. Specific Interventions for Each Problem:
g. Delegation Opportunities:
h. SBAR Report
SBAR Intended for:
1. Situation:
2. Background:
3. Assessment:
4. Recommendation:
i. Psychomotor Nursing Skills Needed:
(E) Evaluation and Reflection
j. Were you satisfied with all your decisions?
k. What did you do well?
l. Did you miss any data or assessment?
m. What could you have done differently?
n. Overlooked interventions or decisions to include now:
o. How will this assignment help with your future nursing career?
p. How did your ability to work through the nursing process improve?
q. How did this help develop your critical thinking skills?
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