HIGH RISK NEWBORN ASSESSMENT FORMAT

IDENTIFICATION DATA
Name of the baby

Age

Sex

Date of birth

Birth weight

HISTORY COLLECTION
Delivery

- singleton/ twins/triplet

Diagnosis

Cord

- Normal/ Prolapsed

Condition at birth

- Active/ Asphyxiated

Any birth anomalities

- Present/ Absent

Treatment at birth

Apgar score

at 1mt

at 5mt

VITAL SIGNS
Temperature

Pulse

Respiration

ANTHROPOMETRIC MEASUREMENT
Weight

Length

Head circumference

Chest circumference

Abdominal circumference

PHYSICAL ASSESSMENT
Activity

- Active/ Dull

Body build

- Thin / Well built

Color

- Pale/ Pink/ Jaundiced/ Cyanosed

Texture

- Smooth/ Dry

Turgor

- Normal/ Dry

Skin

Vernix caseosa

- Present/ Absent

Lanugo

- Present/ Absent

Edema

- Present/Absent

Milia

- Present/ Absent

Mongolian Spot

- Present/ Absent

Size

- Normal/ Macrocephaly/ Microcephaly

Shape

- Normal/ Abnormal

Anterior fontanels

- Palpable/ Depressed/ Bulging

Posterior fontanels

- Palpable/ Depressed/ Bulging

Caput succedaneum

- Present/ Absent

Cephalohematoma

- Present/ Absent

Eyelid

- Normal/ Edematous

Iris color

Sclera

- White/ Blue/ Yellow

Red reflex

- Present/ Absent

Patent nostrils

- Present/ Absent

Nasal discharge

- Present/ Absent

Nasal septal deviation

- Present/ Absent

Flaring of nostrils

- Present/ Absent

Symmetry

Appearance

Pinna in line with eyes

Secretions

- Present/ Absent

Intact lips and palate

Oral trush

- Present/ Absent

Size

- Normal/Abnormal

Neck webbing

- Present/ Absent

Head

Eyes

Nose

Ear

Mouth

Neck

Chest
Shape

Movement

- Symmetry/ Asymmetry

Breath sound

Heart sound

Abdomen
Shape

- Normal/ Distended

Umbilical cord

Whartons jelly

- Present/ Absent

Bowel sounds

- Present/ Absent

Female Genitalia
Labia Majora

- Normal/ Edematous

Labia Minora

- Normal/ Abnormal

Vaginal Discharge

- Present/ Absent

Male Genitalia
Urethral opening

- Present/ Absent

Testis

- Descended/ Undescended

Epispadia

- Present/ Absent

Hypospadia

- Present/ Absent

Spine

- Intact/ Abnormal

Spina bifida

- Present/ Absent

Abnormal curvature

- Present/ Absent

Spine

Extremities
Shape

- Symmetric/ Asymmetric

Range of motion

- Active/ Inactive

Nail Buds

- Pink/ Cynosised

Muscle tone

- Normal/ Abnormal

Polydactylity

- Present/ Absent

Syndactylity

- Present/ Absent

Neuromuscular
Cry

- Weak/ Loud/ High pitched

Lethargic

- Present/ Absent

Activity

- Active and alert/ Drowsy

Reflexes
o Moro Reflex
o Sucking reflex
o Rooting Reflex
o Tonic neck reflex
o Grasp reflex
o Stepping or walking reflex
o Babinski sign
o Glabellar reflex
o Sneezing reflex

DAILY OBSERVATION AND CARE OF THE NEWBORN

POSTNATAL DAY
General condition
Temperature
Pulse
Respiration
Eye care
Cord care
Breast feeding
Baby weight
Bladder
Bowel
Sleep
Chief Complaints
Medical treatment
Vaccination

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