RN Program
CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN
NURSERY
STUDENT NAME: Caleb Le Gear
PATIENT INTIALS: M. D.
CLINICAL SITE/UNIT: Mary Immaculate NICU
AGE: 6 days
Sex: Male
CLINICAL DATE: 05/13/21
RELIGION/CULTURE: Catholic
MATERNAL AND LABOR HISTORY:
Growth/ Development
Erickson: Trust vs. Mistrust (infant is learning to trust those around him to feed and clean him)
Piaget: Sensorimotor Stage (infant is exploring his environment using his hands and mouth to taste things)
LMP: 09/18/21
EDC: 05/15/21
Labor onset: date & time: 05/07/21 at 10:03 AM
ROM date & time: 05/07/21 at 9:51 AM Color: White/Caucasian
Delivery date & time & type: 05/07/21 at 3:45 PM
Maternal health history: G1P1
Labor complications: None
Maternal medications: Morphine, steroids
CURRENT ORDERS: Circle all that apply
Diet: breast, bottle, NPO, NG tube
Treatments: Vitamin K injection, Hep. B vaccine, Erythomycin eye ointment, Triple Dye to Cord
CBC, Blood type & RH, Direct and Indirect Combs
Other: Blood type is O+ and RH is +
NEWBORN ASSESSMENT at time of Admission :
Birth date & time: 05/07/21 at
3:45 PM
Birth weight: 4 lbs 14 oz
Length: 44.1 cm
Mother’s blood type: O+
Delivery type: vaginal
Apgar: 9/10
Today’s weight: 2,099 grams
Head circ: 31 cm
Infant’s blood type: O+
% age +/-: 7th
Chest circumference: 30 cm
GBS status: +
NEWBORN PHYSICAL EXAM (HEAD TO TOE)
Blood pressure: 72/4
Temperature: 98.1 F
Pulse: 130
Respirations: 60
Crying: None
Posture: Supine, straight
Skin: (Color, texture, turgor, pigmentation)
Pink, warm, smooth, dry, intact. Turgor present. No abnormal bruising noted.
Head:
31 cm in circumference, head shape is normal, no bruising noted. Skin is intact.
Hair:
Hair is dark and evenly distributed on scalp with no lesions, lumps, or bruises underneath.
Face:
Face is restful with no signs of distress.
Eyes: (sclera, pupils)
Eyes are PERRLA, symmetrical, with no crusting over eye lids.
Nose:
Nose is patent, center to midline, with no nasal flaring noted.
Mouth:
Lips are pink and moist. Mouth is centered to midline. No teeth present. Palate is present.
Ears:
Ears are symmetrical with no signs of hearing difficulties. No obstructions noted.
Neck:
Moderate head lag is noted. Infant can turn neck to look around environment.
Chest: (breasts, nipples)
Chest rises and falls symmetrically with breathing. Skin is warm, dry, and intact. Nipples even.
Heart:
Heart rate is 130, regular, no murmurs heard. Capillary refill is less that 3 seconds. No cyanosis noted.
Abdomen: (Umbilicus, auscultation & percussion, femoral pulses, inguinal area, bladder)
Bowel sounds heard in all 4 quadrants. Abdomen is round with no signs of bruising.
Genitals: Male (penis, uncircumcised/circumcised, scrotum, testes) Female (mons, clitoris, vagina)
Scrotum and testes descended and present. Penis is circumcised. No irritation noted from procedure.
Buttocks and Anus:
Skin around buttocks and anus is intact with no signs of irritation. Skin cream is applied.
Extremities & trunk: (joints, arms, hands, nails, spine, hips, inguinal and buttock skin creases, legs, feet, Cshaped spine, flat & straight when prone, slight lumbar lordosis, easily flexed and intact when palpated, at least
half of the back devoid of lanugo, full term infant in ventral suspension should hold head at 45 degree angle, back
straight)
Neuromuscular: (Motor function, head lag, neck control)
Reflexes: (Blink, papillary reflex, moro, rooting and sucking, palmar grasp, stepping, babinski, tonic neck, fencer
position, prone crawl, trunk incurvation-galant)
All age appropriate reflexes present.
Pain Assessment:
Pain is at a 0. No signs of physical distress noted.
MEDICATIONS:
List all medications ordered and given to your patient including the reason for the medication and the therapeutic effect. Note: This should be
the physiologic effect of the medication. What does it do to the body to provide the desired therapeutic effects? WHAT ARE THE POTENTIAL
FETAL EFFECTS? What are the nursing implications related to the medication?
Trade Name
Calcidol, D-Vita
Therapeutic effect
Condition that patient is
receiving medication for
Potential Fetal Effects
Nursing implications & patient
education
Generic Name
Vitamin D
A fat-soluble vitamin
occurring in several
forms, especially
vitamin D2 or
vitamin D3, required
for normal growth of
teeth and bones.
Poor bone growth or
premature infants who
are in need for
supplements to help
bone formation.
Infants given excess
vitamin D may develop
atherosclerosis, severe
mental retardation, facial
dysmorphia, kidney
damage, recurrent
infections, and anorexia
Obtain serum calcium twice weekly
during titration. Discontinue if
patient becomes hypercalcemic.
Restrict intake in infants with
idiopathic hypercalcemia.
Therapeutic effect
Condition that patient is
receiving medication for
Potential Fetal Effects
Nursing implications & patient
education
Inhibits protein
synthesis, usually
bacteriostatic, but
may be bactericidal
in high dosages.
Conjunctivitis,
prevention of
ophthalmia neonatorum
caused by Chlamydia,
acne vulgaris
Minor ocular irritations,
redness, pruritus’,
erythema, sensitivity
reactions
Store medication in a light resistant
container at room temperature. Do
not use for treatment of superficial
skin infections. Prolonged usage may
lead to superinfection.
Dose:
10 mcg – 1.25 mg
Route: Tablets,
liquids, capsules
Trade Name
Erygel
Generic Name
Erythromycin
Dose:
0.5%
Route: Ophthalmic
ointment
LAB DATA & DIAGNOSTIC EVALUATION
Include date:
Lab Ordered
CBC
Client Values
5 million
Normal values
5.1-5.3 million
Indications
Low RBC count levels may indicate possible
types of anemias. May also lead to poor
perfusion of organs and tissues.
Lab Ordered
Bilirubin
Client Values
6.3
Normal values
6-8 mg/kg/day
Indications
High levels of bilirubin may lead to
jaundice. High levels of bilirubin can travel
to the baby's brain. This can cause seizures
and brain damage.
PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS
List all nursing diagnosis relevant to patient condition & based on assessment
1. Imbalanced nutrition related to less than body requirements as evidenced by infant unable to tolerate frequent oral feedings.
2. Low birth weight of 4 lbs and 14 oz related to premature birth as evidenced by being born at 34 weeks.
3. Low baby body temperature related to premature birth as evidenced by consistent temperature readings of 97.3 F.
4. Risk for anemia related to low RBC count.
5. Risk for skin break down around the anal area related to frequent bowel movements.
NURSING CARE PLAN
NURSING CARE PLAN
Student Name: _Caleb Le Gear_____
Date: __05/13/21______________
Class: __NUR 242____
Patient Initials: __M. D.___________
A care plan should start with the major issues for that client. Write the top three priority nursing diagnosis for this client, with the highest priority first. Be sure to include “related to”, “as
evidenced by”, or “risk factors” (if at risk diagnosis) for each medical diagnosis. Write a short term and long term expected outcome goal per nursing diagnosis stated in terms of client
achievement - “the client will…”). List at least 3 specific nursing actions (interventions) for each nursing diagnosis and give the scientific rationale for selecting the action you will use to
work toward that goal. BE SURE TO NUMBER EACH INTERVENTION AND CORRESPONDING RATIONALE. INCLUDE PAGE NUMBERS WITH CITATIONS FOR EACH
RATIONALE. REMEMBER: RATIONALE SHOULD NOT CONTAIN WORDS LIKE: THESE, THIS, TO, ETC. THEY MUST DESCRIBE WHY/HOW YOUR INTERVENTION HELP
REACH YOUR GOAL AND MUST BE ABLE TO STAND ALONE AS A STATEMENT.
NURSING DIAGNOSIS
EXPECTED OUTCOME
NURSING INTERVENTIONS
RATIONALE
(NANDA APPROVED)
(Measurable Goal)
(What do you plan to do?)
(Why are you doing this?)
Infant will be able to
tolerate oral feedings
every time infant must be
fed by the time of
discharge.
Alternate between NG tube feeding and oral
feedings until infant can gain wait and able to
tolerate feeding completely by the mouth.
Assess nutritional status and electrolyte levels.
Infant can not be sent home
until he can achieve adequate
weight gain and able to
tolerate feeding by the mouth.
Imbalanced nutrition
related to less than
body requirements as
evidenced by unable
to tolerate frequent
oral feedings.
EVALUATION
Monitor infant’s weight and
development and adjust intake
amounts accordingly. Monitor infant’s
stool to evaluate if infant’s digestive
system can absorb formula.
NURSING DIAGNOSIS
Low birth weight
related to premature
birth as evidenced by
being born at 34
weeks.
EXPECTED OUTCOME
Infant will consume 30
calories per day for 1
week until discharge.
NURSING INTERVENTIONS
Weight infant daily at the same time of day
using the same methods. Monitor infant’s
growth in a chart to track progress. Check
infant reflexes to ensure infant is developing
properly. Monitor Intake and output to assess
weight gains and losses.
RATIONALE
When an infant has a low birth
weight, it is important to track
that weight as the infant grows
to be sure there is no stunting
of development. Weight daily
and charting the data is a
objective way to monitor that.
EVALUATION
Baby can consume 30 calories per
day. As baby grows, monitor how
much baby can intake. As the baby
grows, also monitor vital signs and
muscle/fat development. Electrolyte
levels may also indicate the status of
growth.
NURSING DIAGNOSIS
Low baby body
temperature related
to premature birth as
evidenced by
consistent
temperature readings
of 97.3 F.
EXPECTED OUTCOME
Baby’s body temperature
will remain within 98.3 –
99 F during stay at
hospital.
NURSING INTERVENTIONS
RATIONALE
EVALUATION
Regularly assess vital signs. Take multiple
temperature readings in multiple sites to get a
consistent and accurate temperature reading.
Wrap baby in loose clothing to help baby stay
warm. When cleaning the baby, make sure
water is warm. Dry baby off quickly afterwards
to avoid massive heat loss.
Premature infants with low
birth weights may have a
harder time regulating their
body temperature. It is
important to ensure that baby
stays within normal limits of
body temperature to ensure
proper perfusion to tissues.
Baby’s body temperature remains
between 98.3 – 99 F during his stay at
the hospital. Fingers and toes remain
warm and free of any cyanosis. Skin is
warm, dry, and intact.
Reference List (APA)
Ricci, S. (2016). Nursing Care of the Newborn with Special Needs. In Essentials of
maternity, newborn, and women's health nursing. LWW.
Ricci, S. (2016). P 846 - 847. In Essentials of maternity, newborn, and women's health
nursing. LWW.
Wolters Kluwer, .. (2018). P 558-559, 1706. In Nursing2019 drug handbook. LWW.
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Care Plan Grading Matrix
Student: ________________ Clinical site___________ Date_________
Instructor_____________________
Section
Possible Points
Demographic Data
Name (student/pt initials), Date, Age, Pain score, Growth
Measurements, CC, HPI, PMH, Current Orders, Developmental
Assessment
10
Physical Assessment
25
Medication
10
Lab & Diagnostic Evaluation
5
Medical Diagnosis
5
List of Prioritized Nursing Diagnosis One-part statements
5
Nursing Care Plan
(Dx statements 3 part statements– minimum of 3, Goals –
short & long term, Interventions – minimum of 3, Rationales – 1
for each intervention, Evaluation)
30
Citations, References & APA format
10
Total
100
Notes:
[12]
Score