Newborn Assessment for Nurse Practitioners
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Show notes:
This week’s video is a type of visit that comes up constantly lately and also terrifies me #realtalk
NEWBORN VISITS. Like, freshly cooked, 3-day-old ones. ::shudder::
I actually love them, they're SO CUTE and have the sweetest little cries. But it took me a while to feel more comfortable with caring for them as a nurse practitioner.
I basically all-out panicked when I was a brand new NP when I saw them on my schedule, but with some practice and supportive resources (that I mention in this video), I've felt so much more confident with time.
Newborn Assessments in Primary Care
In this week's video, I break down the pieces of the newborn visit, what to ask & what the most important things to address are to help make sure you've got everything covered.
Newborn Visit Checklist
I've added a newborn visit checklist there that goes along with this week's video. I use it as a quick-text for my newborn babe visits.
You can find it inside the Digital NP Binder. Purchase yours here.
If you liked this post, also check out:
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well hey there it's liz rohr from real
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world np
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and you're watching np practice made
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simple the weekly videos to help save
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you time
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frustration and help you learn faster so
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you can take the best care of your
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patients
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so in this week's video i'm going to be
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talking about a type of visit that
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really scared me
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as a new nurse practitioner and that is
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newborn visits so that day three to five
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first initial visit after discharge from
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the hospital
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i have to be really honest i still find
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them a little bit intimidating
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but in this video i'm going to go
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through the kind of step by step that i
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follow every time
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and that i recommend you do as well so
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one of those super helpful things if you
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have a
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baby who is discharged from the hospital
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setting
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usually they either bring some sort of
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discharge information with you
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or like your hospital system will be
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able to
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have electronic access to the discharge
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records where the neonatologist the
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the provider that assesses them after
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birth gives a really detailed rundown of
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their physical exam
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and all the things that happened there
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so usually i start
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by i think it's really hard not to get
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sucked right into all the details of the
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visit but i really try to start by
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mothering the mother um i mean there are
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actually
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there are many different kinds of
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families that come in with newborn
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babies and not necessarily like a cis
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female
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but typically that's who i see in
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primary care whoever your parent is you
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know mothering the parent
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because for them this is a really
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overwhelming typically
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experience and just checking in with
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them first before you dig into all of
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the kind of assessment details to make
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sure that you've gotten all your ducks
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in a row
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this is certainly easier if you've had
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your own child before but
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i did not when i was a brand new grad so
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um so yeah so once i
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checked in and see how the the family is
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doing whoever the family is there i kind
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of see
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how it went for them how they're feeling
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now
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if this a lot of times birth can be
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pretty traumatic for a family member and
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the
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and the person who's delivering um the
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baby so
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um it's really important to check in
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with that it's helpful if you have a
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rapport with them in the first place
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but at the very least if you've asked
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once you can kind of or
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multiple times in the first visit rather
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the first time meeting them
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it opens the door that if they don't
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fully disclose their experience that
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time
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they can kind of continue on with that
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so
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um kind of after getting to know them
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where they live who they live with what
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support they have at home
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if it's their first child or not those
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are really helpful contextual pieces of
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information
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our clinic also has a standardized
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standardized standardized procedure
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where we ask patients about social
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determinants of health
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and if they have any issues with housing
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with meals like things like that and
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that can kind of help fill in those
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further contextual details
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so as i'm talking about this i
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acknowledge that our visits are pretty
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short
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um mine are about 15 minutes and i have
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to be honest most of the time i go over
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because
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it's a lot to talk about in this visit
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and i hope that you actually get a
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little bit more time closer to the 20 or
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30 minute mark
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but anyway if you have your if as once
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you've checked in with the family
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you can look at your hospital records
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and see you know what is
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uh usually there's a detailed birth
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history document in my ehr
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it doesn't let you chart without it and
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so i'm usually starting with their date
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of birth
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their time of birth which is really
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important when it relates to jaundice
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if they have jaundice the first thing to
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start with
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when if hopefully you have those
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hospital records in front of you
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and if you don't just try your very best
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to get the information from the
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the parents that are there or the family
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members that are there
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but um the first thing you want to think
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about is kind of the the
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history of the delivery and also the
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prenatal care
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did mom have um again i'm saying mom
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because it's usually
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a mom that's there with their newborn
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that is just delivered um
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did did they have prenatal care and did
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they have any infections or
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medical conditions during their
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pregnancy like gestational diabetes
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or other things like that did they take
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any medications during pregnancy
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um and then when can when it comes to
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the actual delivery
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um did they have a vaginal birth did
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they have a cesarean
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emergent scheduled did they have any um
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assistive delivery devices in the cert
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in the delivery with the vaginal birth
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either
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forceps or suction were they induced
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that's all important information what
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was the estimated due date and the date
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at time of delivery were they 40 weeks
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was the baby 40 weeks 39 term baby
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pre-term like that kind of thing
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did the baby have any uh fetal distress
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um any nicu stays
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any things like that were anything any
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complications during the
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the delivery including like a fever
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during the delivery
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um from the from the mom um and so after
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you've kind of gotten your like labor
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history how long the labor was prolonged
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rupture of membranes i'm trying not to
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go too too big into this video but those
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are the general highlights
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if you're touching on that topic you can
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kind of consult and work through your
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brain of what you already learned and
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also what you have of the resources
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there to put all those pieces together
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so again just kind of like recapping
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there's a lot of stuff right checking in
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with the family
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how are you doing do you have records
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what was the prenatal care
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what was the delivery like and then what
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day of birth are we at right now
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and one of the kind of main orienting
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things that is really helpful really
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with all pediatrics but especially with
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newborn babies or
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babies of any age is kind of these
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orienting questions right
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um eating eating elimination
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sleep behavior alertness other kind of
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like ros
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general symptoms nausea vomiting
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diarrhea that whole stuff well not
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really for babies
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right but anyway so checking in with
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those kind of main pillars of pediatric
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wellness right
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how much are they eating and are they
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breastfeeding or formula feeding or both
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because a lot of people do both
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um what are their desires right are they
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hoping to breastfeed are they having a
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hard time
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did they meet with anybody yet i could
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get into a whole different video about
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breastfeeding and and
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that whole thing i'll leave it at that
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but kind of checking in to see
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how that's going for them how often the
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baby is eating
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um and then the next question usually
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typically about that time it should be
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about
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every one to two hours every time they
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cry um
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on demand and then usually in the first
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couple of days to like the first week
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they really should be eating about every
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one to two hours
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with like a stretch of three hours it's
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really hard for the families to do that
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but that's usually what the babies need
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because their tummies are so small when
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they're first born
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so checking in with their nutritional
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kind of intake
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elimination is the next question so how
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many diapers a day
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and usually by the time you're seeing
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them it's day three or four
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of life and at that time between day
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three to four they should have about six
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to eight wet diapers in a 24 hour period
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and they should be stooling by day two
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and
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an important question is in addition to
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how many wet diapers
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how many stooling diapers and it can be
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as often as every time they eat
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or infrequently as every couple of days
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at this point though you want to have
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seen
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some stool and you actually want to also
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document the color too which is kind of
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like a weird gross question right but
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you're trying to assess
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has it changed from meconium to like
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either breast milk
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um stool or formula stool the next thing
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is about sleep
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um and you know it's it's a difficult
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topic and again this is easier if you
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have your own children if you've had a
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child before um or cared for a child
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before especially a newborn baby but
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um sleep is typically they're awake all
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night because their butt like
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in utero they're used to the the mother
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being
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um you know the parent being asleep
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during the night and then
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lulled to sleep with their movements
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during the day so um
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so anyway that can be a difficult
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transition and that's completely normal
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so that's a lot of reassurance for them
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and again they really only have like a
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three hours
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window of time where they sleep like one
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time in 24 hours for the parents to kind
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of catch up
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because they need to eat so often
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because the risk there is dehydration
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you don't necessarily want to scare the
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parents by talking about that but just
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kind of like getting a sense and trying
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to be
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at ease yourself when talking about it
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helps to kind of ease their mind
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and after talking about that um you want
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to kind of again
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going back to your making sure that you
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have that full history what were their
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vaccines
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um when they were born did they get
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hepatitis b did they get vitamin k
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um all of that kind of general history
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stuff and i don't want to get too much
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into that because i don't want this to
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be like a million years long
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but um looking at all of those kind of
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checkpoints and usually your electronic
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health
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record can be really helpful because it
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will prompt you for all of those
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questions and then you'll say oh okay
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i'm gonna go find all of those things
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you know the maternal blood test the
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baby's blood tests like et cetera et
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cetera
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a couple of other screening things to
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keep in mind all babies will
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born in a hospital setting will have a
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hearing screen
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they will have their newborn screening
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labs and then they will also
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have um screening for heart disease like
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a congenital heart disease using the
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oxygen monitoring and if they pass
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there's like pre-ductal and post ductal
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it just has to do with like where they
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measured on the body i think it's like
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hand and foot
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and then the other thing is jaundice so
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there is some sort of jaundice
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bilirubin screening for jaundice and i'm
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actually going to make a separate video
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about that because i see this all the
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time and
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the newborn visit by itself is stressful
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but then you add jaundice on top of it
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can be a little bit intense
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so i'll make a separate video about that
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but they'll be talking i'll be talking
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about jaundice there
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but there's definitely a bilirubin
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screening
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um so yeah and aside from that it's your
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general kind of physical exam and
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and this is very basic right this is the
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basic orientation because
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whenever there's an abnormality you just
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have to go down that path right
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is there like um is there a hematoma in
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the back of their head
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right is there some sort of congenital
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abnormality that they've come out with
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right and typically the nice thing when
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you get that is that usually they've
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already assessed it
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and they've kind of come up with the
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recommendation so for example um i had a
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baby with
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hydronephrosis
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detected on the in utero um
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uh ultrasound and so they already knew
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at the time of birth that this was an
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issue and they already had a scheduled
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appointment
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with the nephrologist to follow up and
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they kind of told me exactly what to do
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right
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and a baby who was born breech and they
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said you know what needs a follow-up
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ultrasound in four to six weeks
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so a lot of the times if you can get
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those hospital records they're really
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helpful
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but like i said every single time
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there's an abnormality outside of the
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window of expected
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is really just taking that that path and
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researching it down and just making sure
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that you're doing your due diligence
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working that up and asking and asking
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all the questions
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of your supporting providers because um
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you know it's normal to feel a little
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uncomfortable with the newborn babies
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even pediatric mps do
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pediatricians do it's just you know you
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don't want to you don't want to miss
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anything so there's no
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no harm in asking questions um the next
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those are that's
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again those are the general kind of
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things to think about
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um when you're doing your assessment and
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then you want to think about their birth
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weight
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their discharge weight and what's their
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current weight and as you remember
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it's going they're going to lose about
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10 percent of their body weight which
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they will regain it at two weeks in
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but you want to kind of see like how
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much have they lost so far
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um and kind of just looking at that
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doing their physical assessment like how
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do they look do they have any
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abnormalities
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do they have any signs of like
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dehydration do they have any jaundice
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um can you get a red reflex that's
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really hard to see but you gotta give it
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your
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you know your best shot and just keep
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trying and trying and you'll find it i
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promise
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um so after you've done your history
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taking
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and assessing where they're at in terms
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of the elimination the intake all of
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that stuff how they're sleeping
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how the feeding is going um and
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uh the next kind of piece and aside from
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the physical exam again going branching
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off depending on the abnormalities that
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you find because
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i can't talk about every single one that
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you could possibly find because again
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this would be like years of conversation
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but just like kind of like reading into
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those cues of like okay if this then
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this you know
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um and the next thing is about
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anticipatory guidance
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um and there's a lot to know here
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especially again if you haven't had your
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own children like there's a lot to
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to think about but like i kind of start
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with just like what are the most
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important things keeping in mind that
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they are likely very sleep-deprived
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overwhelmed and um yeah just like
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exhausted
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so i usually keep it to like the most
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important things like do not miss
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these things between now and your next
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visit
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so always saying arms distance away so i
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see a lot of new families
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where they will be away from the baby
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and they'll be the baby will be on the
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exam table and it's a newborn baby it's
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probably not gonna go anywhere right
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but like some of them are very strong
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and so i always say you know arms
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distance away
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always within reach of the newborn um
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whenever your back is turned always have
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a hands
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on them or near them the other one is
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about um
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body temperature right because they have
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born with the brown fat and so they need
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to make sure that they are
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warm enough and so one of the rules of
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thumb
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is kind of like if you think about your
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own body temperature
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the clothing that you would wear at this
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temperature in the room like add like
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one more layer
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just being mindful that you can over
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heat them and you can't over bundle them
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um and they might not necessarily be
13:16
able to
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kind of communicate that right because
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they're they're new babies and they
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might not necessarily be able to
13:21
modulate that either
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so um the other thing is like people ask
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about the ideal room temperature
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and like there isn't really one but like
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68 to 72
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maybe some baby books say um the other
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thing is about fever monitoring for
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fever right so anything
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that is um greater than 100.4 needs to
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be
13:39
urgently emergently dealt with um and so
13:42
making sure that they have the on-call
13:43
number for the
13:44
clinic or um knowing where to go to the
13:46
nearest er if they need to
13:48
and then just again being aware that if
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you over bundle them in the summer time
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and they feel warm unbundle them for a
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little bit like for like a little while
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not making them cold but
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making sure that it's not falsely high
13:59
because they're super bundled up
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um yeah and then the next stuff is is
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just reinforcement of all of the feeding
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like what are the what are the things
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they need right now they need
14:09
safety they need to eat and they need
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caring for
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right so i'm making sure that they feel
14:14
comfortable without a with
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whichever feeding option they've chosen
14:18
whether it's breastfeeding formula
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feeding or both
14:20
um and breastfeeding we could get that's
14:22
like again a whole other topic and if
14:23
you're interested in
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hearing about that i'm happy to talk
14:26
about that and actually i have a really
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wonderful colleague who is it also a
14:30
she's a physician but she's also a
14:31
lactation consultant
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and um she's pretty wonderful so i'm
14:35
happy to ask her if she's willing to
14:36
come on i don't know she will be she
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might be too shy but
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um i can always ask your questions if
14:41
you have them
14:43
uh but yeah and then in terms of the one
14:45
to follow up depends on what's happening
14:47
right depends if they have jaundice
14:49
depends how well they're eating um
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depends if they have any things you've
14:52
detected or any concerns or how
14:54
concerned the parents are
14:55
but i'll definitely do a check in about
14:57
a week um to see how their weight is
14:59
right
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depending on how they've gained since
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since birth and depending on how it's
15:04
going with the wet diapers and all that
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stuff
15:06
it's it's that's not a very like
15:08
straightforward answer and i know that
15:09
you appreciate straightforward answers
15:10
but if you want one check in one week
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right keep checking babies in a week
15:14
later or sooner
15:16
if you have concerns right unfortunately
15:18
there's no real blanket statements here
15:19
but it's just kind of
15:21
using caution using your clinical
15:23
judgment and
15:24
um yeah so hopefully hopefully that is
15:26
helpful
15:27
if you are interested in the kind of
15:29
like cheat sheet that i have that goes
15:31
along with the newborn visit
15:32
it's actually in the digital mp binder
15:35
which is all of the cheat sheets i've
15:36
ever made plus additional bonus ones
15:38
including the one from today and you can
15:40
purchase that down below this video
15:42
and it's pretty wonderful and it's also
15:44
updated every three months
15:45
so um with brand new stuff so yeah so
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thank you so very much for watching um
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stay tuned for next week's video which
15:51
is all about newborn jaundice and
15:54
hopefully that one is also very helpful
15:56
please let me know what questions you
15:57
have thank you so much for watching
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hang in there and i'll see you soon
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