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  • Physical Assessment

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    ahrhicx
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    This document provides a head-to-toe assessment of normal and abnormal findings in newborns. It lists common normal findings under each body area (head, face, eyes, etc.) and potential abnormalities. Abnormalities include things like cephalhematomas, cleft palate, undescended testes, fractures, and neurological issues like seizures or abnormal tone. The document serves as a reference for providers to evaluate the health of newborns and identify any problems requiring further attention.

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    This document provides a head-to-toe assessment of normal and abnormal findings in newborns. It lists common normal findings under each body area (head, face, eyes, etc.) and potential abnormalities. Abnormalities include things like cephalhematomas, cleft palate, undescended testes, fractures, and neurological issues like seizures or abnormal tone. The document serves as a reference for providers to evaluate the health of newborns and identify any problems requiring further attention.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    53 views3 pages

    Physical Assessment

    Uploaded by

    ahrhicx
    This document provides a head-to-toe assessment of normal and abnormal findings in newborns. It lists common normal findings under each body area (head, face, eyes, etc.) and potential abnormalities. Abnormalities include things like cephalhematomas, cleft palate, undescended testes, fractures, and neurological issues like seizures or abnormal tone. The document serves as a reference for providers to evaluate the health of newborns and identify any problems requiring further attention.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 3

    Area Normal Abnormal

    Head • Molding • Cephalhematoma


    • Overriding sutures • Fracture
    • Caput succedaneum • Sutures fused
    • Fontanelle
    o Full
    o Depressed

    Face • Normal configuration • Abnormal facies


    • Mandibular hypoplasia
    • Forceps injury
    • Facial palsy
    o Partial
    o Complete

    Eyes • Symmetrical • Asymmetry


    • Open • Subconjunctival
    • Red reflex hemorrhage
    • Cataracts
    • Coloboma
    • Conjunctivitis
    • Brushfield spots

    Nose • Symmetrical • Nasal flaring


    • Choanal atresia

    Ears • Normal configuration • Abnormal configuration


    • Response to sound • Low set
    • No response to sound
    • Forceps injury
    • Accessory auricle(s) /
    tags

    Mouth • Normal configuration • Cleft lip/palate


    • Epstein’s pearl • Precocious teeth
    • Glossoptosis
    • Not tongue tied

    Neck • Normal mobility • Webbing


    • Masses
    Chest • Two nipples • Extra nipples
    • Enlarged breasts • Breast abscess
    • Normal respirations • Apnea
    (40-60 breaths/minute) • Cyanosis
    • Retractions
    • Tachypnea
    • Grunting

    • Normal breath sounds • Diminished air entry


    • Crackles/wheezes

    • Normal heart rate • Arrythmia


    • (110-160 beats/minute) • Murmur
    • Tachycardia
    • Bradycardia

    • Peripheral pulses equal • Peripheral pulses differ


    to from apical
    apical • Bounding or faint
    peripheral
    pulses

    Abdomen • Slight protrusion • Convex


    • Distended
    • 3 umbilical vessels • 2 vessels
    • Cord drying • Umbilical inflammation,
    Drainage

    • Normal palpation • Enlarged


    (Liver 2 cm below costal o Liver
    margin) o Spleen
    o Kidneys

    • Bowel sounds present • Bowel sounds absent

    Skin • Vernix • Jaundice


    • Pink colour • Cyanosis
    • Acrocyanosis • Pallor
    • Milia • Petechiae
    • Erythema toxicum • Bruising
    • Telengiectatic nevi • Strawberry hemangioma
    • Mongolian spots • Port wine stains

    Genitalia

    Female • Normal configuration • Abnormal configuration


    • Mucousy vaginal
    discharge
    • Pseudo menstruation
    Male • Normal configuration • Hypospadias
    • Testes in scrotum • Epispadias
    • Hydrocele • Undescended testes

    Anus • Patent • Imperforate anus


    • Fistula
    • Patulous

    Extremities
    Arms, Legs, • Normal • Abnormal
    Hands, Feet • Range of motion • Fractures
    Hips adequate • Paralysis
    Spinal • Click • Weakness
    Column • Normal • Polydactyly
    • Syndactyly
    • Abnormal skin creases

    • Congenital hip dislocation


    • Clunk
    • Sinus
    • Mass
    • Myelomeningocele
    Extremities
    Neurologic
    Exam
    • Normal activity
    • Normal tone
    • Normal DTRs
    • Primitive reflexes present
    (Suck, Root, Moro, Step,
    Place)
    • Ventral suspension, Head
    lag
    • Hypotonic
    • Hypertonic
    • Jittery
    • Seizures
    Charting

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