Physical Assessment - Infant

Situation / Case Scenario:

Baby X aged 8 months is residing in the rural area addressed 5C, Kamarajar
th
Street, Kovoor. Her birth order is 6 . The previous children all of them are
girls all are alive and active. The child is vaccinated appropriately to all the
vaccines. The weight of the child 7 kgs. Both the parents are working; the
eldest sister aged 14 years is taking care of this infant. Perform the
physical assessment.

S.No. Steps Score 1/0 Remarks

A. PRELIMINARY PREPARATION
PHASE
1. Introduces self, confirms beneficiary
details and obtains consent

2. Spreads the mat in the selected working

area and spreads the double sheeted
newspaper

3. Places the community bag in the corner of

the news paper

4. Collects complete identification profile,

birth history from the mother/caretaker.

5. Removes the wrist watch and secures it

in the uniform

6. Takes out the necessary items from outer

compartment like, IEC materials,
stationery pouch, pocket notebook, Paper
bag from outer compartment.

7. Takes the hand washing materials (soap

with case/ hand washing solution, hand
towel, nail brush and a 15x10 cm sized
newspaper/brown sheet) and places it in
the working area.
8. Take the hand washing items places near
the washing area over the footstool /
elevated dry and clean surface

9. Unbuttons the inner compartment

10. Washes the hands using standard steps

11. Takes the needed articles l ike

thermometer, temperature pack and spirit
container from the inner compartment of
the bag and close the upper flap

12. Collects the Developmental Mile

Stones Details:
Mile stones Actual Child's
development development
Cooing 3rd month
Social smile 5th month
Head control 6th month
Turns over 7th month
Crawling 9-10 months
Sits with support 9th month
Sits without support 10th month
Stands with support 10-11 months
Stands without 11-12 months
support

B. ASSESSMENT PHASE
13. Assesses the Anthropometric
Assessment
Measures the Length :
a) Spreads the clean paper/ cloth over a
flat plain surface.
b) Gently places the infant or child in
supine position
 c) Have the responsible person /
caretaker holds the crown of the
child's head firmly against the height
until the measurement is complete.
d) Checks to make sure that the child is
looking up and that the head, body,
and toes are in a straight line.
e) Holds the child's legs together just
above the knee and gently push both
legs down against the measuring
board with one hand, fully extending
the child.
f) Places a mark over the newspaper at
head end.
g) With the other hand, slides the same
cardboard against the child's feet
until the heels of both feet touch the
footboard with toes pointed upward.
h) Places a mark over the foot end of the
paper.
i) Removes the baby out of the paper
and place over the mat in a
comfortable position.
j) Reads the measurement to the nearest
cm in the paper.
k) Records the measured length of the
infant.

14. Measures the Weight:

a) Places the piece of clean cloth over
the infantometer
b) Adjusts the zero level
c) Undresses the infant and places over
the infantometer
d) Places the warm hand cupped over
the infant
 e) Takes two weight measurements and
calculates the average of it
f) Handovers the baby safely to the
mother

15. Measurers the Chest circumference:

a) Places the inch tape at the level of
the nipple in a plane at right
angle to the spine
b) Records the measurement in
midrespiration and record the value.

16. Measures the Head circumference:

a) Measures just above ears and supra
orbital ridge
b) Records the measurement

17. Checks the Temperature Pulse

Respiration assessment
a) Takes out the thermometer from its
case and place the case in the
working area itself
b) Takes the thermometer and pledget to
the hand washing area
c) Soaks the pledget with soap solution
and leave it aside in the hand wash
area itself
d) Rinses the thermometer with running
water and bring it to the working area
e) Takes out the first cotton ball from
the temperature pack
f) Wipes the thermometer from bulb
to stem with the first cotton ball and
secure it between the fingers without
discarding
 g) Axillary temperature: Uses the
second cotton ball to clean the axilla
and discard it. Places the
thermometer in the axilla for 5 mins
h) Concurrently checks the pulse,
respiratory rate of the beneficiary
i) Takes out the thermometer from oral/
axilla, wipes the thermometer from
stem to bulb as a single stroke with
the same first cotton ball and discard
it into the paper bag
j) Reads the thermometer at the eye
level
k) Takes the thermometer to hand
washing area and place in soap
soaked cotton pledge for 10minutes

18. Assesses complete head to foot

assessment and systemic examination
Ensures baby safety and privacy,
attend to baby’s mother cues

Skin, hair, and nails:

a) Inspects skull and face for round,
symmetric and facial movements
b) Inspects for lesions, bruising, and
rashes
c) Palpates skin for temperature,
moisture, and texture and edema
d) Inspects for pressure areas
e) Inspects scalp for lesions and hair
and scalp for presence of lice and/or
nits
f) Inspects nails for consistency, colour,
and capillary refill, shape
Head and Neck:
a) Inspects eyes for drainage and
pupillary reaction to light
b) Inspects mouth, tongue, and teeth for
moisture, colour, dentures.
c) Inspects for facial symmetry

Chest:
a) Inspects expansion/retraction of
chest wall, Jugular distension
b) Auscultates breath sounds anteriorly
and posteriorly
c) Palpates for symmetrical lung
expansion

Abdomen:
a) Inspects abdomen for distension,
asymmetry
b) Auscultates bowel sounds (RLQ)
c) Palpates four quadrants for pain and
bladder/bowel distension
d) Checks urine output for frequency,
colour, odour.
e) Determines frequency and type of
bowel movements

Extremities:
a) Inspects arms and legs for pain,
deformity, edema, pressure areas,
bruises and compares bilaterally
b) Palpates radial pulses, Pedal pulses:
dorsalis pedis and posterior tibial
c) Assesses handgrip strength and
equality
d) Assesses dorsiflex and plantarflex
feet against resistance
e) Checks skin integrity and pressure
areas
 Back:
a) Inspects back and spine
b) Inspects coccyx/buttocks

19. Collects the Immunization Details

IMMUNIZATION:
Age Vaccine Given on Remarks
At Birth BCG
OPV - 1st dose

6 weeks Penta - 1st dose

OPV - 2nd dose

10 weeks Penta- 2nd dose

OPV - 3rd dose
14 weeks Penta- 3rd dose
OPV - 4th dose
6-9 months OPV - 5th dose

9 months Measles vaccine

Optional Vaccines

20. Interprets the overall physical assessment

findings and documents the readings
accurately

C. DISINFECTION AND
REPLACEMENT PHASE
21. Removes the thermometer from the
cotton pledget and rinses under running
water and discards the pledget in the
paper bag

22. Takes the third cotton ball for axillary

temperature from the temperature pack
and dries the thermometer from stem to
bulb and discards the cotton ball in the
paper bag
23. Replaces the thermometer in the case and
place it in working area.

24. Washes the hand using standard steps

25. Uses the spirit applied cotton ball to the

disinfect inner compartment articles
such as thermometer, spirit bottle and
replace it in the inner compartment, close
the flap and zip.

26. Replace the stethoscope in the right side

compartment

27. Replace the IEC materials, stationery

pouch, pocket notebook, inch tape in the
outer compartment

28. Washes hands again and dry with towel

and replace the hand washing items in the
left side compartment of the bag.

29. Hands over the used paper bag along with

the cotton balls and 15x10 cm sized
newspaper on which hand washing
materials was placed to be handed over to
the responsible family member for the
proper disposal.

D. CLOSING PHASE
30. Folds the news paper with used side
inside and place it in the outer
compartment.

31. Writes a clear and concise report

regarding physical assessment, services
rendered along with beneficiary/ family
members' receptivity.
32. Refill, update and prepare the
community bag for the subsequent home
visit

33. Shares the home visit findings and Plan

for next visit with the significant family
member

34. Thanks the family members for their

effective cooperation.

Student score