Physical Assessment

Body Appearance VITAL SIGNS Temperature Respiratory Rate Pulse Rate GENERAL SURVEY Length Head circumference Chest circumference Abdomen circumference Weight SYSTEM OF ASSESSMENT Skin

Techniques

Normal Findings

Actual Findings

36.0 C 48 cpm 146 bpm

Interpretation N O R M A L

Analysis

49 cm 32 cm

32cm

28cm

9.9kg N O R M A

Inspection

Smooth; warm to touch; has good

Newborn babies have higher than normal

skin turgor; presence of lanugo; superficial skin peeling or rashes; yellowish skin color (physiologic jaundice)

Head

Inspection

Normocephalic; hairs evenly distributed; the face is symmetrical

Anterior fontanel diamond shaped; Posterior fontanel triangular; hair is silky and soft and black in color; presence of caput succedaneum

N O R M A L

number of red blood cells. Because the baby has more RBC which is being break down more quickly, more bilirubin is made. Your babys liver removes the bilirubin from their blood. But the liver is a complicated organ and, despite a baby being full term, it can take a few days to work properly. So, bilirubin builds up in the blood and it causes babies to be jaundiced. Reference: Caput succedaneum is a temporary swelling of the soft parts of the head of a newly born infant that occurs during labor, due to the compression of the muscles of the cervix of the uterus and it resolves after delivery. It does not usually cause complications and usually resolves over the first few days. Reference: the bantam medical dictionary 6th edition

Eyes

inspection

Ears

Inspection and palpation

Symmetrical or evenly placed and inline with each other. Non protruding and equal palpebral fissure. Has same skin color with his face; symmetrical, firm;

Symmetrical in size and shape; eyebrows are distinct (not connected in midline) Ears are well formed and complete; symmetrical and is aligned to the outer canthus of the eye; pinna recoiled when folded Symmetric features

N O R M A L N O R M A L

Face

inspection

Nose

inspection

located symmetrically on the midline of the face that is without swelling, bleeding, lesions, or masses. No discharge or flaring and uniform color

Symmetrical; both nostrils open to air flow; presence of milia on the tip of the nose

N O R M A L N O R M A L

Mouth

inspection

The lips should be pink, soft moist, smooth texture with no evidence of lesions or inflammation. Not crack and symmetrical. No retractions;

Mouth, gums and tongue are pinkish; tongue is in midline position; soft and hard palate are intact; uvula in midline

N O R M A L

Chest

inspection

Abdomen

inspection

Almost circular, barrel shape thorax, presence of coarse crackles , rhonchi sounds and murmur; nipples aligned; stippled areola that is 1-2mm Surface is uniform Umbilical cord is in color and in whitish gray in pigmentation; No color, odorless and striae / stretch has 2 arteries and 1 marks are vein; present; No rashes or lesions are present; Normally range from flat to rounded.

N O R M A L

N O R M A L

Genitalia (female)

inspection

N O R M A

Extremities

inspection

Reflexes

inspection

Correct number and formation of fingers; flexion, has good muscle tone; bilateral movement of extremities; legs equal in length; normal position of the feet; presence of faint, red marks Toes flare with dorsiflexion of the big toe.

L N O R M A L

Babinski

Gallant (trunk incurvation)

inspection

Entire trunk flexes toward the side stimulated

Grasp

inspection

Fingers curl tightly, toes curl forward

Moro

inspection

Sharp extension and abduction of the arms with the

N O R M A L N O R M A L N O R M A L N O R

Rooting

inspection

thumbs and forefingers in C position Infant turn to the side touched

Startle

inspection

Stepping

inspection

Sharp extension and abduction of the arms with the thumbs but the hands remain clenched Infant lifts alternate feet as if walking

Sucking

inspection

The infant begins to suck

Swallowing

inspection

Infant swallows fluid and is coordinated with sucking

M A L N O R M A L N O R M A L N O R M A L N O R M A L N O R M A L

Tonic neck

inspection

N O R M A L