SAINT LOUIS UNIVERSITY

SCHOOL OF NURSING
Infant Assessment Tool (1 month-12 months)
Patient’s Profile:
Child’s Initials:________________________ Sex: Male FemaleBirth order: ______
Mother’s initials:____________________ Date & Time of Delivery:_____________ Type of delivery: NSVD Forceps CS
APGAR Score: __________1 min. ________ 5 mins. Ballard’s Score: ____________
Vital Signs: Temp. _______ CR: _______ RR_______ Weight: _____kgs. Length: ____cm.
HEALTH HISTORY
Prenatal Concerns: : None Yes, specify__________________________________________________________________
Postnatal problems: : None Yes, specify __________________________________________________________________
Newborn Screening: No Yes : results: ________________________________
Immunizations received: BCG OPV ( 1 2 3 ) DPT ( 1 2 3 ) antimeasles
anti Hep ( 1 2 3 ) HIB MMR others:specify_____________________Weight: _____kgs. Length: _____cm.
Anthropometrics: Head circ: ____cm Chest circ:____ cm Abdominal circ:___cm Arm circ:_____cm
INTEGUMENTARY & HEENT: Diagnosis:___________________________________________ CARE CONCERNS
Skincolor: pinkish acrocyanotic erythema cyanotic Jaundice mottling Sensory/Perceptual
harlequin’s sign Others:_______________ Turgor: good poor Alteration
Lesions(type):__________________loc.__________________________________________ Impaired Swallowing
Birthmarks: ________________________Pigmentations:_________________________ Risk For Injury
Head:shape: Molding caput succedanum cephalhematoma craniotabes Risk For Aspiration
head control Ant. fonatanelle: ___________Post. fonatanelle:______________
Airway clearance
tonic neck reflex torticollis Hydrocephalus Microcephaly
others: ___________________________________________________________ Tissue perfusion
Eyes: symmetrical assymetrical epicanthal fold Nystagmus Diplopia Nutrition
Color of conjunctiva: pinkish reddish pale others:_________________________ Impaired oral mucus
Color of sclera: anicteric icteric bluish others:________________________ membrane
eye discharges: ____________________ others: ___________________________________ Others:________
Response to face or objects: _______________________________________________
Nose: patent discharges:____________________ Erythematous membrane
Asymmetry of nasolabial folds obstructions:_________ others: ___________________
Ears: symmetrical asymmetrical low-set ear placement deformities:___________
Discharges: ______________ redness: _____________ inflammation: _____________
Response to loud noise: _______________________ others:____________________________
Lips: color: pinkish reddish pale bluish sores fissures
Cleft lip: ___unilateral ___bilateral cleft palate
Mouth: Mucous membrane: moist dry lesions:_________________________________
bleeding tongue mobility:_________________ tonsils: _____________________________
Reflexes: sucking rooting extrusion gag
Lymph nodes: enlargement __________________ tenderness:__________________________
Medications: ______________________________________________________________________
Diagnostic results: __________________________________________________________________
NEUROMUSCULAR ASSESSMENT: Diagnosis____________________________________________ CARE CONCERNS
LOC: Alert irritable absent cry Decreased response to stimuli:_________ tissue perfusion
abnormally sleepy others:__________________________________________________ Growth and development
Reflexes: Tonic neck Moro / startle Palmar grasp plantar grasp Babinski Doll’s eye Safety/injury
Muscle tone: equal unequal Muscle atrophy Others: ___________
 Extremities: asymmetrical polydactily syndactily deformities_______________
 Leg length: equal unequal Gluteal folds: symmetrical asymetrical
 Movements: tremors twitching seizures:type:__________ duration:__________
Meningeal irritation: nuchal rigidiy opisthotonos Brudzinski’s Kernig’s
Medications:______________________________________________________________
Dx results: ________________________________________________________________
CARDIO-PULMONARY ASSESSMENT: Diagnosis:_______________________________________ CARE CONCERNS
Cry: Spontaneous loud weak none shrill hoarse Tissue perfusion
Chest:movement: equal see saw deep Others: ____________________ Gas exchange
Use of accessory muscles: ______ retractions:__________________________ Breathing pattern
Resp sounds: grunting stridor snoring rales:_______ ronchi wheezes Cardiac output
Oxygen therapy: via________ LPM ____ CPAP others: ___________
Cardiac: Apical pulse: Rate: ____ Regular Irregular Deficit: No Yes
Pulses : Radial ____L____R Femoral ____L____R Pedal ____L____R
Capillary Refill: ___ seconds Others: Clubbing Pulsating neck vessels /JVD Bulging chest
Cardiac: Rhythm : Regular Irregular murmurs:grade_______ Thrills Bruits
Medications:______________________________________________________________
Dx results: ________________________________________________________________

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GASTROINTESTINAL & GENITOURINARY: Diagnosis______________________________________ CARE CONCERNS
Feeding: Type: breastfed mixed bottlefed; formula brand _____________ Elimination
solid foods: when introduced:______(type/amount/frequency): ____________________________ Infant feeding pattern
NPO (SINCE: Date/Time): ______________ Nutrition
Enteral: NGT Gastrostomy Jejunostomy Others: __________ others: ____________
Frequency:________ Amount: ___________ Enteral Feeding formula: ______________
Nutrition: obese cachexic bloated abdomen loss of appetite Nausea
Emesis (describe): ______________________________
Abdomen: Soft Tender Firm scaphoid Distended Rigid
Tympanic________ Dull:____________ Abdominal Girth: ____________________
Palpable mass others: ______________
Bowel movements: frequency: ______ consistency:__________ regularity:___________
Last BM:______ Constipated (# of Days) ____ Diarrhea (Characteristics): ____________
discomfort abdominal pain Melena
Bowel Sounds: Normal Hypoactive Hyperactive Absent

Others: ___________________________________________________________________________
Urine: color ______________ Frequency within 24 hrs.______________ Amount:__________
Others: ___________________________________________________________________________
Medications:_______________________________________________________________________
Dx results: ________________________________________________________________________

Assessment of Hydration Status: REFER to IMCI CARE CONCERNS

Decide No dehydration Some dehydration Severe dehydration fluid volume
Look at Well Alert Restless Irritable Lethargic
Eyes Normal Sunken Very sunken
Tears Present Absent Absent
Tongue Moist Dry Very dry
Thirst Drinks normally Thirsty Drinks poorly
Skin pinch Goes back quickly Goes back slowly Goes back very slowly
Pulse Normal Faster than normal Very fast, weak or absent
Fontanelle Normal Sunken Very sunken

REPRODUCTIVE SYSTEM: Diagnosis:_________________________________________________ CARE CONCERN

Breast: symmetrical dimpling masses nipple discharge Male gynecomastia Pain
discharge :characteristics __________________________ others: ______________________ Infection
External Genitalia: Lesions:_____________________________________________ Others:__________
Pain:__________ Inflammation:charac_______________________
Discharge:Characteristics:________________________________________________________
MALE: Hernia: __umbilical __inguinal Phimosis Balanitis Hypospadia
Epispadia
Cryptorchidism penile pain/discharge Scrotum: edema discoloration others:_________
Medications:_________________________________________________________________
Dx results: ___________________________________________________________________

PSYCHOSOCIAL STATUS: Diagnosis:_____________________________________________ CARE CONCERNS

Planned pregnancy? Yes No People involve in the care of child?_____________________ Parent-infant attachment
Quality of marital relationship: satisfied dissatisfied:___________________________________ Parenting process
Quality of parent child relationship:____________________________________________________ Family processes
Child rearing capacity: Adequate inadequate:________________________________________ Growth and dev delay
Developmental state: Infant behavior
Fine motor abilities:__________________________________________________________________ Others:___________
Gross motor abilities:_________________________________________________________________
Language:_________________________________________________________________________
Social/emotional____________________________________________________________________
Signs of neglect/abuse: ________________________________________________________________
Environmental characteristics affecting growth and development: _______________________________
___________________________________________________________________________________
Others: ____________________________________________________________________________

I do hereby certify that all information written on this assessment tool are true and correct, to the best of my knowledge and belief.

Name of the student ___________________________Signature _____________________ Date ________________

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