NCM 120 – Health Assessment Lecture  Each of the five aspects is assigned a

maximum score of 2
Assessing Newborns and Infants
APGAR (Activity, Pulse, Grimace,
Appearance, Respiration) score rates:
 Respiration, crying
 Reflexes, irritability
 Pulse, heart rate
 Skin color of baby and extremities
 Muscle tone
 Maximum achievable total score is 10
 Score under 7 suggests that the baby
is having difficulty
 Score under 4 indicates that the baby’s
condition is critical
 Those with very low scores require
special resuscitative measures and
care

SIGN 0 1 2
Activity Flaccid Some Well flexed
flexion
Pulse Absent <100 >100 Bpm
Bpm
Grimace No Grimace Cough/snee
respons ze
e
Appearan Pale/Blu Blue Completely
ce e extremiti pink
es
Respiratio Absent Weak Good cry
n

Vital Signs
Initial Newborn Assessment –
 Temperature
Anthropometric Measurements
- 97.5-99 F (36.4-37.2 C)
 Respiratory Rate  Weight
- 30-60 Bpm  Length
- breathing is easy and nonlabored  Head and Chest Circumference

Functional Assessment of Newborns, Newborn’s Anthropometric

Infants & Children, Adults/Elderly Measurements – Weight

 Newborn (APGAR Scoring &
Anthropometric Measurements)
 Infants & Children (MMDST & some
Major Developmental Milestones)
 Adults/Elderly (PADC, Lawton Scale for
IADL, KATZ index of Independence on
ADL, Barthel Index)
Initial Newborn Assessment – APGAR
Scoring
 Provides numeric indicator of
newborn’s physiologic capacity to
adapt to extra-uterine life
 Assessed at 1 and at 5 minutes after
delivery
 At birth, most babies weigh from 2.7
to 3.8 kg (Kozier et al)/2500 to 4000 g
(Weber & Kelly)
 Just after birth, newborns lose 5% to
10% of their birth weight because of
fluid loss (normal)
 Regains birth weight in about 1 week
 At 5 to 6 months, infants usually reach
twice their birth weight
 By age 12 months, infants’ weight is
usually 3 times their birth weight
 Weigh the newborn unclothed using a
newborn scale

1|NCM 120 LEC

Newborn’s Anthropometric
Measurements – Length

 Average length varies

 Female babies are usually smaller in
length than male babies
 Rate of increase in height/length is
largely influenced by the baby’s size at
birth and by nutrition
 Measure the newborn from head-to-
heel (Cephalocaudal)

Newborn’s Anthropometric
Measurements – Head and Chest  Head Circumference
Circumference - 33-35.5 cm
 Normal head circumference  Chest Circumference
(Normocephaly) should be assessed in - 30-33 cm
relation to chest circumference
 Chest circumference of a newborn is  Length
usually less than the head - 44-45 cm
circumference by about 2.5 cm (1 in)
 As the infant grows, chest
circumference becomes larger than Newborn Reflexes
the head circumference
 Rooting Reflex
 At about 9 or 10 months, head and
chest circumference are almost the
same
 A newborn’s head circumference is
measured around the skull above the
eyebrows
 Sucking Reflex
 Measure chest circumference by
placing the tape measure at nipple line
and wrap it around the newborn

 Palmar Grasp Reflex

 Plantar Grasp Reflex

2|NCM 120 LEC

  Tonic Neck Reflex
 Moro Reflex
 Babinski Reflex
 Stepping Reflex
Developmental Screening Test:
Developmental Assessment of Infants
and Children - MMDST
 Adopted from Denver Developmental
Screening (DDST)
 A screening tool to identify
developmental delays among children
from birth to 6 years of age
 Intended to estimate the abilities of a
child compared to those of an average
group of children of the same age
 Not a test of intelligence
Developmental Assessment of Infants
and Children – MMDST
Four main Areas of Development are
screened:
1. Personal-social
- tasks which indicates the child’s
ability to get along with people and to
take care of himself
3|NCM 120 LEC
2. Fine-Motor Adaptive
- tasks which indicate the child’s ability
to see and use his hands to pick up
objects and to draw
3. Language
- tasks which indicate the child’s ability
to hear, follow directions, and to speak
4. Gross Motor
- tasks which indicate the child’s ability
to sit, walk, and jump
Assessment of Infants and Children –
Immunization Status
Immunization
- the process by which resistance to an
infectious disease is produced or augmented
Types of Immunity:
1. Active Immunity
- acquired when a person produces
antibody in response to an antigen
can either be:
- a. Natural - exposure and/or
recovery from an infection
- b. Artificial - acquired through the
infection of a small amount of
attenuated (weakened) or dead
organisms (vaccines) or modified
toxins from the organism (toxoids)
into the body
2. Passive Immunity
- a resistance of the body to an
infection in which the host receives
natural (from the mother to her
unborn child through placental
transfer) or artificial antibodies
produced by another source/host
  Abnormal
- Jaundice
- Cyanosis
- Pallor
- Redness
- Ecchymoses
- Petechiae
- Dirty, matted hair
- Tufts of hair over spine

Head, Neck, and Cervical Lymph Nodes

 Normal:
- Fontanelle
- Full range of motion
Assessment of Infants and Children – - Face is normally proportionate &
Immunization Status symmetric
- The neck is usually short with skin
A child’s immunization status can be folds between the head and the
categorized as: shoulder during infancy
1. Incompletely Immunized  Abnormal:
2. Completely Immunized - Very large head
3. Fully Immunized - Oddly shaped head
- One-sided flattening of the head
Assessment of a Pregnant Woman - Third fontanelle
 Estimating Delivery Date (EDC/EDD) - Caput Succedaneum
 Estimating Gestational Age (AOG) - Cephalohematoma
 Maternal Assessment (history) - Hyperextension of the head
- Limited ROM
Subsequent Physical Assessments - Unusual proportions
- Short, webbed neck
Head Circumference
- Distended neck
 Abnormal: - Enlarged or thyroid or palpable mass
- Macrocephaly
Eyes
- Microcephaly
 Normal:
Skin, Hair, and Nails
- Inner canthus distance
 Normal: approximately 2.5 cm
- Physiologic Jaundice - Horizontal slant, no epicanthal folds
- Birthmarks - Outer canthus aligns with tips of
- Milia pinnas
- Harlequin Sign  Abnormal:
- Mongolian Spot - Hypertelorism
- Vernix Caseosa - Sun-setting
- Acrocyanosis - Brushfield Spots (whitish spots in a
- Desquamation ring-like arrangement at the periphery
- Cutis Marmorata of the iris)
- Lanugo (soft, fine hair)
Ears

4|NCM 120 LEC

  Normal:  Abnormal:
- Top of pinna should cross the eye- - Inflammation, discharge, and
occiput line and be within a 10-degree redness of umbilicus
- No unusual structure or markings - Diastasis recti
should appear on the pinna - A bulge at the umbilicus
- No excessive cerumen, discharge, - Abnormal insertion of cord,
lesions, excoriations, or foreign body discolored cord, or two-vessel cord
in external canal - A rigid abdomen
 Abnormal:
Male Genitalia
- Low-set ears
- Abnormal shape  Normal:
- Presence of foreign body or cerumen - Penis is normal size for age and no
- Purulent discharge lesions are seen
- Purulent, serous discharge - The foreskin is retractable in
- Bloody discharge uncircumcised child
- Clear discharge -Urinary meatus is at tip of glans penis
and has no discharge or redness
Mouth, Throat, Nose, Sinuses
- Scrotum is free of lesions
 Normal: - Testes are palpable in scrotum with
- Epstein’s Pearls the left testicle usually lower than the
- Gums appear pink and moist right
- Teeth may begin erupting at 4-6  Abnormal:
months - Phimosis
- Tonsils are not visible - Paraphimosis
- Nose is midline in face, septum is - Hypospadias
straight, and nares are patent - Epispadias
 Abnormal: - Cryptorchidism
- Cleft lip & Palate - Hydrocele
- Inguinal Hernia
Heart
Female Genitalia
 Normal:
- PMI 4th left intercostal space  Normal:
- Mid coast line - Labia majora and minora are pink
 Abnormal: and moist
- Dextrocardia - Newborn’s genitalia may appear
- Cardiomegaly prominent because of influence of
maternal hormones
Abdomen
- Bruises and swelling may be caused
 Normal: by breech vaginal delivery
- Abdomen is prominent in supine  Abnormal:
position - Enlarged clitoris in newborn
- Umbilicus is pink, no discharge, odor, combined with the fusion of the
redness or herniation posterior labia
- Cord should have 3 vessels
Anus and Rectum
- Normal bowel sounds (10-30)
- Abdomen is soft to palpation and  Normal:
without masses and tenderness - Anal opening should be visible, moist
- Perianal skin should be smooth and

5|NCM 120 LEC

 free of lesions  Psychological/Social Stressors
- Meconium passed within 24-48 hours
Functional Assessment Tools
 Abnormal:
- Imperforate Anus 1. Katz Activities of Daily Living (ADL)
Older American Resources and
Musculoskeletal
Services Assessment (OARS)
 Normal: - Bathing
- Feet and legs are symmetric in size, - Dressing
shape, and movement - Toileting
- Extremities should be warm and - Transferring
mobile with adequate capillary refill - Continence
- All pulses should be string & equal - Feeding
bilateral; Independence (1 pt.)
 Abnormal: - No supervision, direction, or personal
- Palmas Simian Crease assistance
- Polydactyly Dependence (0 pt.)
- Syndactyly - With supervision, direction, or
- Phocomelia personal assistance, or total care
- Hemimelia 2. The Barthel Index
- Talipes - Bowels
- Bladder
Terminology
- Grooming
 Functional Assessment
 Activities pf Daily Living (ADLs) (Higher scores indicate higher levels of
independence)
 Instrumental Activities of Daily Living
(IADLs) - Toilet Use
 Psychological Function - Feeding
 Social Functioning - Transfer
- Mobility
Functional Decline
- Dressing
 35.6 million over 65 (2002) - Stairs
- Bathing
Who are limited by chronic condition? (from
Independence (1 pt.)
2000 data)
- No supervision, direction, or personal
 26.1% of those 65-74 (young-old) assistance
 45.1% of those 75+ (old old) Dependence (0 pt.)
 73.6% of those 80+ (oldest) - With supervision, direction, or
personal assistance, or total care
Comorbid Conditions

 Acute Illness
 Alteration in nutrition and/or Hydration
 Chronic Illness
 Delirium
 Dementia
 Economics
 Environment
 Medications
 Psychiatric Comorbidities – Depression

6|NCM 120 LEC