You are on page 1of 2

Mark Payawal 2-8, Nursery 1-5:30 PM Head-To-Toe Assessment BABY BOY F General Measurements Head Circumference Chest Circumference

Abdominal Circumference Crown-to-rump Head-to-heel Birth Weight 34 cm 33 cm 28 cm 32.6 cm 50 cm 3.48 kg 36.7 O C 123 bpm 47 breaths/min

Loss of weight for the first week Vital Signs Crying increases temperature slightly Crying increases HR Crying increases RR

Axillary Temperature Heart Rate Respiratory Rate General Appearance Skin



Ears Nose Mouth and Throat

Neck Chest

Posture : Flexion of head and extremities, which rest on chest and abdomen Presence of Vernix caseosa Presence of lanugo with bald areas Evailing rare veins Edema around the eyes, face and scrotum Presence of Milia Presence of Mongolia spot Anterior Fontanel : diamond-shaped, barely palpable, 4.3 cm Posterior Fontanel : triangular-shaped, barely palpable, 0.7 cm Fontanels are flat, soft and firm Widest part of fontanel measured from bone to bone not suture to suture Presence of Caput succedaneum Presence of Molding Edematous eyelids Brown color Absence of tears Reflexes : red reflex, corneal reflex in response to touch, papillary reflex in response to light Rudimentary fixation on objects and ability to follow midline Position : Top of pinna on horizontal canthus of the eye Startle reflex elicited by loud, sudden noise Pinna flexible, cartilage present Nasal patency Nasal discharge: Thin white mucus Sneezing Intact, high-arched palate Uvula in midline Presence of frenulum of tongue and frenulum of upper lip Reflexes : Sucking reflex, rooting reflex, gag reflex and extrusion reflex Absence of salivation Vigorous cry Presence of Epstein pearls Short, thick and surrounded by skinfolds Presence of tonic neck reflex Anteroposterior and lateral diameters are equal Xiphoid process is evident Presence of a funnel chest

Lungs Heart Abdomen

Male genitalia

Back and Rectum


Neuromuscular System

Slight breast enlargement Respirations are abdominal Bilateral equal bronchial breath sounds Apex : 4th 5th intercostal space, lateral to left sternal border S2 is slightly sharper than S1 Cylindric in shape The liver is palpable 2.4 cm below right costal margin The kidneys are palpable above umbilicus The umbilical cord is brown and drying with 2 arteries and 1 vein Femoral pulses are equal bilaterally Urethral opening at the tip of glans penis Testes are palpable in each scrotum Scrotum is edematous, pendulous, pigmented and covered with rugae Urination within 24 hours Presence of hydrocele Spine intact, no openings, masses or prominent curves Trunk incurvation reflex noted Anal reflex Patent anal opening Voided meconium within 48 hours 10 fingers and toes Full range of motion Nail bed are pink Creases on anterior 2/3 of sole Sole are usually flat Symmetry of extremities Equal muscle tone bilaterally, especially resistance to opposing flexion Equal bilateral brachial pulses Extremities in some degree of flexion Extension of extremity followed by previous position of flexion Head lag while sitting, but momentarily ability to hold head erect Ability to turn head from side to side when prone Ability to hold head in horizontal line with back when held prone