Head To Toe Assessment Of Infant Csepre 425h2u

PHYSICAL EXAMINATION System VITAL SIGNS

Actual findings 

Temperature:

Normal findings

37.44oC



BP: not assessed



RR: 24 m



PR: 110 bpm

is The child's vital

Temperature



36.5°C

Remarks

(because

of signs are within

excess heat production).

the normal range

apical pulse: 100- in relation to his



120 bpm 

RR: 20-30 m



Awake and resting

age.

rates may vary with the age of the child. Rate decreases gradually with age. ANTHROPO-



METRIC

Weight: 7.8 kilograms

Asians are smaller



Head

than Caucasians

circumference

MEASURE-



Height: 63 cm

newborn. Asian children

should be greater

MENT



Head

are smaller at all ages

than

circumference,

Chest

which does not

circumference: 47 cm  SKIN

and

abdominal

circumference: 45 cm 

chest

happened to the

Abdominal

circumference: 46 cm  Light brown and uniform in color

client.  Skin color ranges from Child

has

a

pale white with pink, healthy skin and

 No foul ordor

yellow, brown, or olive has no problem

 No masses, lesions

tones to dark brown or on this.

No wounds,



should be evident, and

laceration Skin is

 moist

black. No strong odor the skin should be lesion free.

19



No rashes



Warm and

 Skin warm,

HAIR

NAIL

be

slightly

soft moist

with good turgor and

uniform to touch

without

Good skin



should

lesions

and

edema.

turgor  Uneven distribution

 Unevenly distributed

All of the findings

 No scalp lesions

 Fine to course

for the hair are

 No masses

 Absence of infestation

found to be within

 Fine to course

 No masses

the normal range.

 Absence of infestation  No lesions  Pinkish nail bed  Nail bed is pink

All of the findings for the nails are



Concave shape

 Concave shape



Color of the nail  Capillary refill backs bed back to original

found to be within the normal range.

within 1-2 seconds

color in less than three seconds. HEAD

 

 Smooth to touch

Smooth to touch Asymmetrical with  Asymmetrical, rounded frontal,

and

Posterior fontanel

occipital

should close at

parietal

flatted

two months while

prominences 

Normal findings.

consistency; anterior fontanel absence of nodules or should close by 12 - 18 months. masses

No palpable lymph  Uniform nodes



No tenderness



Symmetrical facial  Symmetrical expression

such

 Head is non-tender. as

facial

movements

smiling, frowning 

Posterior fontanel is  The posterior fontanel is closed

and

anterior

fontanel is still open.

closed; anterior fontanel is still open.

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EYES

All of the findings

Symmetrica  Eyes are symmetrical

 l

Equal



 Hair evenly distributed; for the eyes are found to be within eye skin intact  Eyebrows symmetrically the normal range.

lashes distribution Eyebrows

are

symmetrically

aligned



and evenly distributed 

Equal movement



No discharge, no

aligned  Equal movement  No

discharge,

no

discoloration of eyelids

discoloration of eyelids  When lids are close, When



close,

lids

sclera

are

is

sclera is not visible

not  Sclera is white

visible

 Pink conjunctiva



Sclera white



Pink conjunctiva

 No edema or tenderness over the lacrimal gland

 No edema or tenderness EARS

over the lacrimal gland  Symmetrical

 Color same as facial  skin

Firm

 not tender 

SINUSES

and 

 No



No

nasal 

discharges 

aligned the normal range.

eye

 Symmetrica 

l 

Auricle

as for the ears are found to be within

with other canthus of the

No lesions



same

facial skin

canthus

NOSE AND

Color

Aligned to the inner 



All of the findings

Symmetrical



Absence of lesions Firm and not tender Symmetrical

All of the findings

No discharge

for the nose and

Absence of nasal sinuses are found to be within the flaring Uniform in color

normal range.

flaring 21



Uniform in color



Nose is non-tender



Not tender



No lesions



No lesions

 Pink mucosa



Pink mucosa

 Nasal septum intact and



Nasal septum intact

in the midline  Sinuses are not tender

and in the midline Sinuses are

 not tender MOUTH



No tooth yet 



Lips is soft,

Tooth

moist,

smooth found to be within the normal range.

texture of lips

texture Gums

Uniform pink color

is 

of gums, tongue and

pink Tongue



for the mouth are

erupted

moist and has smooth  Soft,



yet All of the findings

hasn't

tonsil

is

pink 

Tonsil is pink at the



Smooth



 pink

 Uvula

 positioned THROAT AND NECK

in

is the

midline of soft palate  Uniform in color

Light

pink

hard

palate

hard

palate

Light pink, smooth soft palate

Light pink, smooth Light

tongue

base

tongue

soft palate 

Smooth



base 

rough tongue

Moist and slightly rough tongue



Moist and slightly



middle

Uvula is positioned in the midline of soft palate

 Generally uniform in color

All of the findings for the throat and 22



No palpable lymph nodes

BREAST AND

Neck can move

 Neck can move freely



freely Skin is smooth and

 Skin

uniform in color

is

smooth

within

the

normal range.

and All of the findings

uniform in color

for the breast and



Symmetrical breast  Symmetrical breast and axilla are found to



Symmetrical axilla



No tenderness

 No tenderness



No secretion

 No secretion



No masses or



axilla

CHEST & RES-  

be

within

the

normal range.

No palpable masses or nodules

nodules

PIRATORY

be

nodes in the



AXILLA

neck are found to

 No palpable lymph

Skin is intact



Regular interval in  breathing

Intact skin

All of the findings

Regular pattern of

for the chest and

breathing

the respiratory are

 Absence of tenderness,

found to be within

No tenderness

lesions and palpable

the normal range.

No masses

masses



No lesions

  

Shoulder height is  Symmetrical shoulder height symmetrical



observed  Absence of dyspnea and has regular depths of difficulty in breathing. respiration There equal rise and No

fall of the chest with regular CARDIOVAS-

respiration.  Apical pulse:110

CULAR AND PERIPHERAL

depths

of 

bpm 

No cold extremities  and discolored

Apical pulse is palpable Absence of cold extremities

All of the findings for

the

cardiovascular and are found to

23

extremities ABDOMEN





Uniform skin color

No discolored

extremities  Uniform in color

be

within

the

normal range. All of the findings for the abdomen

in the abdomen 

Symmetric contour 

Symmetric contour

are found to be



Rounded

Rounded or

within the normal



protuberant abdomen 

No lesions

REPRODUC-

 

No tenderness Not assessed

TIVE MUSCULO-



SKELETAL

Uniform in skin color Mobile





Absence of lesions and tenderness  Not assessed

Equal size on both sides of the body



All of the findings

 Smooth coordinated

for

movements

 Absence of deformities,

musculoskeletal are found to be within the normal range.

No  Absence of tenderness

No fractures  Absence of swelling and dislocations noted



of the body

the

fractures and dislocation

deformities noted 

Not assessed

 Uniform skin color

 Equal size on both sides 

range.

No

 No tremors  No palpable nodules

tenderness and swelling 

Does not have tremors and palpable nodules

 ENDOCRINE

10 fingers

and toes  Rapid weight gain (gained 10.16 lbs in

 Gradual weight gain

Infant 0-6 months old should gain 0-

24

HEMATOLO-

four months time)  No bleeding

 No bleeding

GICAL



No bruises

 No bruises

LYMPH

 

Type O No palpable lymph

 Blood Type  No enlarged lymph

NODES

nodes 

No tenderness

2 lbs per month. Normal findings.

Normal findings.

nodes  Not tender

noted

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