NOOTAN COLLEGE OF NURSING

VISNAGAR

SUBJECT:- Nursing Education

TOPIC: - Procedure of Infant Assessment

SUBMITTED TO: SUBMITTED BY:

Mr. Kuldeep jain
Ms. Mansi D. Patel
Assistant Professor 1st
Year M.Sc. Nursing
NCN, Visnagar
NCN, Visnagar

Submission Date : / / 2024

 Bio data
 Name of the Student : Mansi D. Patel
 Year of study : F.Y M.SC Nursing
 Subject Name :Community Health Nursing
 Topic / Procedure :Infant Assessment
 Place :Visnagar
 Time : 30 min
 Methods of Teaching : Demonstration
 Language :Gujarati

INFANT ASSESSMENT

DEFINITION
Infant is defined from the age of 28 days to 1 year. It is a thorough inspection or detailed study of
the entire body or some part of the body to determine the general physical or mental condition of
the body of the infant.

PURPOSES
 To identify normal characteristics in the infant.
 To identify existing abnormalities, if any
 To carry out immediate action if there is any deviation.
 To establish a baseline for future physiological changes.
 To know about the immunization
 To know about the dietary pattern of the infant

SKILLS (METHODS) OF PHYSICAL EXAMINATION

The skills required for physical examination of infant are:

 Look (inspect) -Inspection
 Feel (palpate ) - Palpation
 Tap/thumb (percuss) - Percussion
  Listen (auscultate) - auscultation
 Manipulation- moving of body parts to note its flexibility.

PRECAUTIONS TO BE TAKEN DURING THE PHYSICAL ASSESSMENT

 Keep your hands clean, dry and warm.

 Keep your nails short and free of nail polish.
 Do not expose the infant unnecessary.
 Do not expose the infant to drafts and chills.
 Examine the infant swiftly not more than 10 to 15 minutes.
 If infant is irritable/crying during examination allow him to suck on a nipple.
 Inform mother about outcome of examination.

PREPARATION OF INFANT

It is very important to prepare the parents and infant physically as well as mentally. Adequate
explanation and consent needs to be given about nature of assessment.

1. Physical preparation:
 Maintain privacy, excessive handling and excessive exposure to prevent hypothermia.
 Use appropriate draping and restraints if necessary.
 Maintaining comfortable environment, Warmth/adequate temperature and Comfortable
position.
 Good lighting and appropriate position according to area to be assessed.

2. Psychological preparation: It is nurse duty to allay the anxieties and fear by proper
explanation. Explain the sequence of the procedure to gain parents confidence and co-
operation during examination.

ARTICLES REQUIRED :

Sr. Name of articles Uses/ scientific principle

No.
1. Community home visit bag To have articles on hand for
procedure

2. Soap with soap dish and towel To wash hands

3. bed sheet and draw sheet For covering the infant

4. Weighing scale To Measure the weight

 5. Scale To mark the height on poster

6. measure tape To measure height, and

circumferences

7. TPR Measure vital signs

8. Stethoscope For listening breath and heart sounds

9. Wrist Watch To count the heart rate and

respirations

11. Plain poster paper To take the height.

15. Khoya and small padded mattress To weigh the infant

12. Spirit swabs To clean the thermometer.

13. Kidney Tray/ paper bag To collect waste

14. Recording sheet and pencil To record the procedure.

STEPS OF THE PROCEDURE WITH RATIONALE:

Steps of the procedure Rationale

Select the appropriate area for doing To place the bag and arrange articles
procedure in the home.

Explain the procedure to parents To make them informed for co operation

Collect hand washing material and To wash hands thoroughly

Wash hands

Keep the baby in mother’s lap only and

 assess height and weight of baby. To cause minimal disturbance to baby and fell her
relaxed.

Drape the infant adequately. To prevent hypothermia and excessive exposure.

Keep the required instruments ready so To go in a systematic manner and perform the
that the examinations can be carried out procedure in organized way.
from head to toe.

Inspect skin, fontanels and other body Head to toe examination

parts.

Auscultate heart rate, breath sound and To feel any abnormality in circulatory system
feel respiration

Take vital signs and all Helps to get accurate data as infant will not crying
circumferences. initially.

Articles used in physical examination To prevent cross-infection.

should be clean and dry.

To assess normal growth of infant in this 4 month

Measure height of the baby

At last check weight of the baby To assess normal growth of infant in this 4 month

Check all reflexes include moro, To find out normal physiological development of
rooting, tonic neck, grasp, babinsky baby.
reflex etc.

MEASUREMENT OF VITAL SIGNS.

 Take temperature: (37˚C ± 0.5˚C)

  Count heart rate: 120-140 beats/minute
 Count respiratory rate: 40-60 breaths /minute

PHYSICAL MEASUREMENTS

 Weight: 2.8-3.5 kg
 Length: 50 cm
 Head circumference: 33-35.5 cm
 Chest circumference: 30.5-33 cm
 Color: skin is pink
 Activity: good activity.
 Skin: smooth and velvety—rose petals.

HEAD TO TOE EXAMINATION:

 Head: check for size, shape of fontanels or any other abnormality.

 Fontanels : Anterior Fontanel (Diamond shape, Size :2.4 x4.5 c.m, Closes : 18 month)
 Posterior Fontanel : Triangular shape, Size : 0.5 to 1 cm, Closes : 6 week
 Eye: Check for Conjunctivitis, Epicanthal fold, Inner canthus, Squint, Nystagmus,
Trauma, Lachrymal duct obstruction, Congenital cataract, Corneal opacity.
 Ear: Check for Shape, position of ear. Check for any accessory lobules. Check for
hearing.
 Neck: Check for Any mass in neck, Torticolis, Lymph nodes. Range motion exercise of
Neck. (If neck is short and webbed, it indicates Turner’s syndrome.)
 Nose: Check for Flaring of nose. Depressed nose bridge.(Both signs are the indicatives of
Down’s Syndrome.
 Mouth: Check for Cleft lip and palate. Size of chin. Tongue tie.
 Chest: Check for Retraction of the intercostals space. Brest for size, symmetry, color,
Turgor and any discharge. Auscultate air entry in the lungs. Respiratory rate. Auscultate
hear sound. Cyanosis.(Chest retraction shows severe Respiratory Distress.)

 Abdomen: Check for Contour of abdomen. Exomphalos/Omphalocele. check for liver,

spleen enlargement or any mass or Lump. Inguinal hernia. Femoral artery pulsation in
both side of groin. Lymph node enlargement in groin. (Concave abdomen à
Diaphragmatic hernia
 Genitals: Discharge from vagina. Check for (Male): Scrotum for rugae. Identify Testis in
scrotum. Urethral opening to rule out Epispadias, Shaft of penis, Hydrocele, Inguinal
hernia.
  Rectum: Check for Fistula or any abnormal opening.
 Back : Check for Curvature, Mongolian spot on sacrum, Spina bifida, Meningocele or
Meningomyelocele.

REFLEXES OF THE INFANT

 Rooting reflex: If cheek of infant is rubbed, the infant will turn his head on that side.
 Sucking reflex: Developed at 32-36 Weeks of gestation.
 Moro’s reflex: Grasp the wrist of infant and draw it forward and then drop back on to the
bed, the infant’s body will shows all extremities extending and flexing OR Make a loud
sound by banging the examination table, the limb will extend and flex.(This reflex
Should be Checked Last as The infant Will start Crying).
 Dancing reflex: Place the child in standing position near the table the feet will touch the
table and flex alternately both the legs giving an appearance as infant is dancing. (It
disappears by the 1-2 months).
 Doll’s eye reflex: Turn the head of the infant the eye moves in the opposite direction. It
disappears once the child is able to focus.
 Tonic neck reflex : When infant neck is quickly turned to one side extremities on that
side extend and opposite side flex.
 Grasping reflex: Put your finger near the child’s palm, the child closes its finger around
it.
 Babinski reflex: When stimuli is given to dorsiflexion of the large toe with fanning of
other toes.
 BIBLIOGRAPHY:-

1. Asma Rahim “PRINCIPLES AND PRACTICE OF COMMUNITY

MEDICINE” First edition-2008 published by jaypee brothers

medical publishers (p) ltd.

2.B T Basvanthappa “COMMUNITY HEALTH NURSING”,2nd edition,

2008published by jaypee brothers medical publisher (p) ltd.

3. K PARK “COMMUNITY HEALTH NURSING”, 6th edition 2012

published by M/S Banarsias Bhanot publishers 1167 Premnagar,

Jabalpur.

4. S Kamalam “ESSENTIAL IN COMMUNITY HEALTH NURSING

PRACTICE” 1st edition 2005, published by jaypee brothers

medical publishers (p) ltd.

5. Swarnkar’s “COMMUNITY HEALTH NURSING”, 3rd edition published

by Jaypee brothers medical publishers (p) ltd.