Infant Assessment Components at Discharge

1. General Assessment

  • General appearance
  • State of alertness, behavior
  • Muscle tone
  • Symmetry
  • Response to sound and movement
 

2. Skin

  • Colour
  • Rashes, lesions, petechiae
  • Birthmarks
  • Turgor
 

3. Measurements

  • Head Circumference
  • Length
  • Weight

 

4. Head

  • Sutures
  • Fontanels
  • Bones of skull
  • Symmetry
  • Cephalhematoma
  • Gaze, tracking
 

5. Heart and lungs

  • Auscultate heart sounds over the five areas of the heart: aortic, pulmonic, 3rd left interspace, tricuspid and mitral
  • Rate and regularity
  • Auscultate lungs, air entry
  • Symmetry during respirations
  • Clavicles

 

6. Abdomen and hips

  • Palpate the abdomen for liver, spleen
  • Distention, masses and hernia
  • Observe umbilicus
  • Assess hips for congenital dislocation
 

7. Developmental markers

  • Smiling
  • Cooing
  • Head control