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Infant was taken over attached to mothers breasts, good suckling reflex was
R.L Term
observed. Infant is active and alert, general posture of flexion. Physical
P: 154 R: 46 T: 97.0F SPO2: 97% in room air. RBS: 50 mg/dl. Wt. 3.24 kg
Skin and mucus membrane pink and moist. Head round, nil swelling. Hair is
bulging. Pupils reactive to light equally, no opacity noted sclera white. Pinna
intact and aligned with canthus of eyes. Nose patent. Mucous membrane pink
and moist, tongue freely movable, rooting and sucking reflex present. Uvula
central, no cleft lip or pallet. Neck short no webbing, Clavicle smooth and intact.
Respiration unlabored, chest rises and falls symmetrically. Lungs sound clear
bilaterally. Heart beat strong and regular sounds S1, S2 heard. Nipple prominent
and symmetrical.
Abdomen soft and not distended, bowel sounds heard x 4. Umbilical blood
vessels present, 2 arteries, one vein, femoral pulse equally bonding, Ortolani and
Barlow maneuver done, no hip dislocation noted. Urinary meatus at tip of penis.
Testes descended no lesions to groin, skin folds. Anus patent. Back appears
Mongolian spot seen to gluteus. All reflexes intact blink, suckling, rooting, moro,
21/7/2017 Term Infant was taken in the cot next to , Good cry and active and alert, general
I/O
K.A. posture of flexion. Physical assessment was done.
Skin and mucus membrane pink and moist. Head round, nil swelling. Hair
white. Pinna intact and aligned with canthus of eyes. Nose patent. Mucous
membrane pink and moist, tongue freely movable, rooting and sucking
reflex present. Uvula central, no cleft lip or pallet. Neck short no webbing,
Clavicle smooth and intact. Respiration unlabored, chest rises and falls
symmetrically. Lungs sound clear bilaterally. Heart beat strong and regular
Anus patent. Back appears smooth lanugo observed. Spinal cord, well
reflexes intact blink, suckling, rooting, moro, palmer, plantar, gasp trunk
Infant was taken in a cot, nest to mother. Infant is active and alert,
Skin and mucus membrane pink and moist. Head round, nil
Babinski
.
No. Date Client Age Initials Of
Term/ Intervention Instructor/
Int. Assessment Findings Preceptor
Preterm