Guideline 13: Newborn, Infant, Toddler History and Physical Assessment
Purpose
Thorough assessments are an important component of the nursing process. Assessments provide information on the child's physical, emotional, and developmental health, which enables the nurse to develop a care plan that supports the most appropriate interventions to promote healthy growth and development.
Process
The newborn head to toe assessment should be completed at the first post-partum visit. It may not be possible to complete the full assessment in one visit, and not all of these issues may be pertinent to every client. However, as an important component of the nursing process, consider assessing the systems.
Systems to assess are listed in Table 1 (Newborn and Infant) and Table 2 (Toddler). Newborn assessments should include clothing and diaper removal (with parent/caregiver permission) to assess all physical aspects; toddler assessments may be focused and does not have to include clothing removal unless necessary to assess a concern.
Blood pressure (BP) and temperature for infants and toddlers are not required; the local implementing agency may decide to take BP and temperatures on a case-by-case basis (e.g., if a client is on blood pressure medication, or for teaching parents how to take temperature). For that reason, considerations for referrals to the primary care provider are listed and include parameters for BP and temperature.
Nurses should always make referrals based on concern and clinical judgement, even if the client does not fit criteria listed in tables.
Growth (weight, length and head circumference) should be recorded and plotted on appropriate growth grid. See recommended growth grids here: https:/
www.cdc.gov/growthcharts/index.htm If providing BP and temperature monitoring, pay special attention to Vital Sign (VS) abnormalities in infants < 1 month, as a single VS abnormality may be the only sign of serious illness.
Newborn and Infant Assessment Considerations (0-12 months)
Weight Gain for Infants