Complete Head to Toe Examination

Complete Head to Toe Examination.


The assessment and examination of the patient form a significant component of the nurses’ role. It allows for care for the patient in a prioritized manner giving room and basis for the nursing care plans for the patient (Forbes & Watt, 2015). These will influence the outcome of the patient. When done consistently and timely, the set goals for care can be planned for and be achieved. This article provides for head to toe examination of 14 days old with pathogenic neonatal sepsis/Jaundice.

Vital signs.

The patient has an axilla temperature of 37.0 degrees Celsius. The respiratory rate being 50 beats per minute and no respiratory distress. Both the brachial and the femoral pulses strong and bounding. Oxygen saturation of   99%. The child displays to be in mild pain with a facial grimace with increased facial activity. The baby has squeezed the eyes and mouth open with no cries suggestive of mild pain.

Other measurements:

The weight of the baby: 3.8 kilograms.

Height: 33 centimeters.

Blood sugars: 5.8mmol/l

Systemic assessment of the baby.


Neurological System.

I assessed the neurological system via the use of the Glasgow coma scale. The patient was conscious, opening eyes spontaneously when there is sound on movement in the room. The baby can make cues that correspond to her age. The child can move all the four limbs and is active on observation.

Both the right and the left arms are actives and move spontaneously with no differences. The legs are also moving forth and back with sufficient force against my hands. The pupils retract when penlight is introduced from sides of the eyes. Both the anterior and the posterior fontanels are palpable and pulsating. There is a mild depression of the anterior fontanel, suggestive of mild dehydration. No caput succedaneum.

Regarding growth and development, the baby has a head circumference of 33 centimeters. The sutures are palpable.  On inspecting the spine, it is midline in position, no lumps or hairs. From the history since birth, the mother reports increased body activity without any form of regression.

For the fine and gross motor skills, the baby can assume a stable lying position. The limbs can move spontaneously as well as resisting controlled movements such as immobilizing her lower limbs. Both the lower and upper limbs are symmetrical concerning structure. The baby has a relatively sucking reflex, and the mother reports the weakness to have existed for the last two days. When testing the rooting reflex with the introduction or touching the corner of the mouth with the hands, the baby turns towards the hand indicating a strong rooting reflex. The baby can resist controlled limb movement hence strong Moro reflex.

For the sensory function, the baby can respond to tactile stimuli. She calms down on touch. She is also able to open eyes and move them with the existence of sound validating hearing capability by the child. The baby also shows the ability to smell since she can segregate each caregiver at any given time. She calms when held by the mother and cries when I get hold of her. No seizures have been noted during the assessment, but there is a history of seizures which occurred ones in the previous day. The mother reported that the baby convulsed the previous day when the temperature was high.


On general observation, the baby is alert, alert but mildly irritable. The baby has yellow palms for both the hands and the fingers. This is suggestive jaundice since the normal findings entail pink extremities to show oxygenation of tissues. She has a respiratory rate of 67 breaths per minute. They are shallow in nature. No chest in drawing or nasal flaring. The chest is rising and falling symmetrically. The trachea is centrally placed, no wheezing, grunts nor stridor. The saturation is 99%.

On auscultation, I listened to the breath sounds, and they were equally present in the both lung fields. No adventitious sounds noted.

I palpated the chest, and there was bilateral symmetry in the chest expansion. The capillary refill was occurring after 4 seconds indicating a delay. No subcutaneous emphysema identified.

Cardiovascular system.

On inspection, I examined the circulatory status of both the upper and the lower extremities. They were pale with dominating yellow coloration in both the extremities and the eyes. There was a sluggish capillary refill of 4 seconds in the extremities. No edema in both the lower and the upper extremities. No facial edema as well. The baby was relatively hydrated with a fair skin turgor. The skin returns sluggishly after a skin pinch.

On palpation, brachial pulse rate was 130beats per minute which was regular in terms of rhythm and thready. The baby was relatively warm to touch and poor skin turgor.

On auscultation, the apical beat was 133 beats per minute. When I compared the apical and the peripheral pulse (radial), there was an inconsistency with the peripheral having a lower rate of 128 beats per minute. The s1 and s2 were heard with no heart murmurs noted.

Gastrointestinal system.

From the history, the baby is being breastfed exclusively since birth but has displayed a refusal to breastfeed in the last three days. She passes stool at least 3 times a day. The mother reported of change of the stool to yellow in the three days. The baby has had no pain or cramping or vomiting.

On inspection, the abdomen was rounded and symmetrical in shape; smooth in terms of the contour with no lesions or scars. In the umbilicus, there was no redness, inflammation or discharge. There was no bulging at the inguinal area ruling out an inguinal hernia.

On palpation, no obvious distended abdomen or organomegaly was noted. The baby cries with moderate palpation of the right upper quadrant.

On auscultation, the bowel sounds are heard over the four abdominal quadrants. The bowel sounds were 21, 20, 21 and 23 for the right upper, left upper, right lower and the left lower quadrants respectively.

The Renal System.

The baby had been changed 4 diapers in the last 24 hours that were fully soaked with urine which was yellow. Concerning hydration status, the baby weighted 3.8kilograms. I did not take blood pressure because I lacked the neonatal cuff.  I would have taken the blood pressure in all the four limbs of the baby and compare them for perfusion purposes. In terms of skin condition, the skin was fairly dry with sluggish skin return after a skin pinch.

Urinalysis was not done. Though urine would have been collected and tested for proteins and blood cells which would have shown presence or absence of infection. Creatinine and urea levels would have also been determined.

Musculoskeletal system.

On inspection, I observed that the child’s limb was symmetrical and the child was moving them actively. There was no swelling, redness or any obvious deformity in the limbs. For the range of motion, the limbs were moving with control equally and mild pain manifested in the process. This was expected since during the period of rapid growth in children, there is usually a manifestation of normal muscle aches for the children (Lee et al., 2014).  No redness or swelling on the joints.

On palpation, the muscle tone was strong, and no wasting noted. Despite the mild pain manifested with the movement of the limbs, there existed no tenderness on the limbs.

Integumentary System.

On inspection, the baby had pink skin with the palms and soles being yellow indicating jaundice. The entire body of the child small rashes that were pus-filled and of average size 0f 0.5 millimeters. The rashes also started to emerge three days ago as per the information from the mother. There existed no bruises or injuries on the skin. The child, however, had cradle cap characterized by the thick and crusty scales over the scalp with no ticks or lice.

On palpation, the skin was warm, relatively dry and sluggish return of the skin after a skin pinch. The hair on the scalp was smooth in texture and uniformly distributed.

I did not pass light through the skin of the child because I lacked the transcutaneous bilirubinometer. I would have measured the reflection of the special light when shown through the skin.


The two eye were symmetrical bilaterally and on the same level with the ears. The pupils were constricting to light when introduced from the sides. The conjunctiva was pink in color with no inflammation or discharge. The sclera was yellow indicating central jaundice.


On inspection, the ears were symmetrical with no malposition. No obvious cerumen, inflammation or exudate. The lips and the tongue were pink with no tongue-tie.

On palpation, there were no lesions of the tenderness of the ear.

Laboratory Test.

A sample of blood was taken for examination of the bilirubin level. The bilirubin level was 3mg/dl which was relatively high and abnormal.


Medical Diagnosis.

Neonatal sepsis/neonatal jaundice.

Differential diagnosis.

Breast milk jaundice.

Hemolytic anemia.

Blood type incompatibility.


Urinary tract infections.

Immunization Status.

From the immunization schedule, the baby had received the zero dose oral polio vaccine and the BCG vaccines at birth. She was also given vitamin K and tetracycline eye ointment after birth.


The baby is going to be managed for neonatal sepsis with jaundice. She is on an antibiotic (ceftriaxone) day one, antipyretic acetaminophen 2.5 milliliters three times a day, expressed breast milk 50milliliter and additional supplementary feed 20milliliters three times per day and phototherapy with monitoring of the bilirubin levels and temperature.

 Nursing Care Plan.

Nursing diagnosis 1: Risk for infection related to impaired skin integrity secondary to impaired skin integrity as evidenced by sores and open skin from the breakdown of the pus-filled rashes.

Interventions: Provide isolation of the baby in a separate phototherapy machine and also monitoring visitors. Limit use of invasive devices and procedures to reduce the general risk of infection. Maintaining hygiene while handling the baby. Providing antibiotic cover for 10 days.

Evaluation: substantial isolation of the body was offered, and this was to continue over the period of admission. Visiting was limited to two persons at one given time. The child was on antibiotic cover—ceftriaxone. The child was protected from infections during the period of stay with no development of complication nor eruption of a new infection.

Nursing diagnosis 2: hyperthermia related to hypermetabolic state as evidenced by the warm skin and tachycardia.

Interventions: monitoring of the neonate’s condition to determine the need for intervention and efficiency of therapy. Ensure proper circulation within the phototherapy machine. Breastfeeding the child frequently. Administration of antipyretic, paracetamol syrup 2.5 milliliters three times a day.

Evaluation: the temperature was maintained with no instances of pyrexia.





Forbes, H., & Watt, E. (2015). Jarvis’s Physical Examination and Health Assessment. Elsevier

Health Sciences.

Lee, G. Y., Yamada, J., Shorkey, A., & Stevens, B. (2014). Pediatric clinical practice guidelines

for acute procedural pain: a systematic review. Pediatrics, peds-2013.

North American Nursing Diagnosis Association. (2015). Nursing diagnoses of NANDA:

definitions and classification 2015-2017. Porto Alegre: Artmed.

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