Department of Nursing Education

Pediatric Physical Assessment

Name:__________________________ Date:____________________________

Pt. Initials:_____Pt. Age:_______Family Member/CG Present:____________________

Admission
Diagnosis:_____________________________________________________________

Presenting Signs and

Symptoms for Admission:_________________________________________________

Erikson’s Stage of Development:____________________________________________

Ht._____ Wt._____ HR______ RR______ BP______ Temp______ Allergies_________

Pain Scale: (0-10) ______Verbal Report/Faces Scale/FLACC (circle how assessed)

Nutrition
Diet:______________________ IV Fluids (type and rate):_______________________
Recent wt. loss/gain:________ Birthweight _______ Lips/Gums/Teeth______________

Integumentary
Skin Color:______________ Texture:___________ Rashes:___________
Incisions:________________ IV site:____________ Ostomy:__________

Neurological/Head
LOC/State:_______________ Facial Symmetry___________________________
Sensory Deficit Aids:_____________________ Reflexes:______________________
Fontanels (anterior, posterior size and appearance if present)____________________
Eyes - Pupils:_______________ Discharge:__________ Clarity:___________
Strabismus_________________ Swelling:___________ Ptosis:____________
Ears – Shape:_______________ Symmetry:__________ Discharge:_________

Oxygenation
Respirations (rate, rhythm, depth)___________________________________________
Retractions:___________ Nasal Flaring:_____________ Grunting:_________
Breath Sounds:_________________________________________________________
O2 Therapy:______________________________ O2 Saturation:___________
Cough:______________________Sputum(describe):__________________________
Skin/Nail Bed Color:__________________MucousMembranes:__________________
Respiratory Therapy Treatments(type and frequency):_________________________

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Cardiovascular
Apical Heart Rate_________ Rhythm__________ Murmur_________
Capillary refill__________ Peripheral Pulses/location__________________________
Skin Turgor_______________ Edema___________________________

Musculoskeletal
ROM:_____________________________ Symmetry:_______________________
Activity Tolerance:___________________ Strength:_________________________

GI/GU/Abdomen
Abdomen Appearance:_________________ Bowel Sounds:____________________
Last BM/Usual Pattern:___________________________________________________
Urinary Output:_____________________ Urine Characteristics:_______________

Labs:

Diagnostic Tests/Procedures:

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Discharge Planning/Patient (&/or) Parent Teaching:

Problem Nursing Diagnosis

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Rationale for Choosing Nursing Diagnoses (2)

Pathophysiology Of Diagnosis:

Medications (May Attach Med Cards or Separate Sheet)

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Developmental Impact (Real or Potential) of Hospitalization

Appropriate Play Therapy During Hospitalization

Safety Considerations Based on Developmental Age

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