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    Pediatric Physical Assessment

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    ilovemaine
    This pediatric physical assessment form documents a patient's admission information, vital signs, developmental stage, physical exam findings, labs, diagnostic tests, discharge planning, nursing diagnoses, medications, and considerations for the patient's hospitalization based on their developmental age. Areas assessed include integumentary, neurological, respiratory, cardiovascular, gastrointestinal, and musculoskeletal systems. Safety concerns and appropriate play therapy are addressed.

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    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd

    Pediatric Physical Assessment

    Uploaded by

    ilovemaine
    759 views5 pages
    This pediatric physical assessment form documents a patient's admission information, vital signs, developmental stage, physical exam findings, labs, diagnostic tests, discharge planning, nursing diagnoses, medications, and considerations for the patient's hospitalization based on their developmental age. Areas assessed include integumentary, neurological, respiratory, cardiovascular, gastrointestinal, and musculoskeletal systems. Safety concerns and appropriate play therapy are addressed.

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    Pediatric Physical Assessment (1)

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    This pediatric physical assessment form documents a patient's admission information, vital signs, developmental stage, physical exam findings, labs, diagnostic tests, discharge planning, nursing diagnoses, medications, and considerations for the patient's hospitalization based on their developmental age. Areas assessed include integumentary, neurological, respiratory, cardiovascular, gastrointestinal, and musculoskeletal systems. Safety concerns and appropriate play therapy are addressed.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    759 views5 pages

    Pediatric Physical Assessment

    Uploaded by

    ilovemaine
    This pediatric physical assessment form documents a patient's admission information, vital signs, developmental stage, physical exam findings, labs, diagnostic tests, discharge planning, nursing diagnoses, medications, and considerations for the patient's hospitalization based on their developmental age. Areas assessed include integumentary, neurological, respiratory, cardiovascular, gastrointestinal, and musculoskeletal systems. Safety concerns and appropriate play therapy are addressed.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    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):_________________________

    Nursing\Forms\Nursing Forms\Pediatric Physical Assessment


    DLadd 1/24/05 1
    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:

    Nursing\Forms\Nursing Forms\Pediatric Physical Assessment


    DLadd 1/24/05 2
    Discharge Planning/Patient (&/or) Parent Teaching:

    Problem Nursing Diagnosis

    Nursing\Forms\Nursing Forms\Pediatric Physical Assessment


    DLadd 1/24/05 3
    Rationale for Choosing Nursing Diagnoses (2)

    Pathophysiology Of Diagnosis:

    Medications (May Attach Med Cards or Separate Sheet)

    Nursing\Forms\Nursing Forms\Pediatric Physical Assessment


    DLadd 1/24/05 4
    Developmental Impact (Real or Potential) of Hospitalization

    Appropriate Play Therapy During Hospitalization

    Safety Considerations Based on Developmental Age

    Nursing\Forms\Nursing Forms\Pediatric Physical Assessment


    DLadd 1/24/05 5

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