PEDIATRIC ASSESSMENT TOOL Upon Assessment

● Vital signs
○ HR,RR,BP,TEMP, O2 Sat, Height,
TOOLS OF THE ASSESSMENT
Weight, BMI
● Interview
● Site interpretation
● Physical Assessment
○ IPPA: Inspection, Palpation,
BMI​ = ​Body weight (Kg)
Percussion, Auscultation
Height (m2)
THE INTERVIEW
● Interviewing the family caregivers BMI IMPLICATION
○ Ask questions and note them
○ Avoid being judgemental <18.5 kg/m2 Underweight
● Interviewing the child
118.5 - 24.9 Normal
○ Be age-appropriate
■ Infant, toddler, preschool, 25.0 - 29.9 Overweight
school age (research)
○ Establish rapport >30 Obese
○ Listen
○ Be ready
● Types of Questions III. PAST CHILD ILLNESS
○ Closed Ended Questions (“Did you take ● Medical
John’s temperature?” Yes or No ● Surgical
○ Open Ended Questions (“What did you ● State specific illness and date
do for John?”) Requires describing
IV. FAMILIAL RISK FACTORS
I. GENERAL INFORMATION ● Drug
● Dose
II. HISTORY OF PRESENT ILLNESS ● Frequency
● Onset ● Route
○ When did it start? ● Indication
● Location/Radiation ● Any drug allergies
○ Where is it located?
● Duration V. INFANT DATA
○ How long has this gone on? ● Actual date & time of delivery
● Character ● Type of delivery
○ Does it change with any specific ● Place of birth
activities? ● Weight
○ Any descriptive words to describe the ● Head circumference
quality of the symptom? ● Chest circumference
● Aggravating Factors ● Abdominal Circumference
○ What makes it worse? ● Height/Length
● Relieving Factors ● Difficulty at Birth-prolonged labor, PROM
○ What makes it better? ● Child feeding
● Timing
○ Is it constant, cyclic, or does it come VI. ASSESSMENT OF BODY SYSTEMS
and go? General Appearance
● Severity ● Personal Hygiene/Habits
○ How bothersome, disruptive, or painful ○ Does the child do self care?
the problem? ○ Does the child take baths?
● Site the actions taken ○ Brush teeth?How often?
○ Wash hands before eating?
Example: ● Grooming/Hair
On Saturday morning, John began having long crying ○ Is the hair shiny, strong, well combed,
periods. On Monday night, he developed a fever. John clean?
vomited three times Monday morning & thinks this ● Clothing/Dressing
was caused by teething. Fever persisted until ○ Is it appropriate and clean?
Wednesday morning with complaints of abdominal
pain & difficulty eating. His mother brought him to the Respiration (Objective)
ER at 1:00 PM of same day. ● RR (bpm, breaths/minute)
○ Rapid or slow
 ● Depth ● Dyspnea
○ Shallow, normal, deep ○ Difficult or labored breathing
● Symmetry in chest movement ○ At rest upon exertion (specific)
○ Equal expansion & symmetry
○ Asymmetric expansion suggests Respiration (History of)
pneumonia, a large pleural effusion, rib ● Bronchitis, Asthma, Tuberculosis
fractures or pneumothorax ● Use of respiratory aids, O2 Therapy
● Use of accessory muscles
○ Commonly Neck & shoulder muscles Circulation
○ Used or not used ● Ankle/leg edema
● Nasal Flaring ○ No edema, non pitting, pitting, bilateral,
○ Enlargement of the opening of the unilateral (R/L)
nostrils when breathing ○ Grade 1: 0 mm
● Breath Sounds ○ Grade 2: 3-4 mm rebounds less than
○ Auscultate at the start of the exam 15 sec
○ Normal Breath Sounds ○ 5-6 mm takes 30 secs to rebound
■ Vesicular - soft, low pitched ○ 8 mm deeper takes more than 20
heard over periphery of the seconds to rebound
lungs ● Extremities, numbness? Tingling?
■ Bronchovesicular - soft, medium ● BP: Right Lying & Sitting, Left lying & Sitting
pitched, heard over major ● BP Taking:
bronchi ○ The cuff should be of the appropriate
■ Bronchial - loud, high pitched size for the children’s upper arm. Small
hear over trachea cuffs tend to overestimate while large
○ Abnormal Breath Sounds cuffs underestimate
■ Crackles/rales - like cellophane, ○ The width of the cuff should be calm
made by air moving through and relaxed, seated with their right arm
fluid alveoli (pneumonia) resting at heart level
■ Wheezing - bronchial tubes are
inflamed & narrowed (asthma) Blood Pressure:
■ Stridor - crowing or rooster like
Age Systolic Diastolic
sound; upper airway narrows
Pressure Pressure
(foreign body in airways)
Birth 12 h, 16-36 16-36
AGE NORMAL >1000g
RESPIRATOR
Y RATE Birth 12 h, 31-45 31-45
3kg
Infant <1 year 30-53
Neonate 96 h 35-53 35-53
Toddler 1-2 years 22-37
Infant 1-12 37-56 37-56
Preschool 3-5 years 20-28 mo

School Age 6-11 years 18-25 Toddler 1-2 y 42-63 42-63

Adolescent 12-15 years 12-20 Preschooler 3-5 y 46-72 46-72

School-Age 6-9 y 57-76 57-76

● Cyanosis
● Clubbing of fingers Preadolescent 10-11 y 61-80 61-80
○ Nail clubbing occurs when the tips of
the fingers enlarge and the nails curve Adolescent 12-15 y 64-83 64-83
around the fingertips
○ A result of low oxygen in the blood and Point of Maximal Impulse (PMI) Apical Pulse
could be a sign of various types of lung Heart Rate:
disease
● Sputum Characteristics Age Awake Sleeping
○ Appearance in color (white,yellow, Rate Rate
green), clear or viscous, purulent
Respiration (Subjective) Neonate <28 d 100-205 90-160
 ● Varicosities
Infant 1 mo - 1 y 100-190 90-160
○ Dilated veins (duplex UTZ scanning)
Toddler 1-2 y 98-140 80-120

Preschool 3-5 y 80-120 65-100

School 6-11 y 75-118 58-90

Age

Adolescent 12-15 y 60-100 50-90

● Heart sounds
○ Rubbing sound, clicking sound,
● Nail beds
swooshing sound
○ Color
● Heart rhythm
● Mucous Membranes
○ Regular or irregular
○ Dry or moist

Nutritional/Metabolic Pattern
● ​Skin Color
○ Bluish/cyanosis, pale, reddened area,
yellow, jaundice
● Lesions
○ Blister, nodule, rash, wheal, cyst
● Hair
○ Color, texture, brittle, scalp lesions
● Nail Color
○ Healthy finger/toenails are pink in color
(changes may indicate disease). Blue,
black, white, red, yellow
● Condition of Oral Mucosa
○ Moist, pinkish, no lesions
● Teeth
● Daily food intake
○ Breakfast, lunch, dinner, snacks
● Food supplements/Vitamins
● Food allergies

Elimination
● Bowel Habits
○ frequency, consistency, color, amount,
constipation

● Auscultate the apical pulse

● Compare the peripheral pulse and apical pulse
for consistency (the rate and rhythm should be
similar)
● Capillary Refill
○ The time taken for color to return to an
external capillary bed after pressure is
applied to cause blanching
○ Normal: less than 2 sec; ​brisk (<2 sec)
or sluggish (more than 2 sec)
○ Hold hand higher than the heart level
and press the fingernail or soft pad of ● Bladder Habits
finger until it turns white and take note ○ Frequency, amount, color
of the return of the color once pressure ○ N=pale yellow to deep amber
is released ● Urine Output
● Cyanosis?
● Pallor?
 ○ Normal Children <2 yrs is between
2 Eye opening to pain
2-3ml/kg.hr, >2yrs is between 0.5 -
1ml/kg/hr 1 No eye opening or response

Activity-Exercise
● Daily Activities Best Verbal Response:
● Leisure Activities 5 Smiles, oriented to sounds, follows objects,
● Exercise Routine interacts

Sleep-Rest 4 Cries but consolable, inappropriate

● Time of sleep
● Sleep aids
● Quality of sleep
○ Interrupted or uninterrupted
Sensory-Perceptual
● Vision
○ Ability to follow moving objects, report
of double vision, reading very closely,
titls head to see things better,
complains blurring, Snellen's test
(school age), frequent headaches
● Hearing
○ Check for ear infection, ask how is he
doing in school, check hearing with
normal conversation
● Smell
○ Able to identify the smell of the object
presented
● Aids for vision/hearing
Mental Status
● Oriented/Disoriented to time, place, person
● Alert
● Combative
○ Hitting, pushing, kicking, spitting, and
grabbing
● Lethargy
○ Severe drowsiness in which the patient
can be aroused by moderate stimulo
and then drift back to sleep
● Stupor
○ Only vigorous and repeated stimuli will
arouse the individual, and when left
undisturbed, the patient will
immediately lapse back to the
unresponsive state
● Coma
○ Is a state of unarousable
unresponsiveness
● Pediatric Glasgow Coma Scale
○ Is the equivalent of the Glasgow Coma
Scale (GCS) used to assess the level
of consciousness of child patients
interactions
3 Inconsistently inconsolable, moaning
2 Inconsolable, agitated
1 No verbal response
Best Motor Response:
6 Infant moves spontaneously or purposefully
5 Infant withdraws from touch
4 Infant withdraws from pain
3 Abnormal flexion to pain for an infant
(decorticate response)
2 Extension to pain (decerebrate response)
1 No motor response
All patients with less than 15 need monitoring. Any
combined score of less than 8 represents a significant
risk of mortality.
● Pupil Size, equality and reactivity
○ Size (2-3mm( in bright light
○ B - Brisk
○ S - Sluggish
○ N - No reaction
○ Both pupils should react equally to light
(constrict and dilate in the dark)
○ Consensual reaction to the light source
(opposite eye)
○ PERRLA
■ Pupils Equal, Round and
Reactive to Light &
Accomodation

Best Eye Response:

4 Eyes opening spontaneously

3 Eye opening to speech

 ● Speech impairment
○ Stuttering, slurring, difficulty in
articulating words
● Ability to express

VII. PAIN/COMFORT
● PQRST
● Precipitating
○ What seems to trigger it? Stress?
Position? Certain activities?
● Quality
○ Describe the pain such as sharp, dull,
stabbing, burning, crushing, throbbing,
nauseating, shooting, twisting or
stretching
● Radiation/Region
○ Where is the pain located? Does the
pain radiate? Where? Does it feel like it
travels/moves around? Did it start
elsewhere and is now localized to one
spot?
● Pain Assessment
○ Severity
■ How severe is the pain on a
scale of 0 -10, with 0 being no
pain and 10 being the worst
pain ever? Does it interfere with
activities? How bad is it at its
worst?
○ Time (Onset, Frequency, Duration)
■ When/at what time did the pain
start? How long did it last? How
often does it occur; hourly?
Daily? weekly?
○ Signs and Symptoms
■ Is it accompanied by other signs
and symptoms?
● The faces pain scale revised (Bieri faces)
○ Can you point to the face that shows
how much you hurt?
○ A self report tool for children ages 3 yrs
and above