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:______________
Incisions:________________

Texture:___________
IV site:____________

Rashes:___________
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

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Cardiovascular Apical Heart Rate_________ Rhythm__________ Murmur_________ Capillary refill__________ Peripheral Pulses/location__________________________ Skin Turgor_______________ Edema___________________________ Musculoskeletal ROM:_____________________________ Activity Tolerance:___________________ Symmetry:_______________________ 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\Forms\Nursing Forms\Pediatric Physical Assessment DLadd 1/24/05 Nursing Diagnosis 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 .