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Pediatric Physical Assessment
 

Pediatric Physical Assessment

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Pediatric Physical Assessment

Pediatric Physical Assessment

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    Pediatric Physical Assessment Pediatric Physical Assessment Document Transcript

    • 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):_________________________ NursingFormsNursing FormsPediatric 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: NursingFormsNursing FormsPediatric Physical Assessment DLadd 1/24/05 2
    • Discharge Planning/Patient (&/or) Parent Teaching: Problem Nursing Diagnosis NursingFormsNursing FormsPediatric Physical Assessment DLadd 1/24/05 3
    • Rationale for Choosing Nursing Diagnoses (2) Pathophysiology Of Diagnosis: Medications (May Attach Med Cards or Separate Sheet) NursingFormsNursing FormsPediatric 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 By: Dave Jay S. Manriquez RN. NursingFormsNursing FormsPediatric Physical Assessment DLadd 1/24/05 5