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, impact of hospitalization, appropriate play therapy, and safety considerations. The patient's presenting signs and symptoms, height, weight, heart rate, respiratory rate, blood pressure, and temperature are recorded along with any allergies, pain scale, diet, IV fluids, and weight changes. A full physical exam including integumentary, neurological, respiratory, cardiovascular, musculoskeletal, and gastrointestinal systems is documented.

1. 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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2. 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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3. Discharge Planning/Patient (&/or) Parent Teaching:
Problem Nursing Diagnosis
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4. Rationale for Choosing Nursing Diagnoses (2)
Pathophysiology Of Diagnosis:
Medications (May Attach Med Cards or Separate Sheet)
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5. Developmental Impact (Real or Potential) of Hospitalization
Appropriate Play Therapy During Hospitalization
Safety Considerations Based on Developmental Age
By: Dave Jay S. Manriquez RN.
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