Pediatric Assessment Tool

Patient Name:__________________ Date/Time of Birth:___________________

Weight at Birth:_________________ Weight Now:___________________

VS: Temp=________ Pulse=_________ RR=__________

History of Present Illness:

Maternal History:
Age of Mother:________________OB score:G______P______(____, ____, ____, ____)

Family: Type:__________________Siblings:___________________________________

Congenital/Genetic History:_____________________Blood Type:__________________

Labor and Delivery Complications:___________________________________________

Length of Labor-______________ Meconium: Clear/ Thin / Thick/ Bloody

Physical Assessment:
Risk factors: Hypoglycemia Infection Jaundice
APGAR scores:1 min._________ 5 min. _____________

Skin: Petechiae, Rash, Mongolian spots, Pustule, Milia, Lanugo, Vernix, Birth marks,
Bruises,lacerations, pinkish,pale, acrocyanosis, central cyanosis, jaundice

HEENT: Head circumference:________________ Fontanels:Anterior/Posterior

Head Characteristics:Caput succedaneum Cephalhematoma
PERLA Movement:Symmetrical/Assymetrical
Discharge:___________________

Neck: ROM Lymph nodes:

Mouth:Palate:Intact Cleft Gums

Chest: Circumference of Chest Breast Buds: size

Abdomen: Circumference of Abdomen=__________ Distention Bowel sounds

Tenderness Cord vessel count/Condition

Genitourinary:
Female: Clitoris: Labia majora Labia minora
 Discharge:_____________ Voiding: ____________ # of times/24 hrs_________

Male: Circumcision: Testes/scrotum

Cremasteric reflexline
Urethral Opening: Midline Epispadia Hypospadia
Discharge:_____________ Voiding: ____________ # of times/24 hrs_________

Anus: Rectal Patency:___________ Location

Stool color/consistency

Spine/Back: Straight/ Curved

Hip integrity: Ortolani’s maneuver

Extremities: Symmetry ROM

# of digits Syndactyly, Polydactyly ,Simian crease

Neurologic Reflexes:

Moro Rooting Sucking Palmar Plantar Babinski Stepping Tonic

neck
Patient
Expected
Norms

Growth and Development

Physical Development Actual Measurement Expected Norms
Head Circumference
Chest Circumference
Abdominal Circumference
Length

Actual Performed Skills Expected Norms

Psychomotor
Cognitive

Planned Age Appropriate Activities

Nursing Care

Communication
Medication Administration
Play
Feeding/Nutrition
Safety