Faculty of Nursing

Pediatric Nursing

Assessment Sheet

Student's Name : Section : Date :

Nursing data base:

 Patient's name: Age : Sex :
 Hospital record No : Room No: Bed No:
 Admitted from: home, emergency room, clinic, other
 Diagnosis :
 Chief complains:
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 Past surgical and medical history :

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 Any family member has health problems:

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 Allergies : yes ( ) No ( )
 Type of Allergy
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 Immunization received:

Age Vaccine Route

Feeding Pattern:
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Activity Pattern:
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Current medication:

Name Dose Frequency Route Action Nursing

implication

Laboratory results:

TEST Normal Value Patient Value

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Assessment items Finding

Growth Measurement
 Length / height
 Weight
 Head Circumference (HC)
 Chest Circumference
 Arm circumference
 Skin Fold thickness

Physiological Measurements:
 Temperature
 Pulse
 Respiration
 Blood pressure

Bowel and Bladder control

Motor development
Language development
General Appearance:
 State of awareness (conscious, semi-conscious, unconscious).
 Hygiene (cleanliness, body odor, hair condition, nails, teeth, feet, and clothing
condition).
 Nutritional status (Normal body wt., overweight, underweight).

Skin :
 color (Cyanosis, pallor, erythema, ecchymosis, petachiae, jaundice)
 Texture (Moist, smooth, rough,)
 Turgor ( Normal, loss of skin turgor)

Lymph nodes: (temperature, tenderness, enlarged).

 Cervical , Axillary ,Inguinal
Head , neck :
 Shape
 Head control (Controlled or not controlled)
 Range of motion (No stiffness in movement of head up, down and from side to side).

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 Skull fontanels (should be flat, soft and firm).

 Scalp for cleanliness, lesions, signs of trauma, loss of hair, discoloration).
 Trachea ( in middle, no deviation, rises with swallowing).
 Carotid arteries (not distended neck vein).
Eyes :

 Placement ( symmetric )
 Bulbar conjunctiva (color, discharge, tearing, pain, redness, swelling).
 Sclera (white color).
 Cornea (transparent, or ulceration)
 Pupils (round, clear and equal, react to light and accomodation).

Ears :

 Pinna (normal placement i.e. not low-set ears)

 External canal (pink, no signs of irritation, infection, foreign bodies and packed max.).

Mouth and Throat :

 Lips (no lesions).

 Mucous membranes (bright pink, smooth,).
 Teeth (number appropriate for age, loss of teeth, delayed eruption, obvious discoloration).
 Tongue (freely movable, tip extends to lips, no lesions or mass under tongue).
 Gums (pink color).
 Tonsils (normal size and color).
Chest :
Inspect: size, shape, symmetry and breast development, normal rate and depth of respiration.
Palpate: for tenderness, mass, lesions , respiratory excursion and vocal fremitus.
Percuss: each side of chest in sequence from apex to base. Lobes are resonant except for:-

 Dullness at 5th interspace right mid clavicular line (liver).

o Dullness from 2nd to 5th interspace over left stemal border to midclavicular line
(heart).
o Tympany below left 5th interspace (stomach).

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Auscultate for :
a. Normal breath sounds
1 . Vesicular breath sounds :
(It is heard over entire surface of lungs except upper intrascapular area and beneath
manibrium).

2. Bronchovesicular breath sounds :

(It is heard in upper intrascapular area and manubrium.)

3. Bronchial breath sounds

(It is heard only over trachea near suprastemal notch).
No deviations from expected breath sounds e.g. increased, diminished or absence of sounds.

b. Adventitious sounds :
Such as crackees, wheezes, stridors, pleural friction rub.

Heart
Inspect for size and symmetry of chest wall.
Palpate for :

 Point of maximum impulse (PMI),

 Capillary filling time : should be 1 - 2 seconds {Press forehead, top of hands or foot}.
 No abnormal vibration, e.g., thrills that are similar to cat's purring.
Auscultate for heart sounds :

Should be normal in quality, intensity, rate and rhythm.

 Sl and S2 {clear, distinct, rate equal to radial pulse, regular rhythm}

 Quality {clear and distinct }
 Intensity {strong but not pounding }
 Rate {same as radial pulse}
 Rhythm {regular }
Abdomen :

 Inspect for: Contour (shape), size, tone, skin condition and umblicus {for hemiation, fistula,
cleanliness, and discharge}.
 Auscultate for: Bowel sounds.

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 Palpate for : abdominal organs.

o Liver: Normal size, no tenderness {1 to 2 cm below right costal margin in infants &
young children}.
o Spleen: Normal size, no. tenderness {sometimes 1 to 2 below left costal margin in
infants & young children}.
 Percuss the Abdomen:
It should be tympany over stomach or left side & most abdomens except for dullness just
below right costal margin (liver).
Back:

Normal curvature & symmetry of spine. {Round or C shaped in the newbom, cervical secondary
curve forms about 3 months of age, lumber secondary curve forms about 12 - 18 months,
resulting in typical double S curve}.

o No mass or lesions.
o No signs of scoliosis {include slight limp, crooked hem or waistline, complaint of backache}.
o No stiffness & pain upon movement of neck or back.
Extremities :
o Full range of motion.
o No deviation, swelling, hotness, tenderness or immobility of joints. No foot & ankle
deformities.

o * Others :

NAD = Nothing Abnormal Detection

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