PEDIATRIC PHYSICAL ASSESSMENT

Patient: Patient A Age: 13 years old Weight: 64.3 kg. Height: 157.48 cm. BMI: 26.09
Vital Signs
Pulse Rate: 82 bpm
Respiratory Rate: 17 cpm
Blood Pressure: 120/80mmHg
Body Temperature: 37.2 degree celcius

Part of the Body Normal Findings Actual Findings Deviation from Normal

Skin: The client’s skin is
uniform in color, unblemished
and no presence of any foul
odor, has a good skin turgor,
and skin’s temperature
within normal limit.
Integumentary
Skin: The client’s skin is Skin: Uneven in color.
uneven in color. There is a
slight darkness around the
neck and in the armpit. Stretch
is marks are present in the
surrounding skin of armpit and
in the thighs.

Hair: The hair of the client is Hair: The hair of the client is Hair: There are lice and nits on
thick, silky hair is evenly thick, silky hair and is evenly the client’s hair.
distributed and has a variable distributed and has a variable
amount of body hair. There are amount of body hair. Presence
also no signs of infection and on nits and lice are seen.
infestation observed.
 Nails: The client has a light Nails: The client has a light Nails: There is no deviation
brown nails and has the shape brown nails and has the shape from the normal findings.
of convex curve. It is smooth of convex curve and has the
and is intact with the epidermis. shape of convex curve. It is
When nails pressed between smooth and is intact with the
the fingers (Blanch Test), the epidermis. When nails pressed
nails return to usual color in between the fingers (Blanch
less than 4 seconds Test), the nails return to usual
color in 3 seconds.
Head: The head of the client is Head: The head of the client is Head: There is no deviation
rounded; normocephalic and rounded; normocephalic and from normal findings.
symmetrical. symmetrical.

Skull: There are no nodules or Skull: There are no nodules or Skull: There is no deviation
masses and depressions when masses and depressions from normal findings.
Head palpated. when palpated.

Face: The face of the client Face: The client has some Face: The client has pimple on
appeared smooth and has pimple on her face and some the face and oily face.
uniform consistency and with blemishes as well. The skin on
no presence of nodules or the client’s face is also oily.
masses.
Eyebrows: Hair is evenly Eyebrows: Hair is evenly The patient couldn’t read
Eyes and Vision
distributed. The client’s distributed. The client’s newsprint at 14 inches.
eyebrows are symmetrically eyebrows are symmetrically
aligned and showed equal aligned and showed equal
movement when asked to movement when asked to
raise and lower eyebrows. raise and lower eyebrows.

Eyelashes: Eyelashes Eyelashes: Eyelashes

appeared to be equally appeared to be equally
distributed and curled slightly distributed and curled slightly
outward. outward.

Eyelids: There were no Eyelids: There were no

presence of discharges, no presence of discharges, no
discoloration and lids close discoloration and lids close
symmetrically with involuntary symmetrically with involuntary
blinks approximately 15-20 blinks approximately 15-20
times per minute. times per minute.

Eyes Eyes
o The Bulbar conjunctiva o Transparent bulbar
appeared transparent with conjunctiva with few
few capillaries evident. capillaries noted.
o The sclera appeared white. o The sclera appeared white.
o The palpebral conjunctiva o The palpebral conjunctiva
appeared shiny, smooth and appeared shiny, smooth and
pink. pink.
o There is no edema or o There is no edema or
tearing of the lacrimal gland. tearing of the lacrimal
gland.
o Cornea is transparent, o Cornea is transparent,
smooth and shiny and the smooth and shiny and the
details of the iris are visible. details of the iris are visible.
The client blinks when the The client blinks when the
cornea was touched. cornea was touched.
o The pupils of the eyes are o The pupils of the eyes are
black and equal in size. The black and equal in size. The
iris is flat and round. iris is flat and round.
PERRLA (pupils equally PERRLA (pupils equally
round respond to light round respond to light
accommodation), accommodation),
illuminated and non- illuminated and non-
illuminated pupils constricts. illuminated pupils
Pupils constrict when constricts. Pupils constrict
looking at near object and when looking at near object
dilate at far object. Pupils and dilate at far object.
converge when object is Pupils converge when
moved towards the nose.
 object is moved towards the
nose.
o When assessing the o When assessing the
peripheral visual field, the peripheral visual field, the
client can see objects in the client can see objects in the
periphery when looking periphery when looking
straight ahead. straight ahead.
o When testing for the o When testing for the
Extraocular Muscle, both Extraocular Muscle, both
eyes of the client eyes of the client
coordinately moved in coordinately moved in
unison with parallel unison with parallel
alignment. alignment.
o The client was able to read o The client couldn’t read the
the newsprint held at 14 newsprint held at 14 inches.
inches.
The auricles are symmetrical The auricles are symmetrical There is no deviation from
and has the same color with and has the same color with normal findings.
his facial skin. The auricles are his facial skin. The auricles are
aligned with the outer canthus aligned with the outer canthus
Ears and Hearing
of eye. When palpating for the of eye. When palpating for the
texture, the auricles are texture, the auricles are
mobile, firm and not tender. mobile, firm and not tender.
The pinna recoils when folded. The pinna recoils when folded.
 During the assessment of During the assessment of
Watch tick test, the client was Watch tick test, the client was
able to hear ticking in both able to hear ticking in both
ears. ears.
Nose: The nose appeared Nose: The nose appeared There is no deviation from
symmetric, straight and symmetric, straight and normal findings.
uniform in color. There was no uniform in color. There was no
presence of discharge or nasal presence of discharge, but
flaring. When lightly palpated, there is a presence of nasal
there were no tenderness and flaring. When lightly palpated,
lesions. there were no tenderness and
lesions.
Mouth: Mouth:
o The lips of the client are The lips of the client are
Nose and Sinus uniformly pink; moist, uniformly pink; moist,
symmetric and have a symmetric and have a
smooth texture. The client smooth texture. The client
was able to purse his lips was able to purse his lips
when asked to whistle. when asked to whistle.

o Teeth and Gums: There

o Teeth and Gums: There
are no discoloration of the
are no discoloration of the
enamels, no retraction of
enamels, no retraction of
gums, pinkish in color of
gums.
 gums, pinkish in color of
gums
o The buccal mucosa of the
client appeared as uniformly
pink; moist, soft, glistening
and with elastic texture.
o The tongue of the client is
centrally positioned. It is
pink in color, moist and
slightly rough. There is a
presence of thin whitish
coating.
o The smooth palates are light
pink and smooth while the
hard palate has a more
irregular texture.
o The uvula of the client is
positioned in the midline of
the soft palate.
o The neck muscles are equal
in size. The client showed
Neck coordinated, smooth head
movement with no
discomfort.
o The buccal mucosa of the
client appeared as
uniformly pink; moist, soft,
glistening and with elastic
texture.
o The tongue of the client is
centrally positioned. It is
pink in color, moist and
slightly rough. There is a
presence of thin whitish
coating.
o The smooth palates are
smooth while the hard
palate has a more irregular
texture.
o The uvula of the client is
positioned in the midline of
the soft palate
o The neck muscles are equal There is no deviation from
in size. The client showed normal findings.
coordinated, smooth head
movement with no
discomfort.
 o The lymph nodes of the o The lymph nodes of the
client are not palpable. client are not palpable.
o The trachea is placed in the o The trachea is placed in the
midline of the neck. midline of the neck.
o The thyroid gland is not o The thyroid gland is not
visible on inspection and the visible on inspection and
glands ascend during the glands ascend during
swallowing but are not swallowing but are not
visible. visible

o Lungs/Chest: The chest o Lungs/Chest: The chest There is no deviation from

wall is intact with no wall is intact with no normal findings.
tenderness and masses. tenderness and masses.
There’s a full and symmetric There’s a full and symmetric
expansion and the thumbs expansion and the thumbs
separate 2-3 cm during separate 2-3 cm during
Lungs and Heart deep inspiration when deep inspiration when
assessing for the respiratory assessing for the
excursion. The client respiratory excursion.
manifested quiet, rhythmic There is also an inch-sized
and effortless respirations. scar due to a past accident.
o The spine is vertically o The spine is vertically
aligned. The right and left aligned. The right and left
 shoulders and hips are of
the same height.
o Heart: There were
visible pulsations on the
aortic and pulmonic areas.
There is no presence of
heaves or lifts.
The abdomen of the client has
an unblemished skin and is
uniform in color. The abdomen
has a symmetric contour.
Abdomen There were symmetric
movements caused associated
with client’s respiration. The
jugular veins are not visible.
o The extremities
symmetrical in size and
length.
Extremities
o Muscles: The muscles are
not palpable with
absence of tremors. They
shoulders and hips are of
the same height.
no o Heart: There were no
visible pulsations on the
aortic and pulmonic areas.
There is no presence of
heaves or lifts.
The abdomen of the client has There is striae gravidarum
striae gravidarum 3-5 cm long present on the patient’s
on her lower abdomen. There abdomen due to stretching of
were symmetric movements the skin.
caused associated with client’s
respiration. The jugular veins
are not visible.
are o The extremities are There is no deviation from
symmetrical in size and normal findings.
length.
o Muscles: The muscles are
the not palpable with the
absence of tremors. They
 are normally firm and are normally firm and
showed smooth, showed smooth,
coordinated movements. coordinated movements.

o Bones: There were no

o
presence of bone o Bones: There were no
deformities, tenderness and
presence of bone
swelling. deformities, tenderness and
swelling.
o Joints: There were no
swelling, tenderness and
o Joints: There were no
joints move smoothly.
swelling, tenderness and
joints move smoothly.