Date:_____/ _____ / _____ PEDIATRIC PHYSICAL ASSESSMENT FORM

+ = Further documentation on Skin Integrity page and Psychosocial/Cultural

* = See Narrative Note
L.O.C.: Alert Arouses easily Lethargic Sedated Alert Arouses easily Lethargic Sedated
Unresponsive Restless Asleep Unresponsive Restless Asleep
lMusculoskeletaNeurological /

Oriented to: Self Place Time Situation Unable to assess
Speech: Clear Normal cry Abnormal cry Age appropriate
Unclear (specify): _________________ Unable to assess
Fontanelles: Soft Flat Full Sunken Tense Bulging
Motor: MAE x 4 spontaneous Equal strength Tremors Weakness
Deficit (Specify) ___________________ Unable to assess
Sensory: Numbness Tingling Paralysis (specify): ____________
Joints: Swelling Tenderness Contractures Immobilized
Other _______________________________________
Mobility: Gait steady Gait unsteady unable to assess
Tubes/Drains:
Heart Sounds: Clear Muffled Murmur Rub Gallop
Regular Irregular
Cardiovascular
Self Place Time Situation Unable to assess
Clear Normal cry Abnormal cry Age appropriate
Unclear (specify): __________________ Unable to assess
Soft Flat Full Sunken Tense Bulging
MAE x 4 spontaneous Equal strength Tremors Weakness
Deficit (Specify) ____________________ Unable to assess
Numbness Tingling Paralysis (specify): ____________
Swelling Tenderness Contractures Immobilized
Other _______________________________________
Gait steady Gait unsteady unable to assess
Clear Muffled Murmur Rub Gallop
Regular Irregular

Peripheral Capillary Refill: ≤ 3 seconds seconds ___________ ≤ 3 seconds seconds ___________

Central Capillary Refill: ≤ 3 seconds seconds ___________ ≤ 3 seconds seconds ___________
Edema: Not present Present ___________ Not present Present ___________
Cardiac Rhythm: NSR Other ___________________ Pulses NSR Other ___________________ Pulses
DVT Signs/Symptoms: Not Present Present Not Present Present
Tubes/Drains:
Chest Expansion: Symmetrical Asymmetrical Symmetrical Asymmetrical
Breath Sounds: R: Clear Abnormal (specify): _____________ R: Clear Abnormal (specify): _____________
L : Clear Abnormal (specify): _____________ L : Clear Abnormal (specify): _____________
Retractions: Mild Moderate Severe Intercostal Subcostal Mild Moderate Severe Intercostal Subcostal
Respiratory

Sternal Substernal Sternal Substernal

Cough: None Non-productive Productive None Non-productive Productive
Respirations: Regular Irregular Unlabored Labored Shallow Deep Regular Irregular Unlabored Labored Shallow Deep
Dyspnea Orthopnea Periods of Apnea Tachypnea Dyspnea Orthopnea Periods of Apnea Tachypnea
Nasal Flaring Assisted __________________________ Nasal Flaring Assisted __________________________
Airway/Tubes/Drains:
General Appearance: Flat Round Obese Distended Flat Round Obese Distended
Abdomen: RUQ RLQ LUQ LLQ RUQ RLQ LUQ LLQ
Active Active Active Active Active Active Active Active
Hyopactive Hyopactive Hyopactive Hyopactive Hyopactive Hyopactive Hyopactive Hyopactive
Hyperactive Hyperactive Hyperactive Hyperactive Hyperactive Hyperactive Hyperactive Hyperactive
Gastrointestinal

Absent Absent Absent Absent Absent Absent Absent Absent

Tender Tender Tender Tender Tender Tender Tender Tender
Soft / Firm Soft / Firm Soft / Firm Soft / Firm Soft / Firm Soft / Firm Soft / Firm Soft / Firm
Bowel Elimination: Date of last BM _________ Colostomy Ileostomy Date of last BM _________ Colostomy Ileostomy
GI Alterations: Nausea Vomiting Diarrhea Constipation Nausea Vomiting Diarrhea Constipation
Tubes/Drains: Site _______________ Type __________________ Site _______________ Type __________________
Site _______________ Type __________________ Site _______________ Type __________________
Site _______________ Type __________________ Site _______________ Type __________________
Other:
Voids: Continent Incontinent In/Out Cath Diaper Continent Incontinent In/Out Cath Diaper
Catheter: Spontaneous Spontaneous
None Indwelling Exdwelling Suprapubic None Indwelling Exdwelling Suprapubic
Urine: Urostomy Stent Vesicostomy Urostomy Stent Vesicostomy
Genitourinary

Clear Cloudy Mucous threads Sediment Clear Cloudy Mucous threads Sediment
Bladder: Color/Other: ____________________________________ Color/Other: ____________________________________
Urinary Drains: Non-distended Distended Non-distended Distended
Site _______________ Type __________________ Site _______________ Type __________________
Site _______________ Type __________________ Site _______________ Type __________________
Other: Site _______________ Type __________________ Site _______________ Type __________________
Menses: Light Moderate Heavy Light Moderate Heavy
Skin Temp Peripheral: Warm Cool Hot Warm Cool Hot
Skin Temp Central: Warm Cool Hot Warm Cool Hot
Integumentary

Skin Moisture: Dry Clammy Sweaty Dry Clammy Sweaty

Skin Color: Normal Jaundiced Cyanotic Pale Mottled Pink Dusty Normal Jaundiced Cyanotic Pale Mottled Pink Dusty
Mucous Membranes: Moist Dry Pink Pale Cyanotic Moist Dry Pink Pale Cyanotic
Skin Integrity: Intact Not Intact+ Pressure ulcer+ Surgical wound+ Intact Not Intact+ Pressure ulcer+ Surgical wound+
Rash+ Lesion+ Rash+ Lesion+
Patient Behavior: Clam Cooperative Engaged in care Anxious Tearful Clam Cooperative Engaged in care Anxious Tearful
Family DynamicsPsychosocial /

Withdrawn Affect (specify): ____________________ Withdrawn Affect (specify): ____________________

Uncooperative (specify): _____________________ Uncooperative (specify): _____________________
Family Involvement: Supportive Non-supportive* Involved in care Supportive Non-supportive* Involved in care
No involvement* No involvement*
Developmental Level:
Cultural/Other:

Time and Initials

Time and Initials
Time and Initials