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Pediatric Physical Assessment Checklist

This document contains a pediatric physical assessment checklist used by a nursing student, Iana Khrys T. Godoy, to examine a patient named Rossdale Molina on November 11, 2022. The checklist includes assessments of the patient's vital signs, general appearance, integumentary system, head, eyes, ears, nose, mouth/throat, chest, cardiovascular system, abdomen, and musculoskeletal system. Key findings are recorded for each body system assessed.

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Iana Khrys Godoy
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0% found this document useful (0 votes)
44 views3 pages

Pediatric Physical Assessment Checklist

This document contains a pediatric physical assessment checklist used by a nursing student, Iana Khrys T. Godoy, to examine a patient named Rossdale Molina on November 11, 2022. The checklist includes assessments of the patient's vital signs, general appearance, integumentary system, head, eyes, ears, nose, mouth/throat, chest, cardiovascular system, abdomen, and musculoskeletal system. Key findings are recorded for each body system assessed.

Uploaded by

Iana Khrys Godoy
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd

BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos, Bulacan

PEDIATRIC PHYSICAL ASSESSMENT CHECKLIST

Name of Patient: Rossdale Molina Name of Student: Iana Khrys T. Godoy


Date of Assessment: November 11, 2022 :

I. Vital Signs

A. Temperature: 36.6 C Site: Axillia


B. Pulse: 92 bpm
C. Resp. Rate: 24 cpm

II. General
A. Level of Consciousness:
Alert Lethargic Obtunded Stupor Coma
B. Mood:
Pleasant Irritable Calm Happy Anxious
C. Affect:
Surprise Anger Sadness Joy FearfulDisgust
D. Height 3 feet 5 inches
E. Weight 22.8 kilograms Fear Flat

III. Integument
A. Color Pink Jaundice Pallor Erythema Cyanotic Aprop To Race
B. Hair Distribution Even Uneven
C. Moisture Wet Moist Dry Clammy
D. Temperature Hot Warm Cool Cold
E. Texture Smooth Rough
F. Turgor 1 seconds Good Poor
G. Edema None Little Yes Location:
H. Lesions No Yes Location:
Shape: Size:
Type: Color:
I. Birthmarks Hemangioma Nevi Mongolian Spots
J. Nails Clubbing Pink Cyanotic
K. Capillary Refill 1 seconds Brisk Sluggish Rapid

IV. Head
A. Size: 52 cm Normocephaly Microcephaly Macrocephaly
B. Shape Normocephaly Plagiocephaly Brachycephaly Scaphocephaly
B. Fontanelle(s)
Anterior Close Open Tense Soft Dipped
Posterior Close Open Tense Soft Dipped

V. Eyes
A. General Strabismus Doll’s Eye
B. Pupils: Size: 4 Mm Equal Round Raxn To Light Accom
C. Iris: Color Brown Pink Opaque Sun Setting
D. Conjunctiva Clear Erythema
E. Sclera Clear Jaundice Blue
F. Cornea Clear Opaque Erythema
G. Vision Nearsighted Farsighted Glasses Contacts
H. Blink Reflex Yes No

VI. Ears
A. Position of ears Normal Low Set Ears High Set Ears
B. Pain Left Ear Right Ear None
C. Wax Build Up Left Ear Right Ear None

VII. Nose
A. Drainage Yes No
B. Blockages Yes No
C. Sense of Smell Yes No
D. Flaring Yes No
E. Congestion Yes No
F. Mucous Membranes Moist Pink Pallor Erythema

VIII. Mouth and Throat


A. Mucous Membranes Pink Pallor Erythema Jaundice
B. Tongue Shape Symmetric Asymmetric
C. Tongue Movement Symmetric Asymmetric Freely Movable Protruding
D. Saliva Amount Normal Scanty Excessive
E. Teeth Number 21
F. Teeth Condition Intact Dental Caries
G. Gums Intact Erythema
H. Palate Intact Cleft Over arched
I. Tonsils Pink Exudates Grade 1 Grade 2 Grade 3 Grade 4
J. Gag Reflex Yes No
K. Swallowing Easy Difficult Painful
L. Lymph Nodes Normal Enlarged

IX. Chest
A. Breath Sounds Clear Wheezes Crackles Rhonchi Friction Rub
B. Respiration Even/Regular Irregular Labored Shallow Deep
Apnea Abdominal/Diaphragmatic
C. Chest Expansion Symmetrical Asymmetrical Retraction
D. Cough No Yes Productive Non-Productive
Sputum Color: Amount:
E. SOB Yes No Little Difficulty W/ Respirations

X. Cardiovascular
A. S2 “Dub” Clearly Audible Muffled Murmur
B. S1 “Lub” Clearly Audible Muffled Murmur
C. Heart Beat Regular Irregular
D. Apical Rate 92
E. Apical Rhythm Regular Irregular

XI. Abdomen
A. Shape Flat Round
B. Bowel Sounds Quadrant 1 Quadrant 2 Quadrant 3 Quadrant 4
Active Active Active Active
Hyperactive Hyperactive Hyperactive Hyperactive
Hypoactive Hypoactive Hypoactive Hypoactive
Faint Faint Faint Faint
Absent Absent Absent Absent
C. Palpation Soft Hard Firm Tender
Non-Tender Distended
D. Diet Breastfeeding Formula Feeding Mixed Feeding Solid Foods
E. Toleration Of Diet Good Average Poor
F. Change In Appetite Yes No
G. Recent Weight Change None Gain Loss

XII. Musculoskeletal
A. Back
Sacral Dimple Yes No
Posture Straight Kyphosis Lordosis Scoliosis
B. ROM
Upper Extremities Full Partial Active Passive Assistive
Lower Extremities Full Partial Active Passive Assistive
C. Gait Balanced Unbalanced Limping Shuffled

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