Pediatric Head to toe assessment (1) PDF

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head to toe for children...

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Cuyahoga Community College Pediatric Assessment Rubric

Concepts of Nursing Care of Childbearing Families and Children

Student Name_____________________________

Instructor:____________________________

Pediatric Assessment Introduces self to child and parent Obtain Health History: a) Prenatal and Birth History b) Developmental History c) Social History of family (environmental risks) d) Family Medical History e) Immunization History General Appearance: Activity: ________________________________ (circle one) WNL Undernourished Over nourished Vital signs: Temp: (circle one) Axillary Tympanic Temporal Oral T: Apical pulse listening at 3rd/4th intercostal space Rate and rhythm P: Heart sounds: (presence and location of any murmurs) Assess RR (observing movement of abdominal wall until 7yrs of age) R: Lungs: (sounds, presence of retractions, color and consistency of sputum) Obtain BP (site based on age) Limb: BP: Assess Skin: (well distributed color, soft, smooth, good turgor no breakdown or lesions) Assess head: Normocephalic, no masses, no variations in hair distribution, fontanels for Infant Face: (symmetry, Perrla, sclera white no drainage/redness from eyes or ears. Ears in line with eyes, not low set, no vision or hearing problems. Nares patent no nasal flaring. Oral mucosa moist and pink note presence and condition of teeth) Assess neck: (No masses, tracheal deviation, presence and location of lymph nodes) Assess chest: (Symmetry, any breast tissue present) Assess abdomen: (+BS all 4 quadrants, Round soft and no pain/guarding hernias) Assess back and extremities: (curvature of the spine, note gate, posture, movement, equal push pull for arms and legs. ROM balance and symmetry of Assess genitalia: *Done last especially in school age children any redness, drainage abrasions) Male: testes: descended or undescended. presence of hair Female: labial folds presence of tearing and look for presence of hair Assess Rectum (gluteal folds on infant) patency, any redness or fissures present

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