PEDIATRIC ASSESSMENT FORM

Student:____________________________ Faculty:________________________ Date:______/_____/_____

Nurse:_________________________
Pain scale in use:
Weight:______________________________ (Kg)

ScaleQXPEHU:_______________________________ FACES Rating Scale

HeightEDE\VWDQGXS:____________________________(cm) Numeric Rating Scale

Head Circumference_________________ (cm) Objective Pain Scale

VITAL SIGNS:
Time Temp HR R BP Pain SPO2 Comments:
Score

Hourly Checks On    1 1     Code Key:

Patients          Position:
Lt=Left
Initials Rt=Right
P=Prone
Activity S=Supine
IF=Infant Seat
Family Present H=Held

Bed Type IV Tubing Checks:

=Secure
*=See Focus Note
Side Rails Up
X2 X4 Family Present:
M=Mother
Bed Position
Fa=Father
O= __________
IV Fluids Checked Blank= No visitors

Dressing Change Bed Type:

Bd=Bed
Trach Care/ O2 Care Cb=Crib
C=Cage Top
Labs Drawn Iso=Isolette
SB=__________

AM/PM Care Activity:

BR=Bed Rest
Turned and Positioned RP= Recreation/Play
(ROM) ChL=Child Life
T/P=Test or Procedure
Linen Changed (Identify in Comments)
Amb=Ambulation
Enteral Feeding Bag Tv=watching TV
Changed SL=sleeping
ScT=School Teacher
IV Tubing checked
 Signature_____________________________________________ Time________ AM PM
Precautions:_______________________________ Arm Band on Patient Location __________________
Call bell with in reach of Pt. or family
N Alert Appropriate for age/ condition Lethargic PEARLA
E Cooperative Combative Apprehensive Hyperactive Other__________________
U Fontanel: N/A Open Soft Flat Sunken Full Pulsatilla
R Speech: Clear Slurred Nonverbal Inappropriate Crying Other____________
Motor: Moves all extremities
O Weakness_____________________________________________________________
Paralysis______________________________________________________________
Comments ____________________________________________________________
Color: Normal Pale Cyanotic Jaundice Flushed __________________
S Temperature: Warm Cool
K Condition: Intact Dry Diaphoretic
I Suture Line at _______________
Pressure area at _____________
N
Edema at __________________
Turgor: Normal Tented
IVF No S/S Infiltration No S/S Infection
I CVL  Type______________ Dressing D&I
V PICC EDC PIV Patent D/C Heplock
Location: ____________________________
Rhythm: Regular Irregular Murmur
C Pulses: Strong & equal at ____________________+ Unequal at _____________________
V Capillary Refill Time______sec.
Equipment: None Pacer wires Monitored  Alarms set at ______________________

EBBS clear Labored Shallow Irregular Grunting Stridor Nasal flaring
R Cough  Productive Nonproductive Wheezing Rales Rhonchi Coarse
E Location:_______________________________
S O2__________________
Vent Tracheostomy Suction at Bedside
P
Pulse ox  Alarms set at __________________ Sats___________________________________
Comments:________________________________________________________________________

Denies complaints Mucus membranes pink & moist Other__________________________

G Abd. Soft Flat Tender Distended
I Bowel Sounds: Normal Absent
Hyperactive Hypoactive Passing flatus BM in past 24 hours. Diapered Incontinent
Nausea Vomiting Diarrhea Ostomy___________________________
G-Tube NGT  Clamped Feeds Gravity Suction Feeding Pump
Comments:________________________________________________________________________

Voiding without difficulty Other__________________ Ƒ 'LDSHUHGƑOstomy 

G Urine: Clear Cloudy Color_____________________ Anuric Dialysis  Today
U Continent Incontinent In/Out Cath Foley Care Foley D/Cd  Voided _______#hours
Comments:_________________________________________________________________________
Denies c/o pain No signs/ symptoms
P C/O pain  Location: ___________________________ New Pain Pain NOT related to C/C
A Intensity:___________________ Numeric OPS FACES
I Pain well controlled on current regimen
Intermittent med PCA Epidural
N
Ineffective pain control
 INTAKE
15 16 17 18 19 20 21 22 Total
Nutrition/Facts

PO

Residual

Tube

IVF-1/
Site /
Hour Total

IVF-2
Site/Rate
Hour Total

IVF-3
Site/Rate
Hour Total

IVF-4
Site/
Hour Total

Type of Intravenous Fluids:

#1._______________________________________________________________________________________________________________

#2._______________________________________________________________________________________________________________

#3________________________________________________________________________________________________________________

#4._______________________________________________________________________________________________________________

OUTPUT
URINE BM FOLEY NGT DRESSING EMESIS DRAINS Stool:
BK=Black
BR=Brown
Y=Yellow
G=Green
CC=Clay color
L=Liquid
LO=Loose
MU=Mucoid
W=Watery

1. I/O for 24 hours ____________________________

2. I/O for shift ________________________________