PEDIATRIC ASSESSMENT TOOL

IDENTIFYING DATA:  

Client’s Initials      M  F 
Date of Admission      
Medical Diagnosis      
Age    
(Adjust if premature)
Legal Guardian      
Historian      
Patient’s Chief Complaint      

GENERAL APPEARANCE:

Weight      
Length/Height      
Head Circumference      
Head/Chest ratio appropriate?      
LOC      

Vital signs:
BP      
Pulse     
Temp      
Resp      
Pain level      

PAST HEALTH HISTORY:

Birth History:
Prenatal care       Medication used or illness during pregnancy      
Gestation:	
Method of delivery:	
Birth Weight       Breast  Bottle 
Length of labor and delivery       Medications used      
Apgar score     
Discharged with mother      

PAST HISTORY: 
Growth and development milestones:
Sit alone      
Stand alone      
Walk alone      
Talk in sentences      

Immunization History      

Allergies      
Disabilities/handicaps      
Past Hospitalizations      
Childhood illnesses/injuries      

Family Health History:      

Family Hx of cardiac/renal/liver/diabetes?      

OXYGENATION:

Respiratory rate and quality:      
Breath sounds      
Dyspnea      
Oxygen use      
Respiratory therapy      
Medications used       Pulse ox      
Lab data      

	Circulation:
	Pulse and blood pressure       site      
	Skin color       temperature      
	Capillary refill      
	Lab data      Medications      
	
	Neuro:
	LOC      
	Reflexes      
	Cranial nerves      	
	PERLA      
	Fontanels      

FLUID AND ELECTROLYTE:

skin turgor       
Mucous membranes      
Edema      
Nausea/diarrhea/vomiting      
Change in weight?      

Lab data      
Medications/IV therapy      

NUTRITION:

Usual diet      
# meals/day      
Quality of appetite      
Condition of teeth/gums      
Dietary supplements      

Normal weight       current weight      

ELIMINATION:

Usual voiding pattern      
Incontinent/urgency/frequency/retention      
Pain/burning/difficulty voiding      

Character of urine      
U/A      
Medications      

usual bowel pattern      
Character of stool      
Last bowel movement      
Constipation/diarrhea/blood in stool      
Lab data      
Medications      

Abdomen:      
Soft/firm 
Bowel sounds      
Bladder palpable      
Genitalia/anus      
Lab data       Medications      

ACTIVITY/REST:

Activity status      
Sleep habits      
Rest routine      

ROM      
Muscle tone      
Posture      
Deformity      
Tremors      
Strength      

SAFETY

Skin integrity      
Hair condition      
Condition-eyes/ears/nose      
Breasts/regional lymphatic      
Speech/quality of communication      
Scars/tattoo/rashes/ulceration/bruising/alterations      
Lab data      
Medications      

SOCIAL INTERACTION: Love and belonging

Home environment      
Family support      
Lives with      
Concerns/stresses      
Religion/ethnicity      
Primary language      

SELF ESTEEM:

Hobbies      
School performance      
Sexually active      
Sexual concerns      
Alcohol/smoking/drug use      

ERICKSON stage OF DEVELOPMENT

     

For the adolescent use the “HEADDS” inquiry tool to assess psychosocial status:

Home      

 Education       

Activities       

Depression      

Sex       

Reaction to illness/hospitalization:       

Internet Nursing III Pediatric Assessment Tool