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~ "When I think about all the patients and their loved ones that I have worked with over the years, I know most of them don't remember me nor I them. But I do know that I gave a little piece of myself to each of them and they to me and those threads make up the beautiful tapestry in my mind that is my career in nursing."
Donna Wilk Cardillo reflected in A Daybook for beginning Nurses
Hands by Kerry Goodwin creative commons attribution license, flickr
clients will change,
locations will change
diagnoses will change
what will not change is the public's view of your responsibility and the trust you will incur simply by your profession.
The biggest difference between medical surgical nursing and peds is the age and developmental stage of the patient.
Also, you are not simply dealing with the patient but also with the family.
Dynamics which may affect the patient include the age, diagnosis, family situation, culture, gender, religion.
*Your assessment is the most important skill you have, use it! Think through the nursing process with the information that you have …it's like CSI…only better.*
A head to toe assessment
is needed in the hospital. This usually will be performed on admission and once a shift, every 12 hours, every 8 hours or every four hours, depending on the patient and their stability.
If the patient is brittle or postsurgical assessments are being completed in recovery they are performed every 5-15 minutes.
Once on the floor, immediate assessments may be every every 30 then every hour and then progress to every 4 hours.
But first things first...is the patient stable?
This first video introduces the
This type of assessment is usually
performed quickly in an outpatient setting or ER.
In addition to these quick assessments a detailed history is obtained.
The assessment triangle is used to quickly assess the needs of the patient.
Do they need O2, should they be seen first? Are they critical or stable, sick or not sick.
The triangle assesses the child's appearance, work of breathing and circulation.
It is non-invasive, non-threatening, quick and easy.
tone, interactiveness, consolability, look/gaze and speech/cry.
is assessed. Note the
involved ... retractions, nasal flaring, the child's
...tripoding, and the child's anxiety.
is assessed. What is the child's
Are they pale, mottled, ashen. Is there any cyanosis? How about capillary refill?
*A more detailed assessment is performed after the initial assessment triangle is completed and the patient is stabilized.
*Pain is also assessed with all patients per JACHO standards.*
Infants are assessed using
, children are asessed using
and older children and adults are assessed using
All these are rated using
with zero being no pain and ten being excruciating.
Remember pain is what the patient says it is.
*This is an example of a Face pain rating scale. Be aware that it can be based 0-5 or 0-10. The principle is the same. Most are based on the 0-10 scale as are the others.
In hospital health assessment:
Begin with Health History Interview:
Introduce yourself, state your title, where you are from, the purpose of the interview and approximately how long it will take.
What brings you here today? Chief complaint?
When did it begin?
Where the symptoms are?
How long do they last?
Note characteristics of the symptoms.
What makes the symptoms better? Worse?
Are there accompanying symptoms?
Has self-treatment been tried?
Pain? where, when, how long, constant, intermittent, relief? 5th vital sign
Sleep - Is the patient resting well? What are their current sleep patterns like? Do they nap? How about caffeine ingestion?
Nutrition – Ask the patient about their nutrition and diet. Are there any food allergies or intolerances? Appetite? Note BMI
– recaps the patient’s history and clarifies data received. It briefly retells what the nurse understands.
*The introduction, discussion and summary gives the nurse much needed information; while performing this history you are assessing their overall appearance and noting the patient's level of consciousness. Are they oriented to person, place and time?
Clean, well-rested, and talkative? Or disheveled, inattentive, and lethargic?
Note body movements, emotions, temperament, speech patterns and behavior
Observe for muscle tension, perspiration, or tremors
Alterations in some vital signs can influence other vital signs.
For example, an increased temperature can cause an increase in respiratory rate and heart rate. Pain can increase blood pressure.
Next begin to review each system:
*While completing the physical assessment the nurse uses her skills of inspection, palpation, percussion and auscultation. If pain is a symptom, palpation of the involved area is last!
Skin, hair, nails –
Skin integrity, breakdown, rashes, tears, bruises, birth marks, scars, moles, acne, discolorations, tatoos, texture and turgor
Incision and dressing for drainage
IV site for swelling or redness.
Hair for cleanliness, parasites, dryness or brittleness
Nail beds for integrity, cleanliness, or habitual nail biting
Head and neck –
Tenderness, redness, swelling?
Palpate thyroid and lymph nodes
Ask, any headaches or dizziness?
Nose, paranasal sinuses, sinuses, mouth –
Oral, nasal facial symmetry
Nares for patency and color. Discharge? Color and amount? Odor?
Color, symmetry, moisture and texture of the lips. Moist, cracked, dry?
Gums, tongue, and throat for color, bleeding, or exudate. Oral hygiene. Oral lesions? Sore throat?
Ears and auditory system –
Alignment, position, placement on head,
Ear size, shape, symmetry, intactness, tags
External meatus for discharge or lesions.
Pull down and back under 3, Up and back over 3, to visualize the tempanic membrane
Responses to questions, can they hear without difficulty?
Any difficulties with ears? Tinnitus? Any ear pain?
Eyes and visual system –
Eyebrows, symmetry and hair distribution.
Eyelids, eyelashes, and blinking;
Globe position in the socket.
Color of the eye, the color of the conjunctiva
Lacrimal puncta for color, moisture or discharge.
Redness or crustiness need to be noted as such.
PERRLA - Pupils should be equal, round, reactive to light and accommodation.
Difficulties with their vision? Do they see spots, wear glasses or contacts?
Lungs and respiratory system –
Posture, appearance, effort, and positioning. Even and unlabored? Tripoding?
Shape, muscle development and symmetry of the chest. Anterior to posterior diameter, transverse diameter
Respiratory rate and quality, retractions, nasal flaring
Auscultate breath sounds, wheezing, stridor, rhonchi
SOB or coughing. Is there any history of reactive airway disease or asthma?
Heart and peripheral vascular system –
Skin color? pale, cyanotic...
Jugular vein for pulsations, lifts, or heaves.
Auscultate S1 and S2 heart sounds for rate, rhythm, pitch, or splitting.
Pulses for rate, rhythm, amplitude and contour.
Chest pain or palpitations?
Tone, soft, hard, guarding the abdomen or are the legs drawn up in pain?
Bowel sounds? X4?
Incisions or dressings? Edges approximated? With steri strips? staples? sutures?
Drainage? color? amount? Dressing? Outline the drainage with a pen to see if the area enlarges.
Musculoskeletal - Extremities -
What is the tone of the muscles?
Are the reflexes normal?
Are the extremities normal color?
Is the skin well hydrated?
What is the capillary refill of the toenail beds?
Are the pedal pulses palpable?
Cognizant of the day and time?
What is their level of consciousness?
Can they move and respond appropriately?
Assessed only if problem with parent, guardian or chaperone.
Remind the child that this area is private.
This area can be assessed for rashes, sores, or discharges.
A pediatric hospital assessment
For documentation purposes note:
Diet - type and amount consumed. Was it tolerated?
Safety measures - call light proximity, clutter free floor, adequate lighting, age appropriate toys
Pain level - Pain is often called the fifth vital sign. Noting the pain level with an appropriate tool is a JACHO standard.
Incision: Are the edges approximated? Were sutures, staples or steri strips used? Is there redness, drainage?
Dressing: Is the dressing dry and intact? If there is drainage present is it new? Grossly bloody or serous fluid?
Drains: Is there a drain in place? Is there drainage? Note the amount and color.
Intake: Intake can come from many sources. Be sure and note the source, amount and how it is tolerated.
Calculate the weight of a child in kilograms:
Weight of child in pounds
= Weight in kilograms example:
24 lb child
= 10.91 kg
Divided by 2.2 pounds/kg 2.2 lb/kg
Infants require 100 calories per kilogram of body weight (Adults 30-40)
Output: Output can also occur in various forms. Be careful to note all output
Bladder capacity in ounces = child’s age +2, Example - 3 year old has the capacity of 5 ounces.
Calculating output for infants = 1ml/kg/hour, ex. 5kg infant has 5 ml. urine per hour.
1 gram weight diaper weight = 1 ml of urine
*Pediatric drop factor for IV is 60
Pediatric Data Base and Concept Map is available for download and copying under the heading Pediatric Clinical.
Hockenberry, M. J., & Wilson, D. (2009). Wong's essentials of pediatric nursing (8th ed.). St. Louis, MO: Mosby Elsevier.
Potts, N. L., & Mandleco, B. L. (2012). Pediatric nursing: Caring for children and their families (3rd ed.). New York, NY: Delmar Cengage Learning.
Videos located at:
Pediatric assessment triangle located at
Pediatric Assessment -
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