Physical Examination Sample Pediatric

Nursing assessment is an important step of the whole nursing process.

Physical examination sample pediatric. With a weak or incorrect assessment nurses can create an incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation. Pupils equal round and reactive to light and accommodation. No visible lesions or rashes. 16 5 kg 90th percentile height.

98 on room air bp. Appears lethargic and ill. To understand how the general approach to the physical examination of the child will be different compared to that of an adult patient and will vary according to the age of the patient. Sclerae conjunctivae and fundi are clear bilaterally.

History and physical examination h p examples the links below are to actual h ps written by unc students during their inpatient clerkship rotations. Assessment can be called the base or foundation of the nursing process. Temp 37 8 rectal pulse 156 respiratory rate 45 bp 86 47 spo2 98 on room air growth parameters. Example of a complete history and physical write up patient name.

Patient who is reliable and old cpmc chart. 17 9 85th percentile general. In order to assimilate the information most easily it is suggested that you read through the whole section before examining your first patient to get a general idea of the scope of the pediatric evaluation. This exam includes detailed examination of the reflex responses as well as the functioning of each of the cranial nerves.

103 2of oral last tylenol dose was 4 hours ago. Patient is asleep but easily arousable. Physical exam the following outline for the pediatric history and physical examination is comprehensive and detailed. Patient is a well developed well nourished infant in no apparent distress.

Physical exam format 1. 96 cm 65th percentile bmi. The practitioner in the health care setting assesses the neurologic status of the child by doing a complete neurologic exam. The patient is alert and oriented x3 and in slight distress secondary to pain.

Weight 3 41 kg 10 25 ile height 54 cm 50 ile head circumference 37 5cm 50 ile general. Subheadings in all caps and flush left to the margin. This is the 3rd cpmc admission for this 83 year old woman with a long history of hypertension who presented with the chief complaint of substernal toothache like chest pain of 12 hours.