pediatric_assess - PEDIATRIC ASSESSMENT FORM Student:_...

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PEDIATRIC ASSESSMENT FORM Student:____________________________ Faculty:________________________ Date:______/_____/_____ Initials________ Room #_______ Nurse:_________________________ VITAL SIGNS: Time Temp HR R BP Pain Score SPO2 Comments: Weight:______________________________ (Kg) Scale:_______________________________ Height:____________________________(cm) Head Circumference_________________ (cm) Pain scale in use: ± FACES Rating Scale ± Numeric Rating Scale ± Objective Pain Scale Hourly Checks On Patients 0 7 0 8 0 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 Initials Activity Family Present Bed Type Side Rails Up ± X2 ± X4 Bed Position IV Fluids Checked Dressing Change Trach Care/ O2 Care Labs Drawn AM/PM Care Turned and Positioned (ROM) Enteral Feeding Bag Changed IV Tubing checked Linen Changed Code Key: Position: Lt=Left Rt=Right P=Prone S=Supine IF=Infant Seat H=Held IV Tubing Checks: 3 =Secure *=See Focus Note Family Present: M=Mother Fa=Father O= __________ Blank= No visitors Bed Type: Bd=Bed Cb=Crib C=Cage Top Iso=Isolette SB=__________ Activity: BR=Bed Rest RP= Recreation/Play ChL=Child Life T/P=Test or Procedure (Identify in Comments) Amb=Ambulation Tv=watching TV SL=sleeping ScT=School Teacher
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Signature_____________________________________________ Time________
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pediatric_assess - PEDIATRIC ASSESSMENT FORM Student:_...

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