Pediatric Catheter Assessment Form
Use this form to record a pediatric catheter assessment, document observations, and note the recommended follow-up.
Assessment Details
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Age Group
*
Please Select
Option 1
Option 2
Option 3
Catheter Type
*
Please Select
Peripheral IV Catheter
Central Venous Catheter
Urinary Catheter
Feeding Tube
Other
Reason for Catheter Use
*
Catheter Condition Review
Catheter Condition Observations
*
Rows
Clean
Intact
Patent
Comfortable
Site cleanliness
1
2
3
4
Securement
5
6
7
8
Dressing integrity
9
10
11
12
Patency/flow
13
14
15
16
Patient comfort
17
18
19
20
Insertion Site
*
Nasal
Oral
Upper extremity
Lower extremity
Umbilical
Other
Securement Condition
*
Intact
Needs reinforcement
Loose
Not assessed
Signs of Issues
None observed
Redness
Swelling
Leakage
Discomfort
Blockage
Other
Assessment Outcome
Overall assessment score
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Follow-up recommendation
*
Continue current care
Monitor closely
Adjust/replace catheter
Escalate for clinical review
Other
Submit
Should be Empty: