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    Pediatric Nursing Assessment

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    Stef Reyes
    The pediatric nursing assessment document contains information about a child patient including: 1) Demographic information such as the child's name, age, parents' names and occupations. 2) General observations of the child's appearance, behavior, and home environment. 3) The child's medical history including birth details, developmental milestones, illnesses, and hospitalizations. 4) Physical examination findings organized by body system.

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    Pediatric Nursing Assessment

    Uploaded by

    Stef Reyes
    493 views3 pages
    The pediatric nursing assessment document contains information about a child patient including: 1) Demographic information such as the child's name, age, parents' names and occupations. 2) General observations of the child's appearance, behavior, and home environment. 3) The child's medical history including birth details, developmental milestones, illnesses, and hospitalizations. 4) Physical examination findings organized by body system.

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    The pediatric nursing assessment document contains information about a child patient including: 1) Demographic information such as the child's name, age, parents' names and occupations. 2) General observations of the child's appearance, behavior, and home environment. 3) The child's medical history including birth details, developmental milestones, illnesses, and hospitalizations. 4) Physical examination findings organized by body system.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    493 views3 pages

    Pediatric Nursing Assessment

    Uploaded by

    Stef Reyes
    The pediatric nursing assessment document contains information about a child patient including: 1) Demographic information such as the child's name, age, parents' names and occupations. 2) General observations of the child's appearance, behavior, and home environment. 3) The child's medical history including birth details, developmental milestones, illnesses, and hospitalizations. 4) Physical examination findings organized by body system.

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    of 3

    PEDIATRIC NURSING ASSESSMENT

    l.
    m.
    n.
    o.
    p.

    Name of Student: _____________________________ Date of Assessment: ____________________________


    Informant: _________________________________ Date of Submission: _____________________________
    Childs Name: ______________________________________________ Age: ______ Sex: ________
    Date of Birth: _______________ Address: _______________________________________________
    Ward: _____ Bed No.:_____ Medical Diagnosis/Impression: _________________________________
    Mothers Name: ____________________________ Fathers Name: ___________________________
    Occupation: _______________________________ Occupation: ______________________________
    Age: _____
    Age: _____
    --------------------------------------------------------------------------------------------------------------------------I.

    C.

    General Observations
    A. Appearance and behavior _______________________________________________________
    ____________________________________________________________________________
    B. Parent-Child
    interaction
    ________________________________________________________
    ____________________________________________________________________________
    C. Home environment/living quarters ________________________________________________
    ____________________________________________________________________________

    III.

    Significant past medical history


    A. Family history: Nuclear ______________

    Birth history:
    Place of birth:

    Family member

    Age

    Illness

    Father
    Mother
    Others (specify)

    ____
    ____
    ____
    ____

    _____
    _____
    _____
    _____

    home _____
    clinic _____
    Birth length _____
    length of labor _____
    type of delivery _____
    Forceps _____

    D.

    Neonatal: Cyanosis _____


    Jaundice _____
    Respiratory problems (state type) _____
    Congenital anomalies _____
    Length of hospital stay _____

    E.

    Infancy and Childhood:Breastfed _____


    duration _____
    Bottled _____
    Type of formula _______________
    Vitamins/Mineral ________________________________
    Age of weaning _____
    Feeding problems:
    Vomiting _____
    Constipation _____
    Diarrhea _____
    Colic _____
    Illness:
    ________________________________________
    ________________________________________
    Hospitalizations: No. _____ Separation from parents ________

    Early developmental milestones (approx. age at which the following were achieved)

    Cause of Death
    A.
    ____________________________
    ____________________________
    ____________________________
    ____________________________

    1.
    2.
    3.
    4.
    5.
    6.

    Smiled _____
    Followed objects with eyes _____
    Held head up when prone _____
    Turned self from prone to supine _____
    Cut tooth _____
    Sat with support _____

    Prenatal:
    1.
    2.

    premature birth _____

    Extended __________________________
    IV.

    B.

    fetal death _____

    hospital _____
    Birth weight _____
    No. of weeks gestation _____
    Birth order (1st baby, etc.) _____
    (C.S. _____
    Vaginal _____

    Parental view of presenting problem and/or medical diagnosis


    A. Direct quote of problem: ________________________________________________________
    ____________________________________________________________________________
    B. Description of duration and symptoms/precipitation factors: ____________________________
    ____________________________________________________________________________
    ____________________________________________________________________________

    II.

    Alcohol _____
    Smoking _____
    Depressive states _____
    Crying spells _____
    Previous abortion _____

    Maternal age (during pregnancy) ___________


    Obstetrical/gynecological history:
    a.
    Weight: under weight_____ over weight _____ normal weight gain _____
    b. Nausea/vomiting _____
    duration _____
    c.
    Edema _____
    d. Hypertension _____
    e. Albuminuria _____
    f.
    Urinary tract infection _____
    g.
    Vaginal bleeding _____
    h. Illness (including rashes, fevers, syphilis)
    i.
    Medication taken __________________________________________________
    j.
    X-ray (during what month) __________
    k.
    Drugs _____

    7. Crawled _____
    8. Walked alone _____
    9. Fed self with spoon _____
    10. Said first word _____
    11. Spoke sentences _____
    12. Bowel/bladder trained (day) _____
    13. Bowel/bladder trained (night) _____

    B. Early behavior patterns _________________________________________________________


    _____________________________________________________________________________________
    C. Relationship with siblings _______________________________________________________
    _____________________________________________________________________________________
    D. Relationship with peers _________________________________________________________
    _____________________________________________________________________________________
    E. Problems related to nutrition _____________________________________________________
    _____________________________________________________________________________________
    V.

    Eating/drinking patterns:
    A.

    Meal patterns and appetite ______________________________________________________


    ____________________________________________________________________________

    B.

    Food likes/dislikes _____________________________________________________________


    ____________________________________________________________________________
    Medications/dietary supplement taken _____________________________________________
    ____________________________________________________________________________
    Allergies to food (state what food) ________________________________________________
    To medicine (state medicine) _____________________________________________________
    Problems related to nutrition _____________________________________________________

    C.
    D.
    E.
    VI.

    XII.

    School history
    A.

    B.
    C.

    School
    Age
    Reactions
    Nursery
    ___
    _____________________________________
    Kindergarten
    ___
    _____________________________________
    First grade (primary)
    ___
    _____________________________________
    Present grade (primary) _________________ Starting _____________________________
    School problems ___________________________________________________________

    Eliminating patterns:
    XIII. Physical examination
    A.
    B.

    VII.

    Usual pattern _________________________________________________________________


    Difficulties with eliminations _____________________________________________________

    A. General:

    Sleeping pattern:
    A.
    B.
    C.
    D.

    Usual pattern _________________________________________________________________


    Sleeping rituals ________________________________________________________________
    Special rituals _________________________________________________________________
    Problems wit sleeping ___________________________________________________________

    C. General Appearance:

    C.
    D.

    Level of independence:
    Low _____
    Medium _____
    High _____
    Pattern of self-care (state what activities of daily living child can do) ______________________
    _____________________________________________________________________________
    Occurrence of dependent behavior _________________________________________________
    _____________________________________________________________________________
    Reaction to hospitalization/illness/stress ____________________________________________
    _____________________________________________________________________________

    E. Accessory Structure:

    F. Head:
    IX.

    Temperaments: A. Usual mode ___________________________________________________

    X.

    Play:
    A.
    B.
    C.
    D.
    E.

    XI.

    General color:__________________________
    Texture:______________________________
    Temperature:__________________________
    Turgor: ______________________________
    Lesions (if any): _______________________

    Independence-dependence
    A.
    B.

    Toys available at home _________________________________________________________


    Availability/safety of play area ___________________________________________________
    Favorite toys and activities ______________________________________________________
    Childs initiative and amount of creative play: Low _____
    Medium _____
    High _____
    Preferred play: Solitary _____ Parallel _____
    Cooperative _____

    Discipline:
    A.
    B.
    C.
    D.

    Responsibility for discipline: father _____ mother _____both _____ siblings _____
    Method(s) utilized _____________________________________________________________
    Effectiveness of method(s) ______________________________________________________
    Child reaction ________________________________________________________________

    weight gain:________________
    Chest circumference:_______________
    Abdominal circumference:___________

    B. Vital signs: Temp:_____________ HR:________________ RR: _______________ BP:____________

    D. Skin:
    VIII.

    present weight:_____________
    Length/height:_____________
    Head circumference:_____________

    Hair:________________________________
    Nails: _______________________________
    Dermatoglyphics:______________________

    Shape:_______________
    ROM:_______________

    Symmetry:___________________
    Fontannels:___________________

    G. EENT and Mouth: Periorbital region:__________________


    Conjunctiva:______________________
    Headache:________________________
    Blurring vision:____________________
    Pinnae/ external canal:______________
    Ear discharge:_____________________
    Septum:_________________________
    Lips:___________________________
    Teeth:__________________________
    Tongue:_________________________
    Palates:_________________________
    Toothaches:______________________
    H. Neck:

    Trachea:______________

    I. Lymph nodes:

    submaxillary:_____________________
    Axillary:_________________________

    Sclera:________________
    Pupils:________________
    Visual problems:________
    Strabismus:____________
    Tympanic membrane:____
    Buzzing in ear:_________
    Mucosa:_______________
    Mucosa:_______________
    Gums:_________________
    Uvula:_________________
    Pharynx:_______________
    Gumbleeding:___________

    Thyroid:______________
    Cervical:_______________
    Inguinal:_______________

    J. Chest:

    Shape:______________________
    Chest expansion:______________
    Chest percussion:_____________

    K. Cardiovascular:

    Cardiac rate:_______________ Pulse rate:_________________


    Cyanosis:_________________ Dyspnea on exertion:________
    Limitation of activity:__________________
    Heaves:__________________ Thrills:___________________
    Heart sounds: ________________________
    Murmurs:___________________________

    L. Abdomen:

    Size:__________________
    Hernias:_______________
    Bowel sounds:__________
    Percussion:_____________
    Palpation:______________

    M. Genitalia:

    Symmetry:______________________
    Vocal fremitus:__________________
    Breath sounds:_______________

    Shape:___________________
    Aortic pulsations:__________

    Penis:_________________
    Urethral meatus:_________
    Scrotum:_______________
    Testes
    Labia:________________
    Urethral meatus:________
    Vaginal orifice:_________
    Anus:_________________

    N. Back and extremities:

    Posture:_____________________
    Extremity size:_______________
    Color:______________________
    Mobility:___________________

    XIV. Neurologic
    o
    Spine: Scoliosis
    o
    Inspect joint
    o
    Hip dysplasia
    o
    Inspect knees distance
    o
    Inspect gait
    o
    Plantar reflex
    o
    Muscle Strength: Arms, Legs, Hands, Feet
    o
    Mental Status
    o
    Number Discrimination
    o
    Memory
    o
    Finger-to-nose test
    o
    Heel-to-skin test
    o
    Romberg test
    o
    Touch each fingertips
    o
    Sensory intactness pin
    o
    Cold and warm (reflex hammer)
    o
    Biceps (antecubital), Triceps (elbow), Brachiordialis (radial), Knee, Ankle, Plantar, Abdominal
    o
    Kernigs (flex knee and hip), Brudzinki (flex head)

    Gait:__________________
    Symmetry:_____________
    Temperature:___________
    Muscle strength:______________

    Immunizations: (specify age or date given)


    BCG ______
    OPV # 1 ______
    #2 ______
    # 3 ______
    DPT # 1 ______
    #2 ______
    # 3 ______
    Others _____________________________________________________________________
    XIII.

    Current development level

    A. Gross motor ________________________________________________________________


    ___________________________________________________________________________
    B. Fine motor adaptive __________________________________________________________
    ___________________________________________________________________________
    C. Language ___________________________________________________________________
    ___________________________________________________________________________
    D. Personal-Social ______________________________________________________________
    ___________________________________________________________________________

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