N105 Pediatric Nursing Assessment[1]
Content
University of the Philippines Manila
The health Sciences Center
COLLEGE OF NURSING
Sotejo Hall, Pedro Gil St., Ermita, Manila
NURSING 105
PEDIATRIC NURSING ASSESSMENT
Name of Student: _______________________________
Date of Assessment: _____________________________
Informant: _____________________________________
Date of Submission: _____________________________
Child’s Name: ______________________________________________ Age: ______ Sex: ________
Date of Birth: _______________ Address: _______________________________________________
Ward: _____ Bed No.:_____ Medical Diagnosis/Impression: _________________________________
Mother’s Name: ____________________________ Father’s Name: ___________________________
Occupation: _______________________________ Occupation: ______________________________
Age: _____
Age: _____
--------------------------------------------------------------------------------------------------------------------------I.
II.
Parental view of presenting problem and/or medical diagnosis
A. Direct
quote
of
problem:
________________________________________________________
____________________________________________________________________________
B. Description
of
duration
and
symptoms/precipitation
factors:
____________________________
____________________________________________________________________________
____________________________________________________________________________
General Observations
A. Appearance and behavior _______________________________________________________
____________________________________________________________________________
B. Parent-Child interaction ________________________________________________________
____________________________________________________________________________
C. Home environment/living quarters ________________________________________________
____________________________________________________________________________
III. Significant past medical history
A. Family history: Nuclear ______________
Extended __________________________
Family member
Age
Illness
Father
Mother
Others (specify)
____
____
____
____
_____
_____
_____
_____
Cause of Death
____________________________
____________________________
____________________________
____________________________
B. Prenatal:
1. Maternal age (during pregnancy) ___________
2. 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 _____
l. Alcohol _____
m. Smoking _____
n. Depressive states _____
o. Crying spells _____
p. Previous abortion _____
fetal death _____
premature birth _____
C. Birth history:
Place of birth: hospital _____
Birth weight _____
No. of weeks gestation _____
Birth order (1st baby, etc.) _____
(C.S. _____ Vaginal _____
D. Neonatal:
home _____
clinic _____
Birth length _____
length of labor _____
type of deliver _____
Forceps _____
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 ________
IV.
Early developmental milestones (approx. age at which the following were achieved)
A. 1.
2.
3.
4.
Smiled _____
Followed objects with eyes _____
Held head up when prone _____
Turned self from prone
7. Crawled _____
8. Walked alone _____
9. Fed self with spoon _____
10. Said first word _____
2
to supine _____
5. Cut tooth _____
6. Sat with support _____
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 _____________________________________________________________
____________________________________________________________________________
C. Medications/dietary supplement taken _____________________________________________
____________________________________________________________________________
D. Allergies to food (state what food) ________________________________________________
To medicine (state medicine) _____________________________________________________
E. Problems related to nutrition _____________________________________________________
VI.
Eliminating patterns:
A. Usual pattern _________________________________________________________________
B. Difficulties with eliminations _____________________________________________________
VII.
Sleeping pattern:
A. Usual pattern _________________________________________________________________
B. Sleeping rituals ________________________________________________________________
C. Special rituals _________________________________________________________________
D. Problems wit sleeping ___________________________________________________________
VIII.
Independence-dependence
A. Level of independence:
Low _____
Medium _____
High _____
B. Pattern of self-care (state what activities of daily living child can do) ______________________
_____________________________________________________________________________
C. Occurrence of dependent behavior _________________________________________________
3
_____________________________________________________________________________
F. Reaction to hospitalization/illness/stress ____________________________________________
_____________________________________________________________________________
IX.
Temperaments:
A.
Usual
mode
___________________________________________________
X.
Play:
A.
Toys
available
at
_________________________________________________________
B.
Availability/safety
of
___________________________________________________
home
play
area
C.
Favorite
toys
and
______________________________________________________
activities
D.
Child’s initiative and amount of creative play: Low _____
High _____
E.
XI.
Preferred play: Solitary _____
Parallel _____
Medium _____
Cooperative _____
Discipline:
A. Responsibility for discipline:
father _____
both father and mother _____
mother _____
siblings _____
B. Method(s) utilized _____________________________________________________________
C. Effectiveness of method(s) ______________________________________________________
D. Child reaction ________________________________________________________________
XII.
School history
A. School
Age
Nursery
Kindergarten
First grade (primary)
___
___
___
Reactions
_____________________________________
_____________________________________
_____________________________________
B. Present grade (primary) _________________ Starting _____________________________
C. School problems ___________________________________________________________
XIII. Physical examination
A. General:
present weight:_____________
weight gain:________________
4
Length/height:_____________
Head circumference:_______________
Chest circumference:_______________
Abdominal circumference:___________
B. Vital signs: Temp:_____________ HR:________________ RR: _______________ BP:____________
C. General Appearance:
D. Skin:
General color:__________________________
Texture:______________________________
Temperature:__________________________
Turgor: ______________________________
Lesions (if any): _______________________
E. Accessory Structure:
F. Head:
Shape:_______________
ROM:_______________
G. EENT and Mouth:
G. Neck:
Symmetry:___________________
Fontannels:___________________
Periorbital region:__________________
Conjunctiva:______________________
Headache:________________________
Blurring vision:____________________
Sclera:________________
Pupils:________________
Visual problems:________
Strabismus:____________
Pinnae/ external canal:______________
Ear discharge:_____________________
Tympanic membrane:____
Buzzing in ear:_________
Septum:_________________________
Mucosa:_______________
Lips:___________________________
Teeth:__________________________
Tongue:_________________________
Palates:_________________________
Toothaches:______________________
Mucosa:_______________
Gums:_________________
Uvula:_________________
Pharynx:_______________
Gumbleeding:___________
Trachea:______________
Thyroid:______________
H. Lymph nodes:
I. Chest :
Hair:________________________________
Nails: _______________________________
Dermatoglyphics:______________________
submaxillary:_____________________
Axillary:_________________________
Shape:______________________
Chest expansion:______________
Chest percussion:_____________
Breath sounds:_______________
J. Cardiovascular:
Cervical:_______________
Inguinal:_______________
Symmetry:______________________
Vocal fremitus:__________________
Cardiac rate:_______________ Pulse rate:_________________
Cyanosis:_________________ Dyspnea on exertion:________
Limitation of activity:__________________
Heaves:__________________ Thrills:___________________
Heart sounds: ________________________
Murmurs:___________________________
5
K. Abdomen:
L. Genitalia:
Size:__________________
Hernias:_______________
Bowel sounds:__________
Percussion:_____________
Palpation:______________
Shape:___________________
Aortic pulsations:__________
Penis:_________________
Urethral meatus:_________
Scrotum:_______________
Testes
Labia:________________
Urethral meatus:________
Vaginal orifice:_________
Anus:_________________
M. Back and extremities:
Posture:_____________________
Extremity size:_______________
Color:______________________
Mobility:___________________
Muscle strength:______________
Gait:__________________
Symmetry:_____________
Temperature:___________
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
______________________________________________________________
___________________________________________________________________________
6
LAC:esb
07 July 2004
N105 Pediatric Nursing Assessment
7
The health Sciences Center
COLLEGE OF NURSING
Sotejo Hall, Pedro Gil St., Ermita, Manila
NURSING 105
PEDIATRIC NURSING ASSESSMENT
Name of Student: _______________________________
Date of Assessment: _____________________________
Informant: _____________________________________
Date of Submission: _____________________________
Child’s Name: ______________________________________________ Age: ______ Sex: ________
Date of Birth: _______________ Address: _______________________________________________
Ward: _____ Bed No.:_____ Medical Diagnosis/Impression: _________________________________
Mother’s Name: ____________________________ Father’s Name: ___________________________
Occupation: _______________________________ Occupation: ______________________________
Age: _____
Age: _____
--------------------------------------------------------------------------------------------------------------------------I.
II.
Parental view of presenting problem and/or medical diagnosis
A. Direct
quote
of
problem:
________________________________________________________
____________________________________________________________________________
B. Description
of
duration
and
symptoms/precipitation
factors:
____________________________
____________________________________________________________________________
____________________________________________________________________________
General Observations
A. Appearance and behavior _______________________________________________________
____________________________________________________________________________
B. Parent-Child interaction ________________________________________________________
____________________________________________________________________________
C. Home environment/living quarters ________________________________________________
____________________________________________________________________________
III. Significant past medical history
A. Family history: Nuclear ______________
Extended __________________________
Family member
Age
Illness
Father
Mother
Others (specify)
____
____
____
____
_____
_____
_____
_____
Cause of Death
____________________________
____________________________
____________________________
____________________________
B. Prenatal:
1. Maternal age (during pregnancy) ___________
2. 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 _____
l. Alcohol _____
m. Smoking _____
n. Depressive states _____
o. Crying spells _____
p. Previous abortion _____
fetal death _____
premature birth _____
C. Birth history:
Place of birth: hospital _____
Birth weight _____
No. of weeks gestation _____
Birth order (1st baby, etc.) _____
(C.S. _____ Vaginal _____
D. Neonatal:
home _____
clinic _____
Birth length _____
length of labor _____
type of deliver _____
Forceps _____
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 ________
IV.
Early developmental milestones (approx. age at which the following were achieved)
A. 1.
2.
3.
4.
Smiled _____
Followed objects with eyes _____
Held head up when prone _____
Turned self from prone
7. Crawled _____
8. Walked alone _____
9. Fed self with spoon _____
10. Said first word _____
2
to supine _____
5. Cut tooth _____
6. Sat with support _____
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 _____________________________________________________________
____________________________________________________________________________
C. Medications/dietary supplement taken _____________________________________________
____________________________________________________________________________
D. Allergies to food (state what food) ________________________________________________
To medicine (state medicine) _____________________________________________________
E. Problems related to nutrition _____________________________________________________
VI.
Eliminating patterns:
A. Usual pattern _________________________________________________________________
B. Difficulties with eliminations _____________________________________________________
VII.
Sleeping pattern:
A. Usual pattern _________________________________________________________________
B. Sleeping rituals ________________________________________________________________
C. Special rituals _________________________________________________________________
D. Problems wit sleeping ___________________________________________________________
VIII.
Independence-dependence
A. Level of independence:
Low _____
Medium _____
High _____
B. Pattern of self-care (state what activities of daily living child can do) ______________________
_____________________________________________________________________________
C. Occurrence of dependent behavior _________________________________________________
3
_____________________________________________________________________________
F. Reaction to hospitalization/illness/stress ____________________________________________
_____________________________________________________________________________
IX.
Temperaments:
A.
Usual
mode
___________________________________________________
X.
Play:
A.
Toys
available
at
_________________________________________________________
B.
Availability/safety
of
___________________________________________________
home
play
area
C.
Favorite
toys
and
______________________________________________________
activities
D.
Child’s initiative and amount of creative play: Low _____
High _____
E.
XI.
Preferred play: Solitary _____
Parallel _____
Medium _____
Cooperative _____
Discipline:
A. Responsibility for discipline:
father _____
both father and mother _____
mother _____
siblings _____
B. Method(s) utilized _____________________________________________________________
C. Effectiveness of method(s) ______________________________________________________
D. Child reaction ________________________________________________________________
XII.
School history
A. School
Age
Nursery
Kindergarten
First grade (primary)
___
___
___
Reactions
_____________________________________
_____________________________________
_____________________________________
B. Present grade (primary) _________________ Starting _____________________________
C. School problems ___________________________________________________________
XIII. Physical examination
A. General:
present weight:_____________
weight gain:________________
4
Length/height:_____________
Head circumference:_______________
Chest circumference:_______________
Abdominal circumference:___________
B. Vital signs: Temp:_____________ HR:________________ RR: _______________ BP:____________
C. General Appearance:
D. Skin:
General color:__________________________
Texture:______________________________
Temperature:__________________________
Turgor: ______________________________
Lesions (if any): _______________________
E. Accessory Structure:
F. Head:
Shape:_______________
ROM:_______________
G. EENT and Mouth:
G. Neck:
Symmetry:___________________
Fontannels:___________________
Periorbital region:__________________
Conjunctiva:______________________
Headache:________________________
Blurring vision:____________________
Sclera:________________
Pupils:________________
Visual problems:________
Strabismus:____________
Pinnae/ external canal:______________
Ear discharge:_____________________
Tympanic membrane:____
Buzzing in ear:_________
Septum:_________________________
Mucosa:_______________
Lips:___________________________
Teeth:__________________________
Tongue:_________________________
Palates:_________________________
Toothaches:______________________
Mucosa:_______________
Gums:_________________
Uvula:_________________
Pharynx:_______________
Gumbleeding:___________
Trachea:______________
Thyroid:______________
H. Lymph nodes:
I. Chest :
Hair:________________________________
Nails: _______________________________
Dermatoglyphics:______________________
submaxillary:_____________________
Axillary:_________________________
Shape:______________________
Chest expansion:______________
Chest percussion:_____________
Breath sounds:_______________
J. Cardiovascular:
Cervical:_______________
Inguinal:_______________
Symmetry:______________________
Vocal fremitus:__________________
Cardiac rate:_______________ Pulse rate:_________________
Cyanosis:_________________ Dyspnea on exertion:________
Limitation of activity:__________________
Heaves:__________________ Thrills:___________________
Heart sounds: ________________________
Murmurs:___________________________
5
K. Abdomen:
L. Genitalia:
Size:__________________
Hernias:_______________
Bowel sounds:__________
Percussion:_____________
Palpation:______________
Shape:___________________
Aortic pulsations:__________
Penis:_________________
Urethral meatus:_________
Scrotum:_______________
Testes
Labia:________________
Urethral meatus:________
Vaginal orifice:_________
Anus:_________________
M. Back and extremities:
Posture:_____________________
Extremity size:_______________
Color:______________________
Mobility:___________________
Muscle strength:______________
Gait:__________________
Symmetry:_____________
Temperature:___________
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
______________________________________________________________
___________________________________________________________________________
6
LAC:esb
07 July 2004
N105 Pediatric Nursing Assessment
7
