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 ______________________________________________________________
___________________________________________________________________________
