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Toddler Nursing Assessment Guide

This document contains an assessment guide for evaluating toddlers at San Pedro College Nursing Department in Davao City. The guide includes sections to collect personal data of the toddler and family, administer measurements, and assess the toddler's maternal/birth history, neonatal history, childhood illnesses/immunizations, elimination, nutrition, activity/sleep, growth and development. Key areas of development include physical, language, and psychosocial domains.

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Ola Anna Gamutin
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106 views2 pages

Toddler Nursing Assessment Guide

This document contains an assessment guide for evaluating toddlers at San Pedro College Nursing Department in Davao City. The guide includes sections to collect personal data of the toddler and family, administer measurements, and assess the toddler's maternal/birth history, neonatal history, childhood illnesses/immunizations, elimination, nutrition, activity/sleep, growth and development. Key areas of development include physical, language, and psychosocial domains.

Uploaded by

Ola Anna Gamutin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

SAN PEDRO COLLEGE

Davao City
NURSING DEPARTMENT

ASSESSMENT GUIDE
(TODDLER)

PERSONAL DATA
Name of Patient: _________ Birthday: _______ Age: ___ Ordinal Rank: ___ of __ siblings
Address: ________________ Nationality: _____________ Religion: ______________
Name of Father: _________ Age: __ Educational Attainment: _________ Occupation: ______
Name of Mother: _________ Age: __ Educational Attainment: ________ Occupation: ______

→ADMINISTER MMDST

→ASSESS/INTERVIEW
A. MATERNAL/ OBSTETRICS/PRE-NATAL HISTORY AOG: _G _P _T _ P _A _L

Prenatal Check Up: ________ Complications during pregnancy: ___________


TT Vaccines (include dates): ____________ Medications taken during Pregnancy:
_________
Labor and delivery: ________ No. of hours of labor: _____ Use of Anesthesia: __________

B. BIRTH HISTORY:
Manner of Delivery: NSVD CS Instrumentation Place: House Hosp Lying in
Presentation: _____ Birth Weight: ___ Birth Height: __ Other Measurements (cms) HC: __ CC: __ AC: __

C. NEONATAL:
The child underwent Newborn Screening: ________ Length of Stay in the Hospital: _______
Complications: _________________ Medications: ______________

D. CHILDHOOD:
Childhood Diseases: Mumps Chicken Pox Polio Measles Pneumonia Hepatitis Asthma

Diphtheria Others (pls. specify): _______

Immunization: BCG HepB OPV DPT Measles HiB Hep A Meningitis TT


Others (pls. specify): _______
Allergies: _________________ Congenital Heart Problems: _______________
Previous Hospitalization (Why, Where, Treatment, Outcome): ________________
Serious Injuries (Fractures, Head injuries with loss of consciousness, motor vehicular accident, burns,
lacerations): ____________________
Medications: ____________________

E. ELIMINATION
Toilet Training: Age of Bowel Control: __ Age of daytime bladder control: __
Age of nighttime bladder control: ____
Pattern: BM/day: ____ Consistency: _____ Amount: ______ Color: ____ Urination/day: ______
Accidents: ________________ Regression: _____________________
Problems: Constipation Diarrhea Enuresis Others: ________________
Able to verbalize need to defecate or void? _______________ Child’s response/Attitude: _________

F. NUTRITION:
Breastfeed: Frequency (by demand or every ___ hours) Sucking Strength: ___ Problems: ________
Bottlefeed: Formula milk: _____ Dilution: _______ Frequency: _____ Problems: ______________
Food preferences: __________________ Meal Patterns and appetite: __________________________
Feeding Problems: __________________ Vitamins/ Minerals/ Food Supplements: _______________
Dentition: Age of Onset: ____ S/sx of teething: ________ No. of Teeth: ___ Specify Teeth: _______

G. ACTIVITY AND SLEEP:


Usual sleeping pattern: _________No. of hours ____Naps ____ Rituals _____Problems
Usual daily activities: ___________________Plays ________________ Toys
H. GROWTH AND DEVELOPMENT:
PHYSICAL DEVELOPMENT
 Caphalocaudal Appearance - (include height and weight)
 Personal Hygience

LANGUAGE DEVELOPMENT
 Language/dialects
 Words uttered

PSYCHOSOCIAL DEVELOPMENT
 Describe child’s reactions and psychosocial behavior

Negativism Curiosity Possessiveness Temper Tantrums Imitation Ritualism

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