PEDIATRIC NURSING ASSESSMENT

l.
m.
n.
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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 ______________________________________________________________
___________________________________________________________________________