Pediatric Assessment

PEDIATRIC ASSESSMENT

I. VITAL INFORMATION: NAME: (Initial’s only) AGE: SEX ADDRESS: RELIGIOUS AFFILIATION: ALLERGIES: (medication, food, pollens, or any contact agent, etc.)

EDUCATIONAL ATTAINMENT: CIVIL STATUS: DATE & TIME ADMITTED: PHYSICIAN’S INITIAL: CHIEF COMPLAINT: IMPRESSION/DIAGNOSIS: INFORMANT: (Patient himself/herself, patient’s mother, aunt, etc.) RELATIONSHIP TO PATIENT:

CHILDHOOD ILLNESS: IMMUNIZATIONS: TYPE DPT/DT POLIO MEASLES, MUMPS, RUBELLA H INFLUENZA TYPE B (Hib) TYPHOID INJECTION/ ORAL EVERY 3 YEARS TETANUS BOOSTER (BETWEEN AGES 12-15) HEPATITIS A HEPATITIS B VARICELLA (CHICKEN POX)

DATE

DATE

DATE

DATE

DATE

OTHERS: (Pneumoccal, Influenza, PPD or tine test, etc.)_______________________________ PRENATAL/BIRTH HISTORY: LENGTH OF PREGNANCY (WEEKS): ______________ WERE THERE ANY COMPLICATIONS DURING PREGNANCY OR DELIVERY? YES______ NO _____ IF YES, PLEASE EXPLAIN:

PREVIOUS MEDICAL EXPERIENCE: YES __ NO ___ DATE: REASON FOR HOSPITALIZATION: (Cause, name of hospital, how the condition was treated, how long the person was hospitalized) CURRENT MEDICATIONS:

III. CLINICAL ASSESSMENT III.A. NURSING HISTORY 1. HISTORY OF PRESENT ILLNESS A. USUAL HEALTH STATUS B. CHRONOLOGIC STORY (When started, description of problem, location, character, severity, timing, aggravating or relieving factors, associated factors, client’s perception of what the symptom means and thus the admission)

C. RELEVANT FAMILY HISTORY D. DISABILITY ASSESSMENT (Physical, Social, Mental, Emotional) 2. FAMILY HISTORY OF ILLNESS (Illness in family, mother, father, siblings – Heart Disease, high blood pressure, diabetes, blood disorders, cancer, arthritis, allergies, obesity, alcoholism, mental illness, etc.)

3. PATIENT’S EXPECTATIONS  WHAT SHE EXPECTS TO OCCUR DURING HOSPITALIZATION (patient’s or informant’s verbalization)  REGARDING NURSING CARE

(patient’s or informant’s verbalization)

4. PATTERNS OF FUNCTIONING A. BREATHING PATTERN REPIRATORY PROBLEM: (difficulty of breathing, asthma, etc.) USUAL REMEDY: (positioning, medications, etc.) MANNER OF BREATHING: (regular/irregular, silent, effortless, etc.)

B. CIRCULATION USUAL BP: HISTORY OF CHEST PAIN, PALPITATION, COLDNESS OF EXTREMITIES: PRESENCE OF EDEMATOUS AREA:

C. SLEEPING PATTERN USUAL BEDTIME: (be specific, wake up time) HOURS OF SLEEP: NAP HABITS: PROBLEMS REGARDING SLEEP: USUAL REMEDY: NO. OF PILLOWS: (where, size of pillow) BEDTIME RITUALS: (bath, pray, blanket, toy, story, etc

D. TYPE OF FEEDING: BREASTFED: YES _____NO ___ IF NO, AGE STOPPED: BOTTLE FED: YES ____ NO ____ IF NO, AGE STOPPED: OTHERS: (cup, straw, etc.) USUAL FOOD

AGE: AGE:

TIME

BREAKFAST: (How many cups of rice, size, how many pieces) LUNCH: SNACKS: DINNER: FOOD LIKES: FOOD DISLIKES: FOOD PREFERENCES:

E. DRINKING PATTERNS: TOTAL AMOUNT OF FLUID INTAKE/DAY: KINDS OF FLUID USUALLY TAKEN:

F. ELIMINATION PATTERN BOWEL MOVEMENT: (frequency) CONSTIPATION: (consistency of stool) USUAL REMEDY: (use of laxatives, increased water intake, etc.) BLADDER IRREGULARITIES: (urinary frequency, nocturia, retention, dysuria, complaints, etc.)

G. REST AND ACTIVITIES H. PERSONAL HYGIENE BATH: TYPE: FREQUENCY: TIME OF DAY: ORAL CARE: FREQUENCY OF BRUSHING: CARE OF DENTURES: SHAVING: FREQUENCY: USE OF COSMETICS:

HEALTH SUPERVISION (Physician’s initial, where, what was done, frequency of visits) 5. BRIEF SOCIAL, CULTURAL AND A. RELIGIOUS BACKGROUND: B. EDUCATIONAL BACKGROUND: C. OCCUPATION: D. RELIGIOUS PRACTICES: E. PERSONS SIGNIFICANT TO THE PATIENT: F. SOCIAL ROLE: I.

6. CLINICAL INSPECTION A. VITAL SIGNS: DATE: T= R= P= BP= B. HEIGHT: WEIGHT:

DEVELOPMENTAL ASSESSMENT: GROWTH AND DEVELOPMENT Stage of Development (Erikson) Psychosexual Development (Freud) Physical Development (PTA)* Gross Motor Fine Motor

MANIFESTED BY PATIENT

Cognitive Development (Piaget) Language, Social Moral Development (Kohlberg)

*PTA = prior to admission

EXPECTED BEHAVIOR

C. GENERAL APPERANCE (Orientation, Facial features, body stature, nutrition, symmetry, posture, position, body build/contour, mobility (gait, range of motion), facial expression, mood and affect, clothing, speech, personal hygiene, any contraptions (IV cannula, IV fluid, O2 inhalation, etc.)

SKIN, HAIR, NAILS – Skin: color, temperature, moisture, texture, thickness, edema, mobility/turgor, vascularity, bruising, lesions; Hair: Color, texture, distribution, lesions, dandruff, pest inhabitants; Nails: shape and color, color, capillary refill, etc. HEAD, FACE & LYMPHATICS – Head/Face: size and shape, fontanels, temporal area, any complaints of dizziness, facial features; Lymphatics: Symmetry, Range of Motion, lymphnodes, etc.

EYES, EARS, NOSE, THROAT, MOUTH – Eyes: PERRLA, conjunctivae and sclera, eyebrows, eyelids and lashes, eyeballs, lacrimal status, visual acquity; Ears – size and shape, symmetry, discharges/odor, tenderness, redness, swelling, lesions, hearing acquity; Nose: symmetry, patency, discharges, deformity, nasal mucosa, nasal septum, tenderness; Throat: uvula, tonsils, Mouth: lip color, moisture, lesions, halitosis, teeth and gums, tongue.

NECK & UPPER EXTREMITIES – Neck: symmetry, ROM, lymph nodes, trachea, thyroid gland Upper Extremities: Range of motion, symmetry of joints and muscles, muscle strength (5/5), skin turgor and mobility, capillary refill, deformities, edema, temperature, moisture, lesions, presence of contraptions CHEST, BREAST, AXILLAE: Chest: expansion, use of accessory muscles, rashes, pain, palpitations; Breast: symmetry of size and shape, nipples, discharges, color, temperature, engorgement, tenderness; Axillae: color, redness, tenderness, odor, perspiration, masses

THORAX, LUNGS, RESPIRATORY SYSTEM – Thoracic cage and configuration, symmetric expansion, Breath Sounds: Describe all auscultated lung sounds/clear/decreased/absent, Adventitious: rales/rhonchi/wheeze, Respiratory rate/rhythm/depth/quality/effort of breathing/dyspnea/SOB/cough HEART & CARDIOVASCULAR SYSTEM - Apical Pulse: rate/rhythm/quality, B/P: site/position; Pain: location/frequency/duration/intensity on a scale of 0 - 10/provokes/palleates/quality/ radiates, fatique/dizziness/chest pain/numbness/ tingling in extremeties

ABDOMEN & GI SYSTEM - Abdomen: contour, fundus, skin pigmentation, soft/distended/tenderness/colostomy, lesions, scars, hair distribution, Bowel Sounds: present/ absent, hyper/hypo active, Continence/diarrhea/constipation, Last Bowel Movement/consistency/color, Nausea/Vomiting

GENITALIA/ GENITOURINARY SYSTEM – skin color, hair distribution, presence of lesions, symmetry, vaginal discharges, presence of episiotomy, swelling, bulging, urinary status, hemorrhoids, tenderness, masses

LOWER EXTREMITIES/ MUSCULOSKELETAL SYSTEM – Range of motion, symmetry of joints and muscles, muscle strength (5/5), skin turgor and mobility, capillary refill, deformities, edema, temperature, moisture, lesions

GENERAL APPRAISAL: BODY BUILT: (Ectomorph, Mesomorph, Endomorph) SPEECH: (articulation, pace of the conversation,etc.) LANGUAGE: (Dialects and languages used) HEARING: (hearing acquity) MENTAL STATUS: (consciousness, oorientation, attention, memory, perceptions, etc.) EMOTIONAL STATUS: (cooperation, mood and affect, facial expressions)

HANDICAPS & LIMITATIONS: 1. SOCIAL (Interaction with environment) 2. PHYSICAL (Need for Assistance with ADL's: Bathing, Toileting, Dressing, Feeding, Ambulating, Transferring , etc.)

IV. LABORATORY & DIAGNOSTIC PROCEDURES 1. CLINICAL CHEMISTRY: NAME OF EXAMINATION: DEFINITION: PURPOSE: RESULTS: DATE: COMPONENTS

RESULTS

NORMAL VALUES

SIGNIFICANCE

2. NAME OF EXAMINATION: URINALYSIS DEFINITION: PURPOSE: RESULTS: DATE: RESULT NORMAL SIGNIFICANCE

3. NAME OF EXAMINATION: HEMATOLOGY DEFINITION: PURPOSE: RESULTS: DATE: COMPONENTS

RESULTS

NORMAL VALUES

SIGNIFICANCE

4. RADIOLOGICAL EXAMS AND OTHER SPECIAL EXAMS: NAME OF EXAMINATION: DEFINITION: PURPOSE: RESULTS: DATE: IMPRESSION:

SIGNIFICANCE:

V. TEXTBOOK DISCUSSION: A. DIAGNOSIS:

PATHOPHYSIOLOGY: B. DEFINITION: C. S/Sx FOUND IN THE BOOK PATIENT

MANIFESTED BY

D. SCHEMATIC DIAGRAM MEDICAL MANAGEMENT: NURSING MANAGEMENT: HEALTH TEACHINGS: (DISCHARGE PLANNING)

ON-GOING APPRAISAL DATE: TIME: S0AP/IER-

PROBLEM LIST: 1. 2. 3. 4. 5. NURSING CARE PLAN (SEE ATTACHED SHEET) DRUG STUDY (SEE ATTACHED SHEET)

NURSING CARE PLAN Name of Patient: __________Attending Physician: _________ Age: ________ Ward/Bed Number: ______ Impression/Diagnosis:___________________________ Clustered Cues

Nursing Diagnosis

Rationale (Scientific Basis)

Objectives of Care/ Outcome Criteria (Subject+Verb+ Condition+ Criteria + Target Time)

Nursing Interventio ns

Rationale (Scientific Basis)

Evaluation

Student’s Name: __________________________________ Clinical Instructor: ________________________________

DRUG STUDY Name of Patient: __________Attending Physician: _________ Age: ________ Ward/Bed Number: ______ Impression/Diagnosis: _____________________________ Name of Drug

Dosage, Route, Frequency, Timing

Generic:

Dosage:

Brand:

Route:

Classification Functional:

Frequency:

Chemical:

Timing:

Mechanism of Action

Indication

Adverse Reactions

Contraindications

Side Effects

Special Precautions

Nursing Responsibilities

Student’s Name: ______________________________________ Clinical Instructor: _____________________________________