Pediatric Nursing Process
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PEDIATRIC NURSING PROCESS (FEMALE SURGICAL WARD)
SLR
Ma. Teresa Cercado, RN RC Amor Vagilidad BSN 4D
West Visayas State University COLLEGE OF NURSING
La Paz, Iloilo City
PEDIATRIC NURSING PROCESS I.
VITAL INFORMATION Name: Date and Time of Interview: Sex: Date of Birth: Name of Informant: Age: Relationship to the child: Address: Date and Time Admitted: Chief Complaints: Ward: Religious Affiliations: Name of Mother: Educational Attainment: Occupation: Name of Father: Educational Attainment: Occupation: Approximate monthly income of the family: Mother Father TOTAL Physician: Impression/Diagnosis:
II.
CLINICAL ASSESSMENT A. Nursing History History of present illness a. Usual Health Status
b. Chronologic Story
A. Past Medical History _____Parasitism _____AGE _____AGN _____Allergy (specify): _____Tuberculosis Disorders _____Measles
_____BPN _____Accidents _____Anemia _____Seizures _____Emotional _____Others
Number of previous hospitalizations: Date of last confinement: Where: Reasons for confinement: 1. Family History Birth order of patient: Total number of siblings: Number of living siblings: Serious diseases/illnesses of siblings: Causes of death/serious illnesses of siblings: Heredo-familial diseases: Disease
Maternal/Paternal
Specific Family Member
Tuberculosis Diabetes Mellitus Asthma Hypertension Cancer Genetic Disorders Others 2. Maternal and prenatal History Maternal age when the child was born: Age of gestation and birth 9 months (37 weeks), 8.5 lbs. weight Pre-term Full term Post term Complications related to pregnancy: Parental views of pregnancy:
Patient’s problems (1st month): Child’s ability to get along with people as viewed by parents:
Early behavior patterns as viewed by parents:
Parent’s attitude towards child rearing:
I.
PATTERNS OF FUNCTIONING Nutritional History and Eating Patterns A. Infants up to 1 year TYPE OF FEEDING AGE STARTED 1. Breastfed 2. Bottlefed 3. Mixed 4. Type and Brand of Milk a. Evaporated b. Condensed c. Powdered d. Others
DURATION
INTERVAL
Approximate intake per 24 hours: Problems during weaning: Vitamins and minerals supplement: Type: Dosage/Amount: For children 1 year and above: Meal Breakfast
Morning snacks
Lunch
Afternoon snacks
Supper
Food likes: Food dislikes: Allergies: Problems related to nutrition:
Type and amount of foods usually taken
Supplementary foods: Age Started Kind/type and amount 1-3 4-6 7-9 10-13
Frequency
Elimination Frequency
Problem/difficulti es
Found in textbook
As seen in the patient and/or verbalized by significant person
Usual remedy
Bowel Movement Urination
Toilet Training Age in month started
Significance
Bowel:
Bladder:
Sleeping Patterns: Usual Usual Approxima Sleeping patter time te total arrangeme ns number of nts sleep/24 hours
Special rituals
Problem s with sleeping
Immunization Status: Type 1st Ag 2nd dos e dos e e
Ag e
3rd dos e
Ag e
Boost er 1
BCG DPT OPV Hepa B Measle s/ MMR
Play: a. Appropriateness of available toys
b. Availability and safety of play areas
c. Favorite toys and activities
d. Child initiative and amount of creative play
e. Preferred play: Solitary:________
Parallel:_________ Cooperative: _________ f. Peer interaction
Ag e
Boost er 2
Ag e
I.
DEVELOPMENTAL ASSESSMENT A. Developmental History Applicable during infancy Patterns of Age in developmen months t when manifested
(1-12 months) Age in As seen in months the patient found in and/or textbook verbalized by the informant
Smiles and regards Holds up head when prone Follows objects with eyes Turned self form prone to supine First eruption of tooth Sat with support Crawls/cruis es Stands alone
I.
PRESENT MEDICAL HISTORY A. Measurements: Weight: Height: Head circumference: Chest circumference: B. Clinical Inspection: Date and time taken: Vital Signs: Temperature: _______ Respiratory rate: ________ Pulse rate: _________ Blood pressure: _________ C. Reflexes: a. Sucking Reflex: b. Plantar Grasp Reflex: c. Babinski Reflex: d. Moro Reflex: e. Stepping Reflex:
Significanc e
f. Palmar Plantar Grasp:
II.
PHYSICAL ASSESSMENT
General Appearance:
A. Integumentary System
B. Neurologic System
C. Respiratory System
D. Cardiovascular/ Circulatory System
E. Genito-urinary System
F. Gastrointestinal System
G. Reproductive System
H. Endocrine System
I. Musculoskeletal System
J. Lymphatic System
K. Hematopoietic System
SLR
Ma. Teresa Cercado, RN RC Amor Vagilidad BSN 4D
West Visayas State University COLLEGE OF NURSING
La Paz, Iloilo City
PEDIATRIC NURSING PROCESS I.
VITAL INFORMATION Name: Date and Time of Interview: Sex: Date of Birth: Name of Informant: Age: Relationship to the child: Address: Date and Time Admitted: Chief Complaints: Ward: Religious Affiliations: Name of Mother: Educational Attainment: Occupation: Name of Father: Educational Attainment: Occupation: Approximate monthly income of the family: Mother Father TOTAL Physician: Impression/Diagnosis:
II.
CLINICAL ASSESSMENT A. Nursing History History of present illness a. Usual Health Status
b. Chronologic Story
A. Past Medical History _____Parasitism _____AGE _____AGN _____Allergy (specify): _____Tuberculosis Disorders _____Measles
_____BPN _____Accidents _____Anemia _____Seizures _____Emotional _____Others
Number of previous hospitalizations: Date of last confinement: Where: Reasons for confinement: 1. Family History Birth order of patient: Total number of siblings: Number of living siblings: Serious diseases/illnesses of siblings: Causes of death/serious illnesses of siblings: Heredo-familial diseases: Disease
Maternal/Paternal
Specific Family Member
Tuberculosis Diabetes Mellitus Asthma Hypertension Cancer Genetic Disorders Others 2. Maternal and prenatal History Maternal age when the child was born: Age of gestation and birth 9 months (37 weeks), 8.5 lbs. weight Pre-term Full term Post term Complications related to pregnancy: Parental views of pregnancy:
Patient’s problems (1st month): Child’s ability to get along with people as viewed by parents:
Early behavior patterns as viewed by parents:
Parent’s attitude towards child rearing:
I.
PATTERNS OF FUNCTIONING Nutritional History and Eating Patterns A. Infants up to 1 year TYPE OF FEEDING AGE STARTED 1. Breastfed 2. Bottlefed 3. Mixed 4. Type and Brand of Milk a. Evaporated b. Condensed c. Powdered d. Others
DURATION
INTERVAL
Approximate intake per 24 hours: Problems during weaning: Vitamins and minerals supplement: Type: Dosage/Amount: For children 1 year and above: Meal Breakfast
Morning snacks
Lunch
Afternoon snacks
Supper
Food likes: Food dislikes: Allergies: Problems related to nutrition:
Type and amount of foods usually taken
Supplementary foods: Age Started Kind/type and amount 1-3 4-6 7-9 10-13
Frequency
Elimination Frequency
Problem/difficulti es
Found in textbook
As seen in the patient and/or verbalized by significant person
Usual remedy
Bowel Movement Urination
Toilet Training Age in month started
Significance
Bowel:
Bladder:
Sleeping Patterns: Usual Usual Approxima Sleeping patter time te total arrangeme ns number of nts sleep/24 hours
Special rituals
Problem s with sleeping
Immunization Status: Type 1st Ag 2nd dos e dos e e
Ag e
3rd dos e
Ag e
Boost er 1
BCG DPT OPV Hepa B Measle s/ MMR
Play: a. Appropriateness of available toys
b. Availability and safety of play areas
c. Favorite toys and activities
d. Child initiative and amount of creative play
e. Preferred play: Solitary:________
Parallel:_________ Cooperative: _________ f. Peer interaction
Ag e
Boost er 2
Ag e
I.
DEVELOPMENTAL ASSESSMENT A. Developmental History Applicable during infancy Patterns of Age in developmen months t when manifested
(1-12 months) Age in As seen in months the patient found in and/or textbook verbalized by the informant
Smiles and regards Holds up head when prone Follows objects with eyes Turned self form prone to supine First eruption of tooth Sat with support Crawls/cruis es Stands alone
I.
PRESENT MEDICAL HISTORY A. Measurements: Weight: Height: Head circumference: Chest circumference: B. Clinical Inspection: Date and time taken: Vital Signs: Temperature: _______ Respiratory rate: ________ Pulse rate: _________ Blood pressure: _________ C. Reflexes: a. Sucking Reflex: b. Plantar Grasp Reflex: c. Babinski Reflex: d. Moro Reflex: e. Stepping Reflex:
Significanc e
f. Palmar Plantar Grasp:
II.
PHYSICAL ASSESSMENT
General Appearance:
A. Integumentary System
B. Neurologic System
C. Respiratory System
D. Cardiovascular/ Circulatory System
E. Genito-urinary System
F. Gastrointestinal System
G. Reproductive System
H. Endocrine System
I. Musculoskeletal System
J. Lymphatic System
K. Hematopoietic System
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