PEDIATRIC NURSING ASSESSMENT

1. Biographical Data

Name:

Preferred to be called:

Age:

Sex:

Time of Arrival to Unit:

Mode of Admission:

Mother’s Name:

Occupation:

Age:

Father’s Name:

Occupation:

Age:

Address:

Religion:

Primary Language:

Nationality:

B. Describe (Narrative Form)

1. Child’s Appearance & Behavior

2. Parent-child interaction

3. Siblings and other family members

4. Home environment
C. Chief Concern (Narrative of Present Illness)

D. Wt and Ht:

Temp: ____ (oral, axilla, rectal)

Pulse _____ (regular/irregular)

Respiration _____ (regular/irregular)

BP:

E. Past History

1. Birth History

a. Mother’s health during pregnancy

b. Labor and delivery

c. Infant’s condition immediately after birth(APGAR)

2. Pregnancy, Labor and Delivery

a. Obstetric history (GP, TPAL)

b. Crisis during pregnancy

c. Prenatal attitude toward fetus

3. Perinatal History

a. Wt. and Ht. at birth

b. Loss of wt following birth and time of regaining birth wt

c. APGAR score, level of activity

d. Problem if any (birth injury, congenital anomalies)

4. Dietary History (Feeding History)

5. Immunization and boosters

6. Developmental milestones (growth pattern)

a. Approx. wt. at 6 mos, 1 yr, 2 yrs, 5 yrs

b. Approx.ht. at 1 yr, 2 yrs, 3 yrs, 4 yrs

c. Dentition (including age of onset, number of teeth and symptoms during teething)

d. Hold head steadily

e. Sitting alone without support

f. Walks without assistance

g. Says first words

F. Functional Health Pattern Assessment

1. Health Perception-Health Management Pattern

• Why has your child been admitted?

• How has your child’s general health been?

• What does your child know about this hospitalization?

• Ask the child why he came to the hospital?

If answer is “For operation or for tests”,ask child to tell you about what had happened before,
during and after the operation or tests

• Has your child ever been in the hospital before?

• How was the hospital experience?

• What things were important to you and your child during that hospitalization? How can we be
most helpful now?

• What medications does your child take at home?

• Why are they given

• When are they given?

• How are they given (if a liquid, with a spoon, if a tablet, swallowed with water or other)?

• Does he have any trouble taking medication? If so, what helps?

• Does he have any allergies to medications?

• What does your child know about this hospitalization?

• Ask the child why he came to the hospital

2. Nutritional and Metabolic Pattern

• What are the family’s usual meal times?

• Do family members eat together or at separate times?

• What are your child’s favorite foods, beverages and snacks?

• Average amounts consumed or usual size positions

• Special cultural practices, such as family eats only ethnic food

• What goods and beverages does your child dislike?

• What are his feeding habits (bottle, cup, spoon, eats by self, needs assistance, (any special
devices)?

• Does the child like the food served (warm, cold, one at a time)?

• How would you describe his usual appetite?(hearty eater, picky eater)

• Has his being sick affected your child’s appetite?

• Are there any feeding problems (excessive, fussiness, spitting up, colic), any dental or gum
problems that affect feeding?

• What do you do with these problems?

3. Elimination Pattern

• What are your child’s toilet habits? (diaper, toilet trained [day only or day and night], use of
words to communicate urination and defecation, potty chair, regular toilet, other routines)?

• What is his usual pattern of elimination (bowel movements)

• Do you have any concerns about elimination(bed wetting, constipation, diarrhea)

• What do you do for these problems?

• Have you ever noticed that your child sweats a lot?

4. Sleep-Rest Pattern

• What is your child’s usual hour of sleep and awakening?

• What is his schedule for naps/length of naps?

• Is there a special routine before sleeping (bottle, drink of water, bedtime story, nightlight,
favorite blanket, or toy or prayers)

• Is there a special routine during sleep time such as walking to go to the bathroom?

• What type of bed does he sleep on?

• Does he have his own room or share a room: if he shares a room, with whom?

• What are the home sleeping arrangements (along or with others, such as sibling parent or other
person)?