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 DATE DATE DATE DATE DATE

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)
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 ___ AGE:
IF NO, AGE STOPPED:
BOTTLE FED: YES ____ NO ____ AGE:
IF NO, AGE STOPPED:
OTHERS: (cup, straw, etc.)

USUAL FOOD 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:
I. 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:
6. CLINICAL INSPECTION
A. VITAL SIGNS: DATE:
T= R=
P= BP=
B. HEIGHT:
WEIGHT:
 DEVELOPMENTAL ASSESSMENT:
GROWTH AND MANIFESTED BY EXPECTED
DEVELOPMENT PATIENT BEHAVIOR
Stage of Development
(Erikson)
Psychosexual
Development
(Freud)
Physical Development
(PTA)*
Gross Motor
Fine Motor
Cognitive Development
(Piaget) Language, Social
Moral Development
(Kohlberg)

*PTA = prior to admission

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 MANIFESTED BY

PATIENT
D. SCHEMATIC DIAGRAM

MEDICAL MANAGEMENT:
NURSING MANAGEMENT:
HEALTH TEACHINGS: (DISCHARGE
PLANNING)
ON-GOING APPRAISAL

DATE:
TIME:

S-
0-
A-
P/I-
E-
R-
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 Nursing Rationale Objectives of Nursing Rationale Evaluation
Cues Diagnosis (Scientific Care/ Outcome Interventio (Scientific
Basis) Criteria ns Basis)
(Subject+Verb+
Condition+
Criteria + Target
Time)

Student’s Name: __________________________________

Clinical Instructor: ________________________________
 DRUG STUDY
Name of Patient: __________Attending Physician: _________
Age: ________ Ward/Bed Number: ______
Impression/Diagnosis: _____________________________
Name of Drug Dosage, Route, Mechanism of Indication Adverse Special Nursing
Frequency, Action Reactions Precautions Responsibilities
Timing

Generic: Dosage:

Brand: Route:

Classification Contraindications Side Effects

Functional: Frequency:

Chemical: Timing:

Student’s Name: ______________________________________

Clinical Instructor: _____________________________________