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Pediatric Case Study Template

This case study document outlines the sections and information to be included in a case study report for a student. The report includes sections for sociodemographic data, personal history, physical measurements, physiological measurements, development, nature of the disease, diagnostic measures, prevention, complications, medical management, and nursing management of the patient. Each section lists specific sub-items of information to document about the patient's case.

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Tawfek Reda
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© © All Rights Reserved
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475 views11 pages

Pediatric Case Study Template

This case study document outlines the sections and information to be included in a case study report for a student. The report includes sections for sociodemographic data, personal history, physical measurements, physiological measurements, development, nature of the disease, diagnostic measures, prevention, complications, medical management, and nursing management of the patient. Each section lists specific sub-items of information to document about the patient's case.

Uploaded by

Tawfek Reda
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Case Study

Student’s name:
Student’s number:
Group’s number:
Practical area:
Instructor’s name:

2020-2021

1
Outlines:
1-Sociodemographic data:
a. Child’s name:
b. Age:
c. Sex:
d. Gestational age:
e. Birth date:
f. Date of admission:
g. Stay period:
h. Unit:

2-Personal History:
Item Abnormality
1. Prenatal:

2. Postnatal:

3. Childhood:

4. Medical history:

5. Accidents:

6. Family history:

Member Age Relation Health

2
3-Physical measurement:
Item According to child According to literature
Weight
Length
Head circumference
Chest circumference
Mid arm circumference
Abdominal circumference

4-Physiological measurements:
Item According to child According to literature
Temperature ©
Pulse
Respiration
Blood pressure

5-Development:
Item According to child According to literature
Cognitive &
Language

Motor

Social

Emotional

3
5- Nature of the disease:

*Child’s diagnosis:
*Write specific information about the disease as:
1. Definition:

2. Incidence:

3. Pathophysiology:

4. Etiology:

According to child According to literature

5. Signs & symptoms:

According to child According to literature

4
6. Diagnostic measures:
1.Physical examination:
General appearance
a. Face:
*Emotional state: (Sadness- Happiness- Apathetic- Frightened).
*Physical: ( Flushed-Cyanotic- Pale).
b. Posture: (Well balanced -Straight - Poorly balanced).
c. Hygiene: (Clean – Unclean).”odor”
d. Nutrition: (Well nourished- Poorly nourished).”weight”
e. Activity: (Calm- Hypoactive- Hyperactive- Restless- Irritable- Aggressive-
Withdrawn)
Skin
a.Color: (Pink- Cyanotic- Erythematic- Ecchymosed- Jaundice- Petachiae-
Pigmented- Infection).
b. Texture: (Moist- Smooth- Dry- Scar).
c. Turgor: (Good elasticity- Wrinkled- Prolonged depression).
Hair
a.Color: (Brown- Black- Yellow).
b. Texture: (Strong- Fragile).
c. Distribution: (Normal- Alopecia- Thin- Spots).
d. Hygiene: (Clean – Unclean).”odor”
Nails & Hands
a.Shape: (Convex- Concave- Clubbing).
b. Color: (Pink- Cyanosed- Pale).
c. Quality: (Smooth- Hard).
d. Hygiene: (Clean – Unclean).
e. Palm creases: (Normal- Simian line- Sydney line).
Head
a.Shape: (Symmetric- Swelling).
b. ROM: (Limited- Resistant- Pain- Stiffed- Relaxed).
c. Hygiene: (Clean – Unclean).
d. Fontanels:
*Anterior: (Close- Open- Plugging- Pulsation- Depressed).
*Posterior: (Close- Open- Plugging- Pulsation- Depressed).

5
Eyes
a.Placement (Symmetric- Asymmetric- Abnormal inner canthel distance).
&alignment:
b. Lids: (Symmetric- Asymmetric- Discharge- Redness- Swelling- Lagophthalmos-
Eyelid malposition).
c. Conjunctiva: (Discharge- Redness- Swelling- Itching- Tearing- Clear).
d. Sclera: (White- Yellow staining).
e. Pupils: (React- Not react to light).
Nose & Mouth
a.Placement: (Symmetric- Asymmetric).
b. Appearance: (Discharge- Redness- Swelling- Fungal infection- Clear).
Neck
a.Color: (Pink- Pale- Redness).
b. Lymph nodes: (Tender- Enlarged- not palpable- Mobile- Warm).
c. Placement: (Scoliosis- Contracture- Soft).
Heart
a. Placement: (Symmetric- Asymmetric chest wall).
b. Heart sounds: (Clear- Murmur).
c. Apical pulse: (Tachycardia- Bradycardia- Dyspnea- Appropriate).
Abdomen
a. Placement: (Symmetric- Asymmetric abdominal contour).
b. Shape: (Flappy- Concave- Scars- Distended neck veins- Visible peristalsis
movement- Clear).
b. Umbilicus: (Hernia- Discharge- Swelling- Bleeding- Clear).
c. Hygiene: (Clean – Unclean).
Back
Spine (Symmetric- Asymmetric- Lordosis- Scoliosis- Discoloration- Swelling-
Tenderness- Clear).
Extremities
a.Upper: (Symmetric- Asymmetric- Normal size- Deformities- Warm- Cool- Tender-
Limited- Appropriate mobility).
b. Lower: (Symmetric- Asymmetric- Normal size- Deformities- Warm- Cool- Tender-
Limited- Appropriate mobility- Unsteady – Appropriate gait- Bowlegs-
Knock knee).

6
2- Lab investigations:

According to child According to literature

3-Radiological examinations:

According to child According to literature

7. Prevention:

According to child According to literature


Primary Secondary Tertiary

7
8. Complications:

According to child According to literature

9. Medical management:

According to child According to literature

8
10. Nursing Management:

Nursing diagnosis Goals Intervention Evaluation


Actual Text

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