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Normal Pedia Assessment Guide Sep2023

This document provides an assessment guide for pediatric clients from infancy through adolescence. It includes sections to document the child's vital signs, personal history, family history, past medical history, immunization status, developmental milestones, nutritional intake, sleep patterns, and areas needing health teachings. The guide collects comprehensive information to assess the child's overall health and development.

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krishamarie.roldan
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40 views4 pages

Normal Pedia Assessment Guide Sep2023

This document provides an assessment guide for pediatric clients from infancy through adolescence. It includes sections to document the child's vital signs, personal history, family history, past medical history, immunization status, developmental milestones, nutritional intake, sleep patterns, and areas needing health teachings. The guide collects comprehensive information to assess the child's overall health and development.

Uploaded by

krishamarie.roldan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Division of Maternal & Child Health Nursing

NCM 213B: CARE OF MOTHER, CHILD, ADOLESCENT WELL CLIENTS


(RLE)
First Semester 2023-2024

ASSESSMENT GUIDE FOR NORMAL PEDIATRICS


(for Infant, Toddlers, Pre-schoolers, Schoolers, and Adolescents)

I. VITAL INFORMATION

Name of Child: Date and Time of Interview:


Sex: Date of Birth:
Age: Name of Informant:
Relationship with the child:
Address:
Name of Mother: Age:
Educational Attainment:
Occupation:
Name of Father: Age:
Educational Attainment:
Occupation:
Approximate income of the Family:

II. PERSONAL HISTORY:

A. PRENATAL

Mother’s general health:

B. OBSTETRIC

OB Score: LMP: EDD/EDC: AOG:


Type of Delivery: NSVD CAESARIAN SECTION
Place of Delivery: Home Hospital Health Center Birthing Cent
Analgesia used:
Consultation during pregnancy: Private Physician Municipal Health Officer Others:
Complications during delivery:

C. BIRTH

APGAR Score:
Birth weight: Head circumference:

Parental views of pregnancy:


Patient’s problem (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:

III. FAMILIAL HISTORY

Type of housing (description): Owned Rented

Birth order of the child: Total number of siblings: Number of living siblings:

Serious diseases among Siblings:


Death of siblings: Cause of death:
Heredo-familial disease
Maternal:
Paternal:
IV. PAST MEDICAL HISTORY

Number of past hospitalizations:


Date of last confinement:
When:
Where: Number
of days of hospitalization:
Reason for hospitalization:

V. NUTRITIONAL HISTORY
For infants up to 12 months
Type of feeding Check and Age started Type of milk Dilution Total intake
Specify for 24-
hours
Bottlefeeding
Breastfeeding
Mixed feeding
Total: mL

Age of weaning:
Supplementary feeding (specify):
Vitamins (Type and Amount):

VI. EATING PATTERNS (for older children)

Meals Usual Foods Taken Amount Time of day


Breakfast

Lunch

Supper

Snacks

Food likes:
Food dislikes:
Beliefs and Falacies:

VII. REST AND SLEEP

Usual Bedtime and Waking Hours


Naps
Bedtime rituals
Problems with sleep and usual remedy
Total number of sleeping hours

VIII. ELIMINATION PATTERN

Frequency Problems/Difficulties Usual Remedy

Bowel Movement

Urination

Toilet Training
As observed in the
Age in months Description found in
patient/ verbalized by Significance
started textbook
significant person

Bowel

Bladder
IX. IMMUNIZATION STATUS

1st 2nd 3rd Booster Booster


Type Age Age Age Age Age
dose dose dose 1 2
BCG
DPT

OPV

Hepa B

Measles

MMR

Others
(specify)

X. CEPHALOCAUDAL ASSESSMENT

Temperature: Pulse: Respiratory rate:


BP: Height: Weight:
Head Circumference: Abdominal Girth:

General Appearance:
Head:
Eyes:
Ears:
Nose:
Mouth:
Neck:
Chest:
Back:
Abdomen:
Upper Extremities:
Lower Extremities:
Genito-anal:
Skin:

XI. 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: (pls check appropriately)
solitary
parallel associative
cooperative
f. Peer interaction:
XI. DEVELOPMENTAL ASSESSMENT

Applicable During Infancy (1-12 months)


AGE IN
AGE IN AS OBSERVED IN
MONTHS
PATTERNS OF MONTHS THE PATIENT AND/OR
FOUND IN SIGNIFICANCE
DEVELOPMENT WHEN MANI- VERBALIZED BY THE
TEXT-
FESTED INFORMANT/SO’S
BOOK

Smiles and regards

Hold up head when


prone
Follow objects with
eyes

Turned self from


prone to supine

First eruption of
teeth

SIts with support

Crawls/Creeps

Cruises

Stands alone

Current Developmental Assessment

Found in Textbook Actual Observation Significance


A. GROSS MOTOR
DEVELOPMENT

B. FINE MOTOR
DEVELOPMENT

C. SENSORY
DEVELOPMENT

D. PSYCHOSOCIAL
DEVELOPMENT &
SOCIALIZATION
E. PSYCHOSEXUAL
DEVELOPMENT

F. MORAL
DEVELOPMENT

G. SPIRITUAL
DEVELOPMENT

H. COGNITIVE
DEVELOPMENT

I. LANGUAGE /
SPEECH

XII. AREAS IDENTIFIED NEEDING HEALTH TEACHINGS

AREA CUES HEALTH TEACHINGS

References:

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