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8/6/2019 Pediatric Assessment (1 - 12)
http://slidepdf.com/reader/full/pediatric-assessment-1-12 1/11
UNIVERSITY OF CEBUCollege of Nursing
Cebu City
PEDIATRIC ASSESSMENT(1 month to 12 years)
Name of Patient ________________ Date of Birth ___________ Sex ____
I. PRENATAL HISTORY (of mother)Maternal Age _______ Obstetric Score G __T__P__A__L___M___Prenatal Check-up: ___ Regular ___ Irregular ___ None
Done by: ___ Obstetrician ___ Nurse ___ HilotPlace : ___ Hospital ___ Clinic ___ RHU ___ Home
Maternal Illness : ___ None ___ Fever ___ Rash___ GDM ___ Asthma ___ Heart Disease___ UTI ___ TB ___ Hepatitis___ Allergy ___ Hypermesis ___ PIH
Medications (mother) ________________________________________
II. NATAL HISTORY Date of Birth ___________ Birth Rank ________ Apgar Score _____Place of Delivery ___ Hospital ___ Home ___ Lying-in
Attendant ___ Midwife ___ Hilot ___ OthersGestation ___ Full term ___ Preterm ___ Post termMode of Delivery ___ NSVD ___ Forceps___ C/S (indication)Presenting Part ___ Cephalic ___ Face ___ Breech ___ Transverse
Medications ___ Eye Prophylaxis ___ Vit. K ___ Hep. B
III. POST-NATAL HISTORY Feeding ___ Breastmilk ___ Milk Formula ___ MixedMedical Problems ___ None ___ Respiratory ___ Cyanosis
___ Sepsis ___ Seizure ___ Jaundice
IV. IMMUNIZATIONS __ No __ Yes at: __ Center __Private __ Both
1st dose 2nd dose 3rd dose 1st booster 2nd booster NoneBCGDTPOPV HibHep BPneumoccocalRotavirusFlu
Varicella AMV MMR Others:TyphoidHep. A MeningococcalHPV
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V. FEEDING HISTORY
0 – 6 months ___ Breastfeed ___ Milk Formula ___ Mixed6 – 12 months ___ Breastfeed ___ Milk Formula ___ Mixed
Age semisolid started _________________ Type __________________Food preference : _________________ Allergies _______________Food dislikes : _________________
Vitamin Supplements: Type ____________ When started ____________Amount _________ Duration ____________
VI. PAST MEDICAL/SURGICAL HISTORY ___ Unremarkable ____ Remarkable
If remarkable : ______________________________________________
Date Diagnosis Intervention
Hospitalization (including operation)Date Hospital Diagnosis
VII. FAMILY HISTORY ___ No significant FH ___ Significant FH
__ HPN __ Diabetes __ Asthma __ Heart Disease __ Blood Disorder __ Kidney disease __ Allergy __ Cancer __ TB __ Stroke __ Seizure __ Mental DisorderOthers : _____________________________________
VIII. GROWTH & DEVELOPMENTFirst raised head _____ Rolled over _____ Sat alone _____Pulled up _____ Walked with help _____
Walked alone _____ Talked _____Urinary continence : Day _____ Night _____Control of feces _____Comparison of development with that of other siblings __________________School Grade _____ Quality of Work _________________________
IX. BEHAVIORAL HISTORY
a. Does the child manifest behavior like thumb sucking ________Masturbation ________Temper tantrums ______Negativism ________
b. Does the child have sleep disturbances ? ___ Yes ___ Noc. Phobias __________________________________________________
d. Pica (ingestion of substances other than foods) ______________________e. Abnormal Bowel habits (stool holding) ____________________________f. Bedwetting _____________________________________________
Name of Patient ___________________________________________________
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X. FAMILY HISTORY (insert the Genogram at the back of this page)
XI. REVIEW OF SYSTEMS A. Skin :
Texture ____________ Color _____________
___ Eruptions ___ Hydration ___ Edema ___ Hemorrhagic manifestations ___ Scars ___ Dilated blood vessels ___ Striae ___ Wrinkling
B. Eyes : __ Have the child’s eyes ever been crossed-eyed? __ Any foreign body? __ Any infection?
C. Ears/ Nose and Throat: __ Frequent Colds __ Sore throat __ Sneezing __ Stuffy nose __ Discharges __ Post-natal drip __ Mouth breathing __ Snoring __ Otitis media __ Hearing problem
D. Teeth : Age of eruption of deciduous teeth ____ Age of eruption of permanent teeth ____
E. Cardiorespiratory: __ Dyspnea __ Chest pain __ Cough __ Sputum __ Wheeze __ Expectoration __ Cyanosis __ Edema __ Syncope __ Tachycardia
F. Gastrointestina: __ Vomiting __ Diarrhea
__ Constipation __ Abdominal pain/discomfort __ Jaundice Type of stools ____________
G. Genitourinary: __ Enuresis __ Dysuria __ Frequency __ Polyuria __ Pyuria __ Hematuria __ Vaginal discharge __ Abnormal penis/testesCharacter of stream (urine) __________________________Bladder control __________________________
H. Neuromuscular: __ Headache __ Nervousness __ Diziness __ Tingling sensation
__ Convulsions __ Spasm __ Ataxia __ Muscle or joint pains __ Postural Deformities __ Exercise tolerance
I. Endocrine __ Disturbance of growth __ Excessive fluid intake __ Polyphagia __ Goiter
J. General __ Unusual weight loss __ fatigue __ Temperature sensitivity
I. CHIEF COMPLAINTS ( History of Present Illness) __________________________________________________________ __________________________________________________________ __________________________________________________________ ___________________________________________________ .
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11. GASTROINTESTINAL
Abdomen:
Inspection: __ Flat __ Scaphoid __ Distended __ GlobularPercussion: __ Tympanitic __ Dull __ Fluid WavePalpation: __ Normal __ Splenomegaly __ Mass
__ Hepatomegaly Liver edge ____________Tenderness: Location_______ __ Direct __ Indirect
Bowel Sounds: __ Normal __ Hyperactive __ Hypoactive
Rectal Exam : ___________________________________________________
Comments : _____________________________________________________
12. GENITOURINARY __ Normal __ Mass __ Tenderness (location) ____________
Genitals: __ Normal __ Discharges __ Anomaly MALES:
Circumcised __ Yes __ NoTanner Staging: Tanner Score: _____
FEMALES:Menses started ________ __ Not ApplicableLength of Cycle: ________ __ Regular __ Irregular
Tanner Staging: Tanner Score: _____
Name of patient: __________________________________________________ jalim’11
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