Pediatric Assessment Tool

Student: Clinical Instructor:

Client Initials: Age: Sex:

Date of Care:

Medical Diagnosis (in order of priority):

1 2. 3.

Admit Date:

Chief Admission Complaints:

Last Vital Signs:

T HR RR O2 Sat BP

History of Present Illness:

Treatments/medications taken at home:

Family/child’s understanding of illness:

Past History
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 Screening tests/immunizations (give dates)

Hep B DPT Hib OPV MMR

TB Lead Sickle Cell

Birth History (if child is under 2 years):

Allergies:

Significant Family History:

Child lives with (List all members of the household and provide ages):

Legal Guardian: Grade in school:

Source of family income: Resources available to family:

ASSESSMENT OF GROWTH AND DEVELOPMENT

Norms for Age Assigned Child Deviations from the norm
1. Communication

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a) Verbal

b) Nonverbal

2. Behaviors

3. Play

4. Motor Development

a) Gross Motor

b) Fine Muscle

5. Group Experience

Physical Assessment
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Neurological:

Behavior/level of consciousness:

Reflexes (present / absent, if applicable):

Moro: Grasp: Rooting: Sucking: Babinski: Tonic neck: Gag:

Sensory function (describe):

Gastrointestinal/Genitourinary:

Diet: Weight: Appetite:

Hydration Status:

Bowel Function: Toilet trained:

Urination function: Toilet trained:

Cardiac:

Heart rate: Rhythm:

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Blood Pressure: Peripheral pulses (describe):

Skin color: Capillary refill:

Respiratory:

Resp. rate: Pattern:

Lung Sounds: Use of accessory muscles (describe):

Cyanosis (describe): Clubbing (describe):

.

O2 Sat: Peak flow: PO2: CO2:

Use of O2 (describe):

Intergumentry:

Color: Condition (describe):

Lesions/Birthmarks/Rashes (describe):

Musculoskeletal:

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ROM (describe): Symmetry of extremities / coordination:

Pain (describe): Highest level of locomotion (describe):

Assistive devices used (described):

Psychosocial:

Makes eye contact: Social smile: Laughs: Responds to name:

Follows simple commands: Separation anxiety

Explores surroundings (describe):

Play activities (describe): : Toy/Game preferences:

Child/Parent’s feeling about illness/hospitalization (describe):

Evidence of regressive behavior (describe):

Other Pertinent Information about this patient / family:

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Adolescents Only (complete if patient is >12 years)

Age of menarche: L.M.P (females): Frequency / duration:

Tanner Scale: Sexual activity:

Birth control method: Safe sexual practices (describe):

Hx of STD (describe): Hx of pregnancy: G P

Knowledge deficits regarding birth control, sexually transmitted diseases and/or sexuality (describe):

Other Pertinent Data

Treatments and Diagnostic Tests Purpose Nursing responsibilities

before and after
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 Other Pertinent Data

Treatments and Diagnostic Tests Purpose Nursing responsibilities

before and after

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 Relevant Normal 1st Value Last Value Significance of abnormal findings

Lab tests Values

Blood
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 Hemoglobin
Hematocrit
WBC Total
Lymphocytes
Neutrophils
Monocytes
Eosinophils
Basophils
RBC
Platelet Count
Glucose
Na
K
Calcium
C02
Albumin
Alkaline Phosphatase
Creatinine
BUN
Hemoglobin A1C -
Other:
Arterial Blood Gasses
pH
PC02
PO2
O2 Sat
HC03
Urinalysis
pH
Specific Gravity
Protein
Glucose
Ketones
Nitrites
Leukocyte Esterase

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 Medications

Drug therapy Indication Side Effects Nursing Responsibilities

Date ordered/terminated;
Dose, Frequency, & Route.

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 Medications

Drug therapy Indication Side Effects Nursing Responsibilities

Date ordered/terminated;
Dose, Frequency, & Route.

ADD MORE PAGES FOR MEDICATIONS IF NEEDED

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 EVALUATION OF PATIENT RESPONSES
Problem #1:

Behavioral Outcomes: The client will:

Nursing Interventions Rationale Patient Responses (Evaluation)

Summarize impressions (observations) of patient’s progress toward outcomes:

References:

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 EVALUATION OF PATIENT RESPONSES
Problem #2:

Behavioral Outcomes: The client will:

Nursing Interventions Rationale Patient Responses (Evaluation)

Summarize impressions (observations) of patient’s progress toward outcomes:

References:

14
 EVALUATION OF PATIENT RESPONSES
Problem #3:

Behavioral Outcomes: The client will:

Nursing Interventions Rationale Patient Responses (Evaluation)

Summarize impressions (observations) of patient’s progress toward outcomes:

References:

15
 EVALUATION OF PATIENT RESPONSES
Problem #4:

Behavioral Outcomes: The client will:

Nursing Interventions Rationale Patient Responses (Evaluation)

Summarize impressions (observations) of patient’s progress toward outcomes:

References:

CONCEPT MAP

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PROBLEM #1: PROBLEM #2:

REASON FOR SEEKING HEALTH CARE

 PROBLEM #3:  PROBLEM #4:

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