CEBU INSTITUTE OF TECHNOLOGY – UNIVERSITY

College Of Nursing

PEDIATRIC ASSESSMENT TOOL

Patient’s Name: ________________________________________________________________

Age: _________________________________________________________________________
Address: _____________________________________________________________________
Date of Birth: _________________________________________________________________
Date and time of Admission:______________________________________________________
Ward and Bed #:_______________________________________________________________
Impression: ___________________________________________________________________
Taken by: ____________________________________________________________________

I. Appearance at first sight:

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II. Growth and Development:

A. Physical
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B. Motor
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C. Mental
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D. Psychosocial
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III. Family Data:
A. Occupation of father: _____________________________________________
B. Number of siblings: ______________Male:___________Female:___________
C. Ordinal position of child: ___________________________________________
D. Who stays with the child in the hospital?: _____________________________

IV. Habits of Daily Living:

A. What name do you call the child at home?: ____________________________
B. Has the child ever been away from home?: ____________________________

V. Feeding Habits:
A. Frequency of feedings: _________________________ Type: _____________
B. Extent to help in feeding:___________________________________________
C. Foods: likes:_____________________dislikes:_______________
D. Allergies: food:_____________________drug:_________________

VI. Elimination:
A. Degree of child’s toileting: __________________________________________
B. Words used by child: ______________________________________________
C. Bowel habits: ____________________________________________________
D. Is the child toilet trained at day?:________________night?:_______________

VII. Rest and Sleep:

A. Usual time: sleeping: ________________________waking: _______________
B. Preparation done for bed: __________________________________________

VIII. Exercise in play activity:

A. Usual play: indoor:_______________________outdoor:__________________
B. Length of time spent in play:________________________________________
C. Favorite Activity:__________________________________________________
D. Favorite toy:___________pillow:________________blanket:______________

IX. Personal Hygiene:

A. Bath: __________kind:_________time: __________frequency:____________
B. Oral hygiene: ____________________________________________________
C. Dependence of child for personal hygiene:_____________________________

X. Past illness/hospitalization:
A. What was the illness:______________________________________________

B. Reaction of the child’s parents to the illness/hospitalization:_______________

_________________________________________________________________

C. Community agencies used in the past:

_________________________________________________________________

D. For what reason was the doctor consulted?:

_________________________________________________________________

E: Immunization: ___________________________________________________
 F. Genogram:

XI. History of Present Illness: (Cause of Admission)

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XII. Personal and Social History:

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XIII. Environmental History:

A. General description of surroundings, slum or residential:
_______________________________________________________________

B. General description of the house:

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C. Water source or drainage:

_______________________________________________________________

D. Garbage disposal:
_______________________________________________________________

XIV. Review of Systems:

A. Head:
_______________________________________________________________

B. Eyes:
_______________________________________________________________

C. Ears:
_______________________________________________________________

D. Nose:
_______________________________________________________________

E. Mouth and Pharynx:

_______________________________________________________________

F. Respiratory System:
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G: Cardiovascular System:
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 H. GIT:
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I: Extremities:
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XV. Physical Examination:

A. IPPA
 Head
I-
P-
P-
A-
 EENT
I-
P-
P-
A-
 Skin
I-
P-
P-
A-
 Respiratory SysteM
I-
P-
P-
A-
 Cardiovascular System
I-
P-
P-
A-
 GIT
I-
P-
P-
A-

 Extremities
I-
P-
P-
A-

B. Vital Signs:
 Temperature:_______________________________________________
 Pulse Rate:_________________________________________________
 Respiratory Rate:____________________________________________
 Blood Pressure: _____________________________________________

C. Laboratory Results