West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City ASSESSMENT FOR NORMAL PEDIATRICS ( For Infants,

Toddlers, Pre-schoolers, Schoolers)

I. VITAL INFORMATION Name of Child: Sex: Date of Birth: Age: Address: Name of Mother: Educational Attainment: Occupation: Name of Father: Educational Attainment: Occupation: Approximate Income of the Family: Name of Informant: Relationship with child:

Age: Age: Monthly:

II. PERSONAL HISTORY A. Prenatal Mothers general health ( Did the mother had toxemias, analgesia or radiation therapy, viral or other infections?): Medications taken during pregnancy: Pain, bleeding, threatened abortion: None: Yes: Specify: B. Birth Duration and circumstances of labor: Analgesia Used: Delivery: Home: Complications: Birth Weight: AOG: C. Neonatal: Feeble: Resuscitated: Convulsions: Pallor:

Hospital:

Type:

Vigorous: Cyanosis: Hemorrhage: Dyspnea:

III. FAMILIAL HISTORY Birth Order of the Child: Number of living siblings: Serious diseases/ illness of siblings: Congenital diseases among siblings: Death of siblings: Heredo-familial diseases: Total Number of Siblings: Type of housing: Cause of death:

IV.PAST MEDICAL HISTORY Number of Past Hospitalizations: Date of last confinement: Reason for hospitalization: Number of days of hospitalization: V. NUTRITIONAL HISTORY Feeding (check and specify) Bottlefeed: Supplementary feeding: Vitamins: Food likes: Dislikes: Beliefs and fallacies: Breastfeed: Type: Amount: Mixed: ___________ Age started: When: Where:

VI.EATING PATTERNS (For older children) Usual Foods Taken Breakfast Time of Day

Lunch

Supper

Snacks

VII. REST AND SLEEP Usual bedtime: Naps: Bedtime rituals: Problems with sleep: Usual remedy: Total number of hours of sleep: VIII. ELIMINATION PATTERNS A. Bowel Elimination Frequency: Problems: Usual Remedy: B. Urinary Remedy Frequency: Problems: Usual Remedy: IX. IMMUNIZATION STATUS Rising time:

1ST dose age OPV DTP MMR BCG Hepa A Hepa B CT Others (specify):

2nd dose

3rd dose

booster 1

booster 2 Date received

Date age received

Date age received

Date age received

Date age received

X. CEPHALOCAUDAL ASSESSMENT Head:

Eyes:

Ears:

Nose:

Mouth:

Neck:

Chest:

Back:

Abdomen:

Extremities Upper:

Lower: Genito-anal:

Skin:

Temperature: Height: Weight:

Pulse:

Respiratory Rate:

BP:

XI. DEVELOPMENTAL ASSESSMENT Found in Textbook Actual Observation Significance

A.Gross Motor Development

B.Fine Motor Development

C.Sensory Development

D.Psychosocial Development and Socialization

E.Psychosexual Development

F.Spiritual Development

G.Cognitive/Intellectual Development

H.Language/Speech Development

XII. AREAS IDENTIFIED NEEDING HEALTH TEACHING A. Nutrition

B.

Activities

C.

Immunization

D.

Safety

E.

Others