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West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

NURSING
PROCESS
HIGH-RISK PEDIATRICS

Submitted by:
Khryss Paula S. Baldonado
BSN II-C

Submitted to:
Sir Jesus P. Borcelo
Clinical Instructor
PEDIATRIC NURSING PROCESS

I. VITAL INFORMATION

Name of child: Date & Time of Interview:

Date of birth: Name of Informant:

Sex: Relationship with the child:

Age:

Address:

Date & Time Admitted:

Chief Complaints:

Ward:

Religious Affiliation:

Name of Mother:

Educational Attainment: Age:

Occupation:

Name of Father:

Educational Attainment: Age:

Occupation:

Approximate Monthly Income of the Family:

a.) Mother-

b.) Father-

c.) Others-

TOTAL

Physician:

Impression/Diagnosis:

Pre-op Diagnosis:
Post-op Diagnosis:

II. CLINICAL ASSESSMENT:

A. NURSING HISTORY
History of Present Illness

Usual Health Status

Chronologic Story:

Past Medical History

Parasitism __________ Tuberculosis __________ Anemia __________


AGE __________ Measles__________ Seizure __________
AGN __________ BPN __________ Emotional Disorder __________
Allergy __________ Accidents: Others:

No. of previous hospitalizations:

Date of last confinement:

Where:

Reasons for confinement:

Family History

Birth order of patient:

Total no. of siblings:


No. of living siblings:

Serious diseases/illnesses of siblings:

Causes of death/serious illnesses of siblings:

Heredo-familial diseases:
Tuberculosis __________ Hypertension ___________
DM __________ Cancer ___________
Asthma __________ Genetic Disorders:
Others:

Maternal and Perinatal History

Maternal age when the child was born:


Age of gestation and birth weight
Preterm
Full term
Post term

TYPE OF DELIVERY Home attendant/midwife Hospital


Spontaneous
Caesarian Section/forceps

Complications related to pregnancy:

Parental views of pregnancy:

Parental problem (1st month):

Childs ability to get along with people as viewed by parents:

Early behavior patterns as viewed by parents:

Parents attitude towards child rearing:

III. PATTERNS OF FUNCTIONING


A. Infants up to 1 year N/A
TYPE OF FEEDING Age Started Duration Interval
Breastfed

Bottlefed

Mixed

Type and brand of


milk:
Evaporated
Condensed
Powdered
Others specify:
Dilution

Approximate intake per 24 hours:


Problems during weaning:

Vitamins and minerals supplement


Type: Dosage/Amount:

Nutritional History and Eating Patterns


Meal Type and Amount of Foods Usually Taken

Breakfast

Morning Snacks

Lunch

Afternoon Snacks

Supper

Food likes and dislikes:

Allergies:

Problems related to nutrition:

Supplementary Foods
Age started Kind/Type and amount Frequency
1-3

4-6

7-9

Elimination Patterns
Frequency Problems/Difficulties Usual remedy
Bowel movement

Urination

Toilet Training
Age in Found in textbook As seen in the patient Usual remedy
months and/or verbalized by
started significant person
Bowel
Bladder

Sleeping patterns
Usual patterns Usual time Approximated Sleeping Special rituals Problems with
total no. of arrangement sleeping
hours of
sleep/24 hrs.
Bedtime

Waking time

Immunization Status
Type 1st Age 2nd Age 3rd Age Booster Age Booster Age
dose dose dose 1 2
BCG
DPT
OPV
Hepa B
Meases/MMR

Play
a.) Appropriateness of available toys:

b.) Availability and safety of play areas:

c.) Favourite toys and activities:

d.) Child initiative and amount of creative play:

e.) Preferred play: solitary __________ parallel __________ cooperative ___________

f.) Peer interaction:

IV. DEVELOPMENTAL ASSESSMENT

Developmental History
AS SEEN IN THE
AGE IN
PATTERNS PAIENT AND/OR
MONTHS
OF AGE IN MONTHS FOUND IN VRBALIZED BY
WHEN SIGNIFICANCE
DEVELOP- TEXTBOOK THE
MANIFE
MENT INFORMANTS/
S-TED
SOs

Smiles and
regards

Hold up head
when prone

Follow objects
with eyes
Turned self
from prone to

Supine

First eruption
of teeth

Sat with
support
Crawls/creeps

Criuses

Stands alone
Current Developmental Assessment
OBSERVATIONS FOUND IN ACTUAL
AREAS AGE SIGNIFICANCE
TEXTBOOKS OBSERVATION

Gross motor

Fine motor

Sensory

Psychosocial
Psychosexua
l

Spiritual

Cognitive

Moral

Language
and speech
V. PRESENT MEDICAL HISTORY
A. MEASUREMENTS

Weight: __________(gm) Height: __________ (cm) Head circ. __________(cm)

VI. PHYSICAL ASSESSMENT

A. GENERAL APPEARANCE

B. INTEGUMENTARY, HAIR AND NAILS

C. HEAD AND NECK INCLUDING REGIONAL LYMPHATCS

D. EYES, EARS, NOSE, MOUTH, AND THROAT


E. BREAST AND REGIONAL LYMPHATICS

F. THORAX AND LUNGS

G. CARDIOVASCULAR SYSTEM

H. GASTROINTESTINAL SYSTEM

I. UPPER AND LOWER EXTREMITIES/ MUSCUOSKELETAL SYSTEM


J. GENITO-URINARY SYSTEM

K. NEUROLOGIC SYSTEM

L. HEMATOPOIETIC SYSTEM
VII. LABORATORY EXAMS AND DIAGNOSTIC PROCEDURES

Name of examination:
Definition:

Preparation:

Purpose:

Date:

Name of Examination Result Normal Values Significance


Name of Examination Result Normal Values Significance
TEXTBOOK DISCUSSION
A. DEFINITION
B. CLINICAL MANIIFESTATIONS
C. SCHEMATIC DIAGRAM
D. MANAGEMENT
VIII. LIST OF PRIORITY NURSING PROBLEMS
IX. TEXTBOOK DISCUSSION

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