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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
Age:
Address:
Chief Complaints:
Ward:
Religious Affiliation:
Name of Mother:
Occupation:
Name of Father:
Occupation:
a.) Mother-
b.) Father-
c.) Others-
TOTAL
Physician:
Impression/Diagnosis:
Pre-op Diagnosis:
Post-op Diagnosis:
A. NURSING HISTORY
History of Present Illness
Chronologic Story:
Where:
Family History
Heredo-familial diseases:
Tuberculosis __________ Hypertension ___________
DM __________ Cancer ___________
Asthma __________ Genetic Disorders:
Others:
Bottlefed
Mixed
Breakfast
Morning Snacks
Lunch
Afternoon Snacks
Supper
Allergies:
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:
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
A. GENERAL APPEARANCE
G. CARDIOVASCULAR SYSTEM
H. GASTROINTESTINAL SYSTEM
K. NEUROLOGIC SYSTEM
L. HEMATOPOIETIC SYSTEM
VII. LABORATORY EXAMS AND DIAGNOSTIC PROCEDURES
Name of examination:
Definition:
Preparation:
Purpose:
Date: