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Assessment of a Preschool Age Child (age 3-6 years, not enrolled in school)
Student(s)
Age of Client
Person(s) _________ child _________ mother _________ father _________ other: _______________________________________
Interviewed
Current Medications
Name Indication
Complementary and Alternative Modalities in Health Care (herbals, supplements, chiropractic, shaman; if none, indicate NONE)
Name Indication
Description Date/Year Residual Problems
Previous
medical
conditions
Previous
hospitalizations
Injuries
Surgeries
Newborn Course
Findings (Do not use ‘normal’, ‘within defined limits’, etc.)
Birth History
(Gestational age and growth
pattern; length & weight)
APGAR
(Apgar score and type of
resuscitation if required)
Neonatal Complications
(Respiratory, infections, feeding,
hyperbilirubinemia, congenital
abnormalities)
Family Detail
Placement in the family
Family structure
Cultural heritage
Family History
Person Age Current medical issues; Person Age Current medical issues;
or cause & age at death or cause & age at death
Mother
Father
Maternal Paternal
grandmother grandmother
Maternal Paternal
grandfather grandfather
Aunt or Uncle Aunt or Uncle
(specify) (specify)
Aunt or Uncle Aunt or Uncle
(specify) (specify)
Sister Brother
Sister Brother
Sister Brother
Examinations
Date Findings/Comments
Physical exam
Dental exam
Vision exam
Hearing exam
Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
Technique in your textbooks) expected findings of the child you assessed)
(bullet findings; do not use ‘normal’, ‘within defined limits’, etc.). Place an asterisk if you deem this a ‘Concern’ for
this client)
Vital Signs Heart rate:
Respiratory rate:
Height/Weight Ht for 50th percentile: Per caregiver:
Wt for 50th percentile: Ht:
Wt:
Skin:
Inspect skin for
coloration,
birthmarks, lesions,
turgor.
Hair and Nails
Inspect scalp for
texture and hair
distribution.
Head and Neck
Inspect and palpate
for symmetry and
suppleness.
Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
Technique in your textbooks) expected findings of the child you assessed)
Eyes, ears, nose, and
throat:
Inspect eyes for
color and
appearance.
Perform appropriate
visual screening.
Inspect ears for
position and surface
characteristics.
Inspect mouth for
color, lesions, and
intactness.
Inspect teeth for
presence and
characteristics.
Respiratory
Inspect chest for
respiratory effort
and depth.
Auscultate anterior
and posterior chest
for lung sounds.
Cardiovascular
Evaluate pulse for
rate, rhythm,
characteristics
(apical for infant,
radial for older child)
Auscultate heart
sounds
Abdomen:
Auscultate for bowel
sounds
Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
Technique in your textbooks) expected findings of the child you assessed)
Inspect for
symmetry, color,
surface
characteristics.
Very gently palpate.
Musculoskeletal:
What should the
patient be doing
now?
Inspect development
appropriate for age.
Inspect muscle
strength.
Inspect symmetry of
movements
Inspect gait and
coordination
Neurological:
Observe gait for
balance and
coordination.
Test extremities for
superficial tactile
sensation.
Evaluate general
mental status.
Cite Resource(s) for
Expected Findings
Teaching/Learning
Based on findings collected, outline areas of teaching that will promote health for this client/family (focus on *Concern items).
Topic Rationale 1) To whom will you direct the teaching to?
2) What techniques will you use?
3) How will you evaluate if learning has occurred?
Self-Evaluation of Therapeutic Communication & Assessment Technique During the Interview
Which therapeutic techniques did
you use to obtain the health
history? Explain if they were
effective or not and any
recommendations you may have?
What techniques did you use to
perform the physical assessment?
Explain if they were effective or
not and any recommendations you
may have?
What techniques did you use to
build trust with the caregiver(s)?
Explain if they were effective or
not and any recommendations you
may have?
Pediatric Teaching/Learning Project GRID
Students:
Teaching Topic (focus on one topic only from your ‘Concern’ column):
Nursing Diagnosis (Wellness/Health Promotion Focus with AEB; relate it to your teaching topic):
2) 2)
Cognitive outcome:
Domain of Learning: 1) 1)
2) 2)
Affective outcome:
Domain of Learning: 1) 1)
2) 2)
Psychomotor outcome:
Cite Resources: