ARELLANO UNIVERSITY

Legarda, Manila

PEDIA WARD
NURSING HISTORY
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Name of student: Danica B. Fababeir Date of Rotation: Feb 8, 2010

Group and Section: Group VI Sec- NCM101 B Adviser: Francis Mamaril
Patient Name:
Nickname: Age:
Sex:
Ethnic Origin: Birth Date:
Race: Filipino
Religion:
Contact Information:
Name of Person Providing Information:

Chief Complaint:
History of Present illness:
Onset: Type of symptoms
Location:
Duration
Severity:
Influencing factor
Past evaluation of the problem:
Previous therapies: none
Current therapies:

PAST HISTORY (detailed description of the child’s prior health status)

Birth history (prenatal history, description of delivery, condition of the baby at birth,
post natal care and concerns):
All major past illnesses and injuries:
Age at time of each:
Illness:
Injury:
Related surgery:
Hospitalization:
Transfusion:
Treatment outcome:
Complication of residual problem:
Child’s reaction to the event:

CURRENT HEALTH STATUS

Allergies: none
Current medication:
Immunization:
Activities and exercise:
Sleep patterns:
Nutrition:
Safety measures used:
Health maintenance care:

FAMILY HISTORY
Infectious diseases:
Allergies:
Disorder of the different body system:
Problem pregnancies:
Learning problems:
Identifying the health status of:
Father:
Mother:

PSYCHOLOGICAL DATA:
Family composition:
Family members living in home:
Person caring for child:
Financial resources:
Health insurance:
Description of housing & home environmental: well ventilated, stable home
Spiritual life: non-participative in church activities

DEVELOPMENTAL DATA
Fine & Gross motor milestone:
Cognitive:
Language:
Current skill:
Academic performance:
Interaction with other children:
Interaction with family member:
Interaction with strangers:
.

ARELLANO UNIVERSITY
Legarda, Manila

PEDIA WARD
PHYSICAL ASSESSMENT
Name of student: Danica B. Fababeir Date of Rotation: Feb 8, 2010

Group and Section:

Patient Name:
REVIEW OF SYSTEMS
BODY SYSTEM EXAMPLES OF PROBLEMS TO IDENTIFY
General General growth pattern of overall health status, active of tires easily, fever,
sleep patterns, allergies, types of reaction (hives, rash, respiratory difficulty,
swelling, nausea), seasonal or with each exposure , alertness of child.
Skin & Lymph
(Dry skin) Rashes, dry skin, itching, changes in skin color or texture, tendency of
bruising swollen or tender lymph glands.
Hair and Nails Hair loss, changes in color and texture, use of dye or chemicals on
hair, abnormalities or nail growth or color, clubbing.
Head Headaches
Eyes Vision problems, squinting, crossed eyes “lazy eyes,” wears glasses, eye
infections, redness, tearing, burning, rubbing, swelling eyelids.
Ears Ear infection, frequent discharge from ears, tubes in ears hearing loss (hearing
test ever done?); hearing aids or cochlear implants.
Nose & sinuses Nosebleeds, nasal congestion, runny nose, sinus pain or infection;
nasal obstruction, difficulty breathing, snoring at night.
Mouth and throat Mouth breathing difficulty in swallowing, sore throats, strep
infection, mouth odor, tooth eruption, cavities, braces, voice change, hoarseness
speech problem.
Cardiac & hematologic Heart murmur, anemia, hypertension, cyanosis, edema,
rheumatic fever, chest pain.
Chest & respiratory Trouble with breathing choking episode, cough, wheezing,
cyanosis, exposure to tuberculosis, and other infections.
Gastrointestinal Vowel movements, frequency, color, regularity, consistency,
discomfort, constipation or diarrhea, abdominal pain, bleeding from rectum,
flatulence, nausea or vomiting, appetite.
Urinary Frequency, urgency, dysuria, dribbling, enuresis, urinary stream, age when
day and night, dryness attain
Reproductive female For pubescent children, menses onset, amount, duration,
frequency, discomfort, problems, vaginal discharge, breast development.