EXCELSIOR COMMUNITY COLLEGE

FACULTY OF PURE AND APPLIED SCIENCES

SCHOOL OF NURSING
NURS 4011 Nursing Care of Children and Adolescents
Paediatric Assessment Guide

1. Guidelines for objective data

a. name of client
b. age, date of birth
c. date of admission, medical diagnosis
d. present complaint, history of present complaint, past medical, surgical history
e. allergies, immunization status
f. social, family history
g. nutrition history
h. developmental milestones, play
i. school performance (where relevant)
j. obstetric history (for all clients 1 year and below, any client for which it is important)
k. physical examination

2. Health Promotion
a. safety (accident/injury protection)
b. nutrition
c. health management (for example- care of teeth, exercise, sleep)
d. immunization

3. Safety precautions by age group (areas to be included in age specific health promotion teaching)
a. Infants - Aspiration, Falls, Poisoning, Burns, Suffocation
b. Toddler - Burns, Poisoning, Drowning, Aspiration, Falls, Motor Vehicles
c. PreSchool Age - Community Safety, Poisoning, Falls, Motor Vehicles, Falls, Burns
d. School Age - Community Safety, Burns, Sports Injuries, Firearms, Drugs, Drowning
e. Adolescents- Motor vehicles, Firearms, Drowning, Sports

4. Psychosocial stages of development-Eric Erickson

a. Infant – 0-1yr Trust vs. Mistrust
b. Toddler - 1-3yrs Autonomy vs. Shame and Doubt
c. Preschooler - 3-5yrs Initiative vs. Guilt
d. School-age – 6-12yrs Industry vs. Inferiority
e. Adolescent – 13-18yrs Identity vs. Role Confusion

5. Immunization schedule
a. Birth to six weeks: BCG
b. Six weeks: IPV and DPT/Hep B/HIB (Pentavalent)
c. Three months: OPV and DPT/Hep B/HIB (Pentavalent)
d. Six months: OPV and DPT/Hep B/HIB (Pentavalent)
e. Twelve months: MMR
f. Eighteen months: OPV, DPT and MMR booster
g. Booster: DPT

Adapted from UWISON –USED WITH PERMISSION

 For entry to Nursery and Basic School all the above vaccines are necessary

h. Four to six years: OPV and DPT booster

i. Booster: DT (over age 11years)

For entry to Primary School all the above vaccines are necessary

6. Paediatric parameters *

Pulse rate Respiratory Haemoglobin Glucose

Newborn: 70-170 (120) Newborn : 40-90 Term: 16.5 g/dL FPG < 5.6 mmol/L
1-11mnths: 80-160 (120) 1 yr: 20-40 I month: 13.9 g/dL PM < 7.8 mmol/L
2 yrs: 80-130 (110) 2 to 3 yrs: 20-30 2 months: 11.2g/dL
4yrs: 80-120 (100) 5 yrs : 20-25 6 months: 12.6g/dL
6 yrs : 75-115 (100) 10 yrs : 17-22 6-24 months: 12g/dL
8yrs: 70-110 (90) 2-6yrs: 12.5g/dL
10 yrs: 70-100 (90) 6-12yrs: 13.5g/dL
Anterior fontanel closes -18 months, Posterior fontanel -2-3months

7. Cerebrospinal fluid ranges*

Glucose Protein White blood cells

preterm 1.3-3.5mmol/L 0.65-1.50g/dl 0-25 WBC × 106 cells/L
term 1.9-6.6mmol/L 0.20-1.70g/dl 0-22 WBC × 106 cells/L
child 2.4-4.4mmol/L 0.05-0.40g/dl 0-7 WBC × 106 cells/L

8. Major Developmental milestones by age group**

Infant Toddler Preschooler
Rolls over Walks up and down stairs Uses scissors
Sits up Undresses self Rides bicycle with training
Stands Scribbles on paper wheels
Able to say 1 or 2 words Kicks a ball Throws a ball
Uses pincer grasp well Has a vocabulary of 1,000 Holds a bat
words – uses short sentences Writes a few letters
All parts of speech are well-
developed

School-age Adolescents

Possesses reading ability Fine motor skills well-

Rides a two-wheeled bike developed
Jumps rope Gross motor skills improve due
Plays organized sports to growth spurts
Mature use of language Able to apply abstract
thought and analysis
Adapted from UWISON –USED WITH PERMISSION
Adapted from UWISON –USED WITH PERMISSION