Universidad de Sta.

Isabel
College of Health Sciences
Nursing Program

Case Recording Form

Name: Angelica Aycardo Flores Section: BSN 2A

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

Name: Josefa Age: 18 moths Weight:11.5kg Temperature: 37.5ºC
ASK: What are the child’s problems? Cough and Difficulty Initial visit? / Follow-up visit?

CHECK FOR GENERAL DANGER SIGNS  General danger signs present?

YES NO /
NOT ABLE TO DRINK OUR BREASTFEED Remember to use danger sign
VOMITS EVERYTHING  when selecting classification
CONVULSIONS 
LETHARGIC OR UNCONSCIOUS

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Pneumonia

Yes / No
 Count the breaths in one
 For how long? 7 Days minute.
No chest indrawing
41 Breaths per minute.
No stridor
Fast breathing?
 Look for chest indrawing
 Look and listen for stridor
DOES THE CHILD HAVE DIARRHEA? Yes No

 For how long? Days  Look at the child’s general

 Is there blood in the stools? condition
Is the child:
Lethargic or unconscious?
Restless or irritable?

 Look for sunken eyes

 Offer the child fluid, is the
child:
Not able to drink or drinking
poorly?
Drinking eagerly, thirsty?
 Pinch the skin of the abdomen.
Does it go back very slowly
(longer than 2 seconds)?
Slowly?
DOES THE CHILD HAVE FEVER? (by history/ feels hot/ temperature
37.5ºC or above) Yes No
Decide Malaria Risk: High Low
 For how long? Days
 If more than 7 days, has  Look or feel for stiff neck
fever been present every  Look for runny nose
day? Look for signs of MEASLES:
 Has child had measles  Generalized rash and
within the last three  One of these: cough, runny
months? nose, or red eyes

If the child has measles now or 

Look for mouth ulcers
within the last 3 months: If yes, are they deep and
extensive?
 Look for pus draining from
the eye
 Look for clouding of the
cornea
DOES THE CHILD HAVE AN EAR PROBLEM? Yes No

 Is there ear pain?

 Look for pus draining from the
 Is there ear discharge?
ear
If yes, for how long?
Days  Feel for tender swelling
behind ear
THEN CHECK FOR
MALNUTRITION AND
ANAEMIA


Look for visible severe wasting

Look for palmar pallor
Severe palmar pallor? Some
palmar pallor?
 Look for oedema of both feet
 Determine weight for age
CHECK THE CHILD’S IMMUNIZATION STATUS Return for the next immunization
Circle immunization needed today Very Low Not Very Low on:

BCG DPT1 DPT2 DPT3

OPV 0 OPV 1 OPV 2 OPV 3 Measles (Date)

ASSESS CHILD’S FEEDING if child has ANAEMIA OR VERY LOW FEEDING PROBLEMS
WEIGHT or is less than 2 years old
 Do you breastfeed your child? Yes No
If yes, how many times in 24 hours? Times. Do you breastfeed
during the night? Yes No
 Does the child take any other food or fluid? Yes No
If yes, what food or fluids?
How many times per day? Times. What do you use to feed the
child?
If very low weight for age: how large are servings?
Does the child receive how own serving? Who feeds the child and
how?
 During the illness, has the child’s feeding changed? Yes No
 If yes, how?
ASSESS (Circle all signs present) CLASSIFY