PEDIATRIC NURSING ASSESSMENT

Care of Normal Preschooler

A. Child’s Information

Name: Xian Vince A. Mabatid Date of Assessment: March 1, 2022

Address: Purok 1, Brgy. Lacasa, Hinatuan, Surigao del Sur
Birthdate: 04/21/17 Age: 4 Sex: Male Birth place: Hinatuan, Surigao del Sur
Religion: Roman Catholic Nationality: Filipino
Temperature: 36.7 Pulse: 110 bpm Respiratory: 28 Height: 3’1’’ Weight: 14kg

Instructions: Please indicate in narrative form your specific observations or significant assessment findings on
the space provided for each area.

Area Assessment
Skin Soft and has a smooth skin.
Head The size of his head is 41.5 cm or 16.3 in.
Neck Symmetrical, no signs of lumps, nodules and masses.
Eyes They are symmetrical, blink reflex are normal, the sclera are white and the conjunctiva
is pink.
Ears Ear is symmetrical, the ear canal is the same color as the skin, has little earwax, the
eardrums are pinkish gray in color and the tympanic membrane is in the neutral
position and its color is pearly gray.
Nose Symmetrical, mucous membrane is red, septum is in the middle, no deformities, and
inflammation or skin lesions.
Mouth and Symmetrical lips, pinkish lips and gums, tongue is light pink, buccal folds are normal,
Throat posterior oropharynx are normal.
Chest & Movement of the chest are symmetrical, the rate and rhythm is normal, chest
Lungs expansion is normal, no tenderness, mass or swelling.
Heart 110bpm, no bulge on chest, normal heart beat sounds
Abdomen Symmetrical, bowel sounds are normal, soft abdomen, no tenderness occurred, no
visible of lesions or scars.
Genitalia No tenderness, masses, or plaques occurred.
Anus Deeply pigmented, coarse, and moist.
No lesions, inflammation, rash, masses and additional opening.
Back and No deformities, normal gait, no tenderness, no muscle bulk.
Extremities

Neurologic Assessment
Behavior Start showing independent and more interested in other kid. He also sometimes show
tantrums and can talk simple sentences.

Motor Can walk, run, climb, kick and can walk up and down stairs.
Functioning

Reflexes Blinking reflex is normal and can automatically response to stimulation.

Sensory Can able to identify what is hot and cold.

Functioning

Developmental Milestone

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 Gross Can run, walk, kick, throw, catch a ball, jump with feet together, dance, start to use
Motor ride–on toys, and can count one to three only.
Skills
Fine Motor Can clap hands, can manipulate pencils and crayons well enough to color and draw,
Skills picking up and putting down objects, and can feed himself enough.
Language Can use pronouns like I, you, me and uses simple phrases or micro sentences to
Skills communicate with others also understands concept of ‘mine’ and ‘his/hers’
Play Sometimes he plays alone, he also plays with his sister and he sometimes imitate what
the other children do.

D. Functional Heath Pattern

Instructions: Mark (/) if the question requires a Yes or No answer on the space provided for the answer and
supply questions with the needed answer.

1. Health Perception – Health Management Pattern

🗸
a. Has your child ever been in the hospital? ___Yes____No
If yes, reason for hospitalization: High fever
🗸
b. Does your child take medications at home? ___Yes____No
If yes, reason for taking medication: ___________________
c. How medication/s are given? _______________________
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d. Does your child have trouble taking the medication? ___Yes____No
If yes, what do you do?_____________________________________

2. Nutritional and Metabolic Pattern

a. What time do you usually eat breakfast? 7am Lunch? 11am Dinner? 6am
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b. Do family members eat together? ___Yes____No___Sometimes
c. What are your child’s favourite food? Fried chicken
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D. Does your child eat by himself/herself? ___Yes____No
If no, Who feeds your child?________________________________

3. Elimination Pattern
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a. Is your child wearing a diaper? ___Yes____No
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If no, is your child toilet trained? ___Yes____No
b. What words are used by your child when he/she wants to?
Urinate Ma, mangihi ko Defecate Ma, kalibangon ko
c. What is the usual pattern of elimination (bowel movement)? ___________
d. Do you have any concerns on the following?
Bedwetting______Constipation_______Diarrhea_________

4. Sleep-Rest Pattern

a. What is your child’s usual hours of sleep? 9 hours awakening 6am

b. What is his/her nap schedule?_____________ Length of Naps:_______________
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c. Is there a special routine for sleeping? ___Yes____No
If yes, what is his/her routine?__________________
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d. Is your child sleeping alone? ___Yes____No
If no, Who sleeps with him/her? Parents and siblings

5. Activity Exercise Pattern

a. What is your child’s schedule during the day?

He will go with his father to the funerary shop and sometimes I will teach him how to write and read.

b. What is your child’s favourite activities or toys?

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He likes forging since he will always go to his father’s funerary shop and he can see people making caskets.

c. What is his/her usual television viewing/gadget schedule?

Usually when he is in the house he use gadget in morning around 10am and usually in evening around 8pm

d. What is his/her favourite tv programs or online shows?

I don’t usually check the phone but sometimes it is about balls and 2 kids playing.

e. What is his/her usual bathing habits/schedule?

His usual bathing schedule is 8 in the morning.

f. What is your child’s dental habits?

He do thumb sucking everytime.

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g. Does your child need help with dressing or grooming?____Yes____No

If yes, who helps your child? Usually my husband and eldest daughter

6. Cognitive - Perceptual Pattern

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a. Does your child have any hearing difficulty? ___Yes____No
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b. Does your child have any hearing problems? ___Yes____No

7. Self-Perception –Self-Concept Pattern

a. What makes your child angry? Sharing toys anxious?
Sad?____________ fearful or afraid? Snakes

8. Role Relationship Pattern

a. Who usually takes care of your child during the day? his father night? Mother
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b. Does your child have security object/s?____Yes___No
If yes, what is the object/s?________________________

9. Sexual Reproductive Pattern (Skip this part)

10. Coping-Stress Tolerance Pattern

a. How do you handle your child if he/she is having stress or temper tantrums?

When he is having temper tantrums I would just ignore him until he will stop crying.

11. Value-Belief Pattern

a. What is your child’s religion?

Roman catholic

b. what are your religious practices?

Going to church every Sunday.

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