شيت اطفال 2022

Faculty of Nursing Assiut University
Pediatric Nursing Department
2021-2022
-0-
Contents
No Items Page
1. Nursery school 2
2. Emergency 11
3. Surgical 23
4. Re hydration 35
5. Premature 50
-1-
Nursery school observation guide
Well child Report
Name of the school :
Student's Name :
Group :
Period from :
Instructor Name:
Staff member Name :
-2-
1- Personal and family History :
A- Personal History:
Child Name: Date of birth: / /
When he/she joined school:
Address:
B- Family History:
Father name Age:
Occupation
Mother's Name: Age:
Occupation:
Number of Sibling Brothers: Sisters:
2- Compare the level of growth and development of this child

to the normally expected level in relation to physical and
physiological growth motor, emotional, social and
intellectual development
Growth and
Growth and
Type of growth development of the
development of the
and development same age from the
current child
text book
Physical growth:
-3-
Growth and
Growth and
development of the
current child
text book
Physiological growth:
Motor Development:
-4-
Growth and
Growth and
development of the
current child
text book
Emotional
Development:
-5-
Growth and
Growth and
development of the
current child
text book
Social Development:
-6-
Growth and
Growth and
development of the
current child
text book
Intellectual
Development:
-7-
3- Describe the child's play interest and activities
4- How is the nursery school helping or failing to meet this

child's needs ( through).
a- The daily program of the school:
-8-
b- Teachers:
c- School building:
-9-
d- Equipments and facilities:
e- Peer group:
f- References:
- 10 -
(Emergency Unit)
- 11 -
Assessment sheet (Emergency Unit)
Child's Name:- Age: Sex:
Child history:-
1- Prenatal and birth history
• Pregnancy (Normal - Complicated)
• Labor and delivery (Normal - Induced - CS)
2- Developmental history:
• (Sets with support - Sets without support - Self feed - His
language is appropriate to his age)
3- Nutrition:
• (Breast feeding - Complementary feeding - Supplementary
feeding - Adult food)
4- Past medical history:
• (Major illness - Accident or injury - Operation or
hospitalization - Allergies)
5- Vaccination received:
 B.C.G.
 D.P.T.: first dose second dose third dose
 Polio: first dose second dose third dose
 Viral hepatitis: first dose second dose third dose
 Measles
 Booster dose
 MMR
6- Present complain:
7- Physical measurements:
 Length or height cm – Weight kg

 Head circumference cm – Chest circumference cm
 Arm circumference cm
- 12 -
8- Physiological measurements:
 Temperature C ° - Pulse B/m
 Respiration C/m - Blood pressure mmHg
Physical Examination
1- General appearance:
a) Face:
 Emotional state: (Sadness - Happiness - Apathetic –Feel frightened)
 Physical: (Cyanosis – Flashed - Normal - Pale ).
b) Posture (Position):
c) Hygiene: (Clean - Bad odor).
d) Nutrition: (Normal weight - Low weight - Over weigh).
e) Behavior: (Calm - Hypoactive - Hyperactive - Restlessness -Irritable
- Aggressive - Withdrawn).
2- Skin:
a) Color: (Normal - Cyanotic - Erythematic - Ecchymosed – Jaundice
petachiae - pigmentation - Infection).
b) Texture (Moist - Smooth - Excessive dry ness - Scars).
c) Turgor (Good elasticity - Wrinkled - prolonged depression).
3- Accessory structures:
a) Hair:
- Texture (Strong - Fragile)
- Distribution (Normal - Alopecia - Thin - Spots)
- Hygiene (Clean - Unclean - Bad odor)
b) Nails
- Shape : (Convex - Concave - Clubbing nails)
- Color (Pink- Cyanosed - pale)
- Quality (smooth- Hard)
- Hygiene:(Clean - Unclean)
- Creases of the hand (Normal - Simian line- Sydney line)
c) Lymph nodes:
- Cervical: - (Tender- Enlarged - Not Palpable - Mobile - Warm)
- Axillary: (Tender- Enlarged- Not Palpable- Mobile- Warm)
- Inguinal: (Tender- Enlarged- Not Palpable-Mobile- Warm)
4- Head:
• Symmetric facial feature - Swelling - head control well
• Range of motion (Limited- Resistance to movement- Normal Pain-
Stiffness).
- 13 -
• Hygiene of the scalp:- (Clean - Unclean).
• Fontanels:
• Anterior Fontanel :( Close -Open - Pulsation - Depressed)
• Posterior fontanel: (Close - Open - Pulsation - Depressed)
5- Eyes :
• Placement and alignment :- ( Symmetric-Asymmetric-Abnormal inner-
canthel distance)
• Lids :-( Symmetric - Asymmetric - Discharge - Redness - swollen -
Inability to completely close eye - Mal-Position of lids)
• Conjunctiva:- (Redness- Swollen- Discharge- Normal -Itching - Tearing)
• Sclera :- (White - Yellow staining)
• Pupils:- (React to light- not reacts to light-Dilated)
6- Ears
• Pinna: (At the Level of the eye - Low Set Ears)
• Discharge: (Odor, Color, Waxy discharge)
• Hygiene: (Clean – Unclean)
7- Nostrils:
• (Symmetric - Asymmetric - Patent - Discharge -inflammation -
Hemorrhage -Flaring of alae nasi)
8- Mouth and throat:
• Lips: - (Cyanosis - Pallor- Normal -Creaks - Cleft lip).
• Mucous membrane: (Moist - Smooth - Dry - Bleeding - Ulceration -
pigmented - Koplik's spots).
• Teeth: (Number ( ) - Loss - Caries).
• Tongue: (Rough-texture - Fissuring -Tongue tie - Coated)
• Palate: (Intact - Slightly arched - Cleft palate - red - swollen)
• Tonsils and oropharenx: (Inflammation - Normal -Covered with gray
membrane)
9- Neck
• Flexible - Limited motion- Stiffness- Venous enlargement- Clean - Unclean)
10- Chest:
• Shape: (Pigeon shape- Funnel chest - Symmetry - asymmetry-
rachitic rosary).
11 -Lungs
• (Symmetric vibration - asymmetry vibration - Right lobe resonance-
Left lobe dullness - Normal breath and voice sounds- abnormal breath
and voice sounds)
- 14 -
12- Heart
• (Symmetric chest wall – Asymmetric chest wall – Normal point of maximum
impulse – Abnormal point of maximum impulse – Normal heart sounds –
Abnormal heart sounds – Tachycardia – Bradycardia).
13- Abdomen
• Symmetry of Abdomen contour - Flabby - Concave - Scars -Distended veins -
Visible peristalsis - Normal peristaltic movements)
• Umbilicus: (Hernia – Normal -discharge)
• Hygiene: (clean- unclean)
14- Genitalia
a- Male:
• Glands: (Swelling - Skin lesion -Normal - Inflammation)
• Urethra meats : (Central - Hypospaidias -Epispadias-
Circumcision)
• Scrotum: (Wrinkled - Inflammation - Hydrocyle)
• Testes: (Present two testes - present one testis -absent testes)
b- Female:
• Labia majora and minora: (Normal - abnormal urethral moats')
• Vaginal opening : (Discharge - lesions – Normal - Inflammation)
15- Anal region
• (Fissure-tears in mucosa - Bleeding - Firmness- Rash - pin worms)
16- Back and extremities
• Spine: (Symmetric of spine-lourdoses-Sclerosis-discoloration-
Swelling- tenderness)
• Extremities:
• Upper: (Symmetric - Normal size - Deformities -Warm - Cool -
Tenderness- Limited mobility)
• Lower:- ( Symmetric - Normal size - Deformities -Warm -Cool -
Tenderness- Limited mobility - normal gait - Bowleg -Knock-knee)
17- Neurology
 Infant: ( Roll over- Sits - Stand – walk)
 Present reflexes according to he/she age:
1)
2)
3)
4)
5)
6)
- 15 -
Nursing Record
• Patient's name:- Age: Sex:
• Room No: Bed No: Hospital No:
• Date of admission: Wt. On admission:
• Diagnosis:
• Date:
• Activity allowed:
• Activity observed:
• Diet:
Time Items Nursing remarks
Vital signs
Temp: Pulse:
Resp: Bl.p:
Growth & Development:
Wt. Ht Teeth no.
Sitting - standing - Walking Bladder
control - Bowel control Language
appropriate to age
Bath care:
Bed bath- partial bath
Tub bath- shower:
Stool
frequency:
Amount:
Color:
Consistency:
Abnormal content:
Intake:
Kind:
Amount:
Output
Kind:
Amount:
- 16 -
Medications:
Treatment :
 Compresses:
 O2 therapy:
 Dressing:
 Others:
Nursing care:
- 17 -
Health education sheet
Patient's name: Age:

Diagnosis
Topic Item Health teaching
- 18 -
- 19 -
Nursing care plan

Diagnosis
Nursing Patient
Intervention Evaluation
Diagnosis goal
- 20 -
Nursing Patient
Diagnosis goal
- 21 -
Nursing Patient
Diagnosis goal
- 22 -
( Surgical Unit )
- 23 -
Assessment sheet (Surgical Unit)
Child history:-
3- Nutrition:
 B.C.G.
 Measles
 Booster dose
 MMR

- 24 -
a) Face:
b) Posture (Position): (Well Balanced - Straight).
2- Skin:
a) Hair:
b) Nails
c) Lymph nodes:
4- Head:
Stiffness).
- 25 -
• Fontanels:
5- Eyes :
canthel distance)
6- Ears
7- Nostrils:
membrane)
9- Neck
10- Chest:
rachitic rosary).
11 -Lungs
and voice sounds)
- 26 -
12- Heart
13- Abdomen
14- Genitalia
a- Male:
Circumcision)
b- Female:
15- Anal region
• Extremities:
17- Neurology
1)
2)
3)
4)
5)
6)
- 27 -
Nursing Record
• Diagnosis:
• Date:
• Diet:
Vital signs
Temp: Pulse:
Resp: Bl.p:
Wt. Ht Teeth no.
appropriate to age
Bath care:
Tub bath- shower:
Stool
frequency:
Amount:
Color:
Consistency:
Abnormal content:
Intake:
Kind:
Amount:
Output
Kind:
Amount:
- 28 -
Medications:
Treatment :
 Compresses:
 O2 therapy:
 Dressing:
 Others:
Nursing care:
- 29 -

Diagnosis
- 30 -
- 31 -
Nursing care plan

Diagnosis
Nursing Patient
Diagnosis goal
- 32 -
Nursing Patient
Diagnosis goal
- 33 -
Nursing Patient
Diagnosis goal
- 34 -
( Re-hydration Unit )
- 35 -
Assessment sheet (Re-hydration Unit)
Child history:-
3- Nutrition:
 B.C.G.
 Measles
 Booster dose
 MMR

- 36 -
a) Face:
b) Posture (Position): (Well Balanced - Straight).
2- Skin:
a) Hair:
b) Nails
c) Lymph nodes:
4- Head:
Stiffness).
- 37 -
• Fontanels:
5- Eyes :
canthel distance)
6- Ears
7- Nostrils:
membrane)
9- Neck
10- Chest:
rachitic rosary).
11 -Lungs
and voice sounds)
- 38 -
12- Heart
13- Abdomen
14- Genitalia
a- Male:
Circumcision)
b- Female:
15- Anal region
• Extremities:
17- Neurology
1)
2)
3)
4)
5)
6)
- 39 -
Assessment of the degree of Dehydration
History of illness:
1) Usual stool frequency:
2) Current stool frequency:
3) Stool consistency:
 Looser but usual frequency.
 Looser and more frequent.
 Watery.
4) Duration of diarrhea:-
 More than 4 days.
 More than 14 days.
5) Stool appearance:-
 Bloody & watery stool.
 Bloody & loose, bulky & foul smiling stool
6) Urination:-
 Oliguria
 Anuria for more then 6 hours
7) Vomiting:
 More than 4 time per hour
 Coffee appearance
8) Weight on admission: kg
9) Weight Before discharge kg
10)Previous treatment:
11) Exanimations:-
 Alert & interested in his surrounding.
 Alert but irritable
 Lethargic or may appear unconscious
- 40 -
2- Eyes:
 Normal
 Sunken
 Very Sunken
3- Presence of tears:
 Present
 Absent
4- Mouth & tongue:-
 Moist
 Dry
5- How thirsty the child's is ? (the child's response when offered
water)
The child drinks:-
 Normally
 Eagerly
 Poorly or unable to drink
6- Skin pinch (skin turgor):
 The skin return to normal rapidly where pinching
 The skin return to normal slowly where pinching
 The skin return to normal very slowly where pinching
(More than 2 seconds )
- 41 -
The degree of dehydration is:
No dehydration
Some dehydration
Severe dehydration
Management plan:
Plan: A
Plan: B
Plan: C
- 42 -
Nursing Record
• Diagnosis:
• Date:
• Diet:
Vital signs
Temp: Pulse:
Resp: Bl.p:
Wt. Ht Teeth no.
appropriate to age
Bath care:
Tub bath- shower:
Stool
frequency:
Amount:
Color:
Consistency:
Abnormal content:
Intake:
Kind:
Amount:
Output
Kind:
Amount:
- 43 -
Medications:
Treatment :
 Compresses:
 O2 therapy:
 Dressing:
 Others:
Nursing care:
- 44 -

Diagnosis
- 45 -
- 46 -
Nursing care plan

Diagnosis
Nursing Patient
Diagnosis goal
- 47 -
Nursing Patient
Diagnosis goal
- 48 -
Nursing Patient
Diagnosis goal
- 49 -
( Premature Unit )
- 50 -
Assessment sheet (Preterm Infant)
Student's Name: Date:
Infant's Name: Age :
Gestational age at birth:
Diagnosis:
General measurements
Head circumference cm
Chest circumference cm
Weight: kg.
Length cm
Physiological measurements:
Temperature C˚
Pulse b/m
Respiration c/m
General appearance
 Posture: (flexion of the head and extremities-Extension of the
extremities -Extended legs -Rotated thigh -Extended neck)
 Skin (pink - Bright red - Smooth - Dry -Vernix Caseosa - Ecchymosed -
Milia - Lanugo hair - Errythema - Mongolian - Spots - Acrocanosis -
edema )
 Head (molding-caputsucccdaneum- cephaihematoma)
-Anterior fontanel:-chap: (open-close-plugging-depressed)
- Posterior fontanel:-chap: (open -close(
 Eyes (open - closed - absence of tears - blinking reflex - ability to follow
midline objects - inability to follow objects - discharge)
 Ears (pinna at the level of the eye - low set ear)
 Nose (Nasal patent - Sneezing - flaring - Discharges)
 Mouth (intact - cleft lips - cleft palate - absent or minimal salivation -
Natal teeth)
 Neck (short-Thick-Excessive folds-persistence to flexion)
 Chest shape (symmetry -asymmetry)
(anteroposterior and lateral diameter equal - slight sternal retraction pigeon
chest- breast enlargement )
- 51 -
 Lung (normal respiration -abnormal respiration -bilateral equal bronchial
breath sounds-retraction -periodic irregular breathing-wheezing)
 Heart (normal heart sounds-abnormal heart sounds )
 Abdomen (Distention - cylindrical - umbilical hernia - absent of bowel
sounds - enlarges liver- enlarged spleen-ascites -inflammation of the cord
stump-equal femoral pulses- absent femoral pulses)
 Female genitalia (swelling labia mijora- swelling labia minora -swelling
clitoris- absent of vaginal opening -mass hi labia- fecal discharge from
the vagina)
 Male genitalia (urethral opening at the tip of glans of the penis-
epispadies -hypospadies -tests palpable in the scrotum-undescended
tests- hydrocele-mass in the scrotum)
 Rectum and anus (passage of meconium -anal fissure- imperforated
anus)
 Back (spin intact -opening- mass- prominence curves - spinal bifida)
 Extremities (symmetry- asymmetry -nails pink -cyanosis of nails-
negative scarf signs- full range of motion -sole covers with creases -no
creases-hip dislocation )
Reflexes present Weak absent
Blinking reflex
Papillary reflex
Grasping reflex
Sucking reflex
Swallowing reflex
Rooting reflex
Gaging reflex
Tonic neck reflex
Moro reflex
Starter reflex
- 52 -

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Faculty of Nursing Assiut University

Pediatric Nursing Department

Well child Report

Name of the school :

Staff member Name :

2- Compare the level of growth and development of this child

4- How is the nursery school helping or failing to meet this

 Length or height cm – Weight kg

Patient's name: Age:

Topic Item Health teaching

Patient's name: Age:

 Length or height cm – Weight kg

Patient's name: Age:

Topic Item Health teaching

Patient's name: Age:

 Length or height cm – Weight kg

Patient's name: Age:

Topic Item Health teaching

Patient's name: Age:

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