HEALTH HISTORY AND PHYSICAL ASSESSMENT

BIOGRAPHIC DATA

a. Child’s name:

b. Parent’s name
Mother:
Father:

c. Address:

d. Contact Number

Mother:

Father:

e. Age of child:

f. Sex:

g. Culture:

h. Ethnicity:

i. Date of birth:

j. Place of birth:

k. Religion:

l. Medical Diagnosis / admitting Diagnosis/ Doctors Impressions:

m. Date of Admission:

n. Pediatrician/ Physician:

o. Health Insurance:

p. Source of Referral:

q. Source of Information (indicate the percentage)

Client:

Relative, specify the relationship with client:

Friend:

Medical Records:

Referral:

Others, specify:
Chief complaint (establish the major specific reason for the child’s and parents’ professional health
attention.)

a. Reason for seeking care

b. Record in the words of the informant, parent and child

- Patient's or parent's own brief account of the complaint and its duration. Use the words of the
informant whenever possible.

History of Present Illness

P: What provokes symptoms? What improves or exacerbates the condition? What were you doing
when it started? Does position or activity make it worse?

Q: Quality and Quantity of symptoms: Is it dull, sharp, constant, intermittent, throbbing, pulsating,
aching, tearing or stabbing?

R: Radiation or Region of symptoms: Does the pain travel, or is it only in one location? Has it always
been in the same area, or did it start somewhere else?

S: Severity of symptoms or rating on a pain scale. Does it affect activities of daily living such as
walking, sitting, eating, or sleeping?

T: Time or how long have they had the symptoms. Is it worse after eating, changes in weather, or
time of day?

P: Unsay hinungdan sa mga sintomas? Unsa nga mga butang ang nakatabang o nakapalala sa
kahimtang? Unsa ang imong gibuhat sa panahon nga nagsugod kini? Nalala ug nanghingusog ba kini
tungod sa posisyon o aktibidad?

Q: Kalidad ug Kantidad sa mga sintomas: Mao ba kini'y bug-at, tingog nga kutob, nagkadaiyang,
nagapalihok sa usa ka tunga-tunga, nagapulsar, nagalugnaw, nagasakit, nagatagak o nagadungog?

R: Pagbanaag o Rehiyon sa mga sintomas: Nagalakip ba ang kasakit, o nahimong usa ka dapit
lamang? Kanus-a pa kini nagsugod sa pareho nga dapit, o nagsugod kini sa lain nga dapit?

S: Kagrabe sa mga sintomas o pag-rating sa usa ka skala sa kasakit. Naapektuhan ba kini ang mga
aktibidad sa adlaw-adlaw nga pagpuyo sama sa paglakaw, paglingkod, pagsakaon, o pagkatulog?

T: Panahon o pila na ka dugay nagpakita ang mga sintomas. Mas grabe ba kini human sa pagkaon,
pagbag-o sa panahon, o panahon sa adlaw?
 Past History – ask the mother about her pregnancy and the delivery of the child (newborn and
infant)

Birth History – prenatal influences have significant effects on a child’s physical and emotional
development (newborn and infant)

1. Prenatal

a. Pregnancy (concerning the mother’s health during pregnancy)

• General Health

• Prenatal diseases or conditions (e.g. gestational diabetes, cardiac or kidney disease)

• Access to prenatal care

• Number of pregnancies

• Use of prescribed or over-the-counter medications, tobacco, alcohol, illegal drugs

A. Antenatal: Health of mother during pregnancy. Medical supervision, drugs, diet, infections
such as rubella, etc., other illnesses, vomiting, toxemia, other complications; Rh typing and serology,
pelvimetry, medications, x-ray procedure, maternal bleeding, mother's previous pregnancy history.

2. Labor and delivery

a. Nature of labor and delivery: duration of pregnancy and labor, type of anesthesia, type of
delivery and complications

b. Obstetric history (GP, TPAL)

c. Crisis during pregnancy

d. Prenatal attitude toward fetus

B. Natal: Duration of pregnancy, birth weight, kind and duration of labor, type of delivery,
presentation, sedation and anesthesia (if known), state of infant at birth, resuscitation required, onset
of respiration, first cry.

3. Perinatal History (infant’s condition immediately after birth)

a. Wt and Ht at birth

b. Loss of wt following birth and time of regaining birth wt

c. APGAR score, level of activity

d. Problem if any (birth injury, congenital anomalies)

C. Neonatal: APGAR score; color, cyanosis, pallor, jaundice, cry, twitchings, excessive mucus,
paralysis, convulsions, fever, hemorrhage, congenital abnormalities, birth injury. Difficulty in sucking,
rashes, excessive weight loss, feeding difficulties. You might discover a problem area by asking if baby
went home from hospital with his mother.

4. Feeding History

a. Breast or Formula: Type, duration, major formula changes, time of weaning, difficulties. Be
specific about how much milk or formula the baby receives. How does caretaker mix the
formula?

b. Vitamin Supplements: Type, when started, amount, duration.

c. "Solid" Foods: When introduced, how taken, types.

d. Appetite: Food likes and dislikes idiosyncrasies or allergies, reaction of child to eating. An idea of
child's usual daily intake is important.

e. Eating habits

2. Past medical history: including all diagnoses, infections, Accidents and Injuries (include
ingestions): Age, type/nature, severity, sequelae. (Toddler, Preschooler, School Age and
Adolescence)

3. Past Hospitalizations: including operations, age. Include place of hospitalization and duration
of hospitalization.

4. Past Surgeries: where and by whom for what diagnosis

5. Allergies, with specific attention to drug allergies: detail type of reaction. Results of allergy
testing gif performed.
6. Medications patient is currently taking- prescribed, OTC, homeopathic. Include dose,
formulation, route and frequency.

7. Immunizations – all immunizations and “boosters” are listed, stating

(name of the specific disease, number of injections, dosage, ages when administered, and
occurrence of any reaction following the immunization)

IMUNIZATION SCHEDULE

1. Hepatitis B (HepB) 6. Rotavirus (RV

- shortly after birth
- 3 doses (4 wks interval) - 2, 4, 6 mos of age
2. DTaP (Diphtheria, Tetanus, Pertussis)
7. MMR (Measles, Mumps, Rubella)
- 2, 4, & 6 mos of age
- booster (15-18 mos + 4-6 y/o) - 12-15 mar 2nd dose 4-6 y/o
3. Hib (Haemophilus influenzae type b)
- 2, 4, and 6 mos of age 8. Varicella (VAR) Chickenpox
- booster (12-15 mos of age)
- 12-15 mos of age, 2nd dose 4-6 y/o
4. Polio (IPV)
9. BCG (Bacillus Calmette-Guérin)
- 2,4, + 6-18 mos of age.
- booster (4-6 y/o) - within the first 24 hours of life or
soon after birth
5. PCV13 (Pneumococcal conjugate
vaccine) 10. Hepatitis A (HepA)

- 2, 4, 6 mos of age + 12-15 mos - 12-23 mos of age, 2nd dose

- 6-18 mos later
8. Growth and Development

 Motor and Mental Development First raised head, rolled over, sat alone, pulled up, walked with
help, walked alone, talked (meaningful words; sentences), formal screening when appropriate.

 Approximate weight at 6 months, 1 year, 2 years, and 5 years of age.

 Approximate length at ages 1 and 4 years

 Dentition, including age of onset, number of teeth, and symptoms during teething

 Urinary continence during night; during day

 Control of feces.

 Comparison of development with that of siblings and parents.

 School grade, quality of work.

 Developmental milestone includes:

Age of holding up head steadily:

Age of sitting alone without support:

Age of walking without assistance:

Age of saying first words with meaning:

Present grade in school:

Scholastic performance:

If the child has bestfriend:

Interactions with other children, peers, and adults:

 Physical Growth including menarche and other pubertal developments

 Behavioral History

 Does child manifest any unusual behavior such as thumb sucking, excessive masturbation,
severe and frequent temper tantrums, negativism, etc.?
  Sleep disturbances.

 Phobias.

 Pica (ingestions of substances other than food)

 Abnormal bowel habits, ex. - stool holding.

 Bed wetting (applicable only to child out of diapers).

9. Habits – (child’s habits, activities or development)

1. Behavior patterns such as nail biting, thumb sucking, pica, rituals, and unusual movements (head
banging, rocking, overt masturbation, walking on toes)

2. Activities of daily living, such as hour of sleep and arising, duration of nighttime sleep and naps,
type and duration of exercise, regularity of stools and urination, age of toilet training, and daytime or
nighttime bed-wetting

3. Unusual disposition; response to frustration

4. Use or abuse of alcohol, drugs, coffee or tobacco

10. Sexual History – essential component of adolescents’ health assessment, alerts the nurse to
circumstances that may indicate screening for sexually transmitted infections or testing for pregnancy.

Physical Assessment

GENERAL SURVEY

VITAL SIGNS

- Blood Pressure (older than 3 years old):

- Temperature:
- Pulse Rate:
- Respiratory Rate:
- Growth Measurements: Infants

Head circumference:

Chest Circumference:

c. Abdominal circumference:
d. Length:

e. Weight:

GENERAL APPEARANCE

- Does the child appear well or ill overall?
- Is the child’s height and weight
proportional?
- Does the child appear well nourished?
- What is the child’s color?
- Is posture normal?
- What is the child’s hygiene level?
- Are lesions or symptoms of a specific
illness present?
- Are there any significant body odors?
- Does the child appear relaxed or
distressed? Lethargic or distressed?
- Is breathing easy or distressed?

FINDINGS:

MENTAL STATUS

- LOC
- Child’s alertness
- Orientation
- Awareness of person, place and time
- Appropriateness of behavior and mood
- Recent / remote memory

FINDINGS:

INTEGUMENTARY SYSTEM

1. Skin

- Color - Rashes, petechiae, desquamation,

- Edema pigmentation, jaundice, texture, turgor
- Turgor - Lymph node enlargement, location,
- Temperature mobility, consistency
- Moisture - Scars or injuries, especially in patterns
- Birthmarks - nevi, hemangiomas, suggestive of abuse
mongolian spots etc

FINDINGS:
2. Hair

- color - Infestation
- distribution - Quality
- Texture - Characteristics

FINDINGS:

3. Nails

- Color - Texture
- Shape - Capillary refill

FINDINGS:

HEAD AND FACE

1. Size, Shape and symmetry

Check the face for symmetry

2. Measure head circumference

3. Infancy

- Examine anterior fontanel (size and the - Scalp and hair

tensions) - Infant should be able to hold head
- Sutures (overriding) erectly by 4 months of age.

FINDINGS:

EYES

1. General

Strabismus, Slant of palpebral fissures,

Hypertelorism or telecanthus

2. Inspect external eye (color of sclera, conjunctiva, eyebrows and eyelashes)

3. Visual acuity in each eye

Snellen chart for school age

Snellen symbol chart (E chart) or Faye Symbol chart (pictures) for preschool age

4. Assess for symmetric gaze (for young and old children)

5. EOM

6. Assess the pupils

7. Red reflex

FINDINGS:

EARS

1. External structures

2. Check position, shape features and alignment

3. Examine ear canal and ear drum (early childhood)

4. Check tympanic membrane

5. Test the hearing acuity

a. Tested in infants by noting reaction to loud noise/ bell

b. Older children may be tested with whispered voice

FINDINGS:

NOSE AND SINUSES

1. External structures

a. Deviation in shape, size, color and nasal flaring

2. Push up tip of nose and shine light into each nostril

3. Note structure, patency of nares, discharge and tenderness

4. Percuss and palpate sinuses of children over age 3

FINDINGS:

MOUTH AND THROAT (EXAMINE LAST IN YOUNG CHILDREN)

1. Examine lips (colors, fissures) , mucosa (color, vesicle, moist or dry), gums, tongue (color,
papillae, position and tremors), palate (intact, arch)

2. Examine the teeth for timing and sequence of eruption, number and position

3. Note the size, position, symmetry, and appearance of the tonsils

4. Check gag reflex (Use tongue blades during examination)

FINDINGS:

NECK

1. Assess and palpate the trachea position and thyroid glands

2. Palpate the lymphnodes (size, mobility, swelling, temperature, and tenderness)

3. Palpate submaxillary, sublingual, and parotid glands

4. Determine mobility of neck (presence or absence of nuchal rigidity)

5. Assess for any additional masses (cyst and nodes)

FINDINGS:

RESPIRATORY

A. Inspection

Carefully assess respirations for rate, depth (shallow or deep), quality (effortless, difficult, or labored)
and rhythm (regular and irregular)

Evaluate breath sounds for noise, grunting, snoring, use of accessory muscles

Chest wall configuration

Nasal component of breathing (enlargement of both nasal openings during inspiration)

Palpate back or chest for respiratory movement and fremitus

Percuss lungs
Begin with anterior lung from apex to base with child lying or sitting

Auscultate lungs

Equality of breath sounds

Rales, wheezes, rhonchi

Upper airway noise

FINDINGS:

CARDIOVASCULAR

Inspect and palpate the precordium for heaves and apical impulse

Check pulse rate, symmetry and rhythm amplitude (apical pulse at 4th ICS until age 7; apical pulse at 5th
after age 7). Check both upper and lower.

Auscultate heart sounds

Rate rhythm

Evaluate for any presence or murmurs

Quality of heart sounds

FINDINGS:

PERIPHERAL AND LYMPHATIC SYSTEM

Location, size, sensitivity, mobility, consistency. One should routinely attempt to palpate occipital,
preauricular, anterior cervical, posterior cervical, sub mandibular, submental, axillary, epitrochlear, and
inguinal lymph nodes.

FINDINGS:

BREAST

Inspect size, shape and symmetry and palpate the areola nipple and axillary lymphnodes

FINDINGS:

GASTROINTESTINAL/ABDOMEN
Inspect the contour of the abdomen

Abdomen is prominent when standing and supine in infants and children

After age 4, abdomen is prominent when standing but flat when supine

Umbilicus should be pink without redness or discharge

Auscultate bowel sounds same as adult

Percussion

Palpate for masses or tenderness

Tenderness - avoid tender area until end of exam

Liver, spleen, kidneys

May be palpable in normal newborn

Rebound, guarding

Have child blow up belly to touch your hand

FINDINGS:

GENITOURINARY

Male

- Inspect hair, penis and location of urinary meatus

o (Size, Placement, Contour, Skin integrity,Appearance,Inflammation, discharges and
presence of pain upon urination)

- Inspect the symmetry and palpate scrotum and testes to determine if both are descended
- Check urine for frequency, amount, color, and characteristics
- Check stool for frequency, color, characteristics, (diarrhea; check the amount) and difficulty

FINDINGS:

MUSCULOSKELETAL

Assess spine and posture (sacral dimple, kyphosis, lordosis and scoliosis)

Inspect neck, extremities, hips and spine for symmetry, increased or decreased mobility and anatomical
defects

Assess gait, joints, and muscles

Test muscle strength

Ask the child to touch the toes, rise from sitting, run a short distance, and pick up objects then observe
carefully

FINDINGS:
 NEUROLOGIC (ASSESS CHILD OVER 2 YEARS THE SAME AS ADULT)

- Level of responsiveness (arousal and awareness) – if there will be head trauma

o Eye opening
o Verbal responses
o Motor responses
o Examine head for signs of trauma; mouth, nose, and ears for evidence of blood and CSF
- Test balance, coordination and accuracy of movements
- Sensory function
- Assess level of consciousness, behavior and speech (below 2 years old)

FINDINGS:

DEVELOPMENTAL THEORIES

a. Jean Piaget’s Stages of Cognitive Development

b. Erik Erikson’s stages of childhood – Developmental Task

c. Sigmund Freud’s stages of childhood – Psychosexual stage

d. Lawrence Kohlberg’s stages of Moral Development

Chronologic Gross Fine Personal and Language Skills Play

al Age Development Development Socialization
8 years old Normal and Normal and Normal and Expected Normal and Normal and
(school age) Expected Expected Behavior: Expected Expected
Behavior: Behavior: Behavior: Behavior:

Observable Observable Observable Behavior: Observable Observable

Behavior: Behavior: Behavior: Behavior:

Stage Expected Behavior Observed Data Nursing

Developmental Theories (based on Implication
the present
age)
8 year-old
Piaget’s Stages of Cognitive (school age)
Development

Erikson’s stages of
childhood

Freud’s stages of childhood

Kohlberg’s stages of Moral

Development
(Starting from preschooler
up to adolescent)