Pediatric Health Nursing- Clinical (Pediatric Ward Assessment Sheet)

(Pediatric Ward Assessment Sheet)

Case Study

Student's Name:

Date:

Dr. Atyat Mohammed Hassan Page 1

 Pediatric Health Nursing- Clinical (Pediatric Ward Assessment Sheet)

1- Personal data:
Child Name: Date of birth: / /
Age: Sex:
Diagnosis:
Date of admission:
Date of discharge:

1- 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
Type of growth Growth and development development of the
and development of the current child same age from the text
book
Physical growth:

Physiological growth:

Dr. Atyat Mohammed Hassan Page 2

 Pediatric Health Nursing- Clinical (Pediatric Ward Assessment Sheet)

Growth and
Type of growth Growth and development development of the
and development of the current child same age from the text
book
Motor Development:

Growth and
Type of growth Growth and development development of the
and development of the current child same age from the text
book
Social Development:

Dr. Atyat Mohammed Hassan Page 3

 Pediatric Health Nursing- Clinical (Pediatric Ward Assessment Sheet)

Growth and
Type of growth Growth and development development of the
and development of the current child same age from the text
book
Intellectual
Development:

The same age from the

Items The current child
text book
Investigations:

Dr. Atyat Mohammed Hassan Page 4

 Pediatric Health Nursing- Clinical (Pediatric Ward Assessment Sheet)

Treatment:

Items The current child The same age from the

text book
Clinical
manifestations:

Dr. Atyat Mohammed Hassan Page 5

Pediatric Health Nursing- Clinical (Pediatric Ward Assessment Sheet)

Assessment sheet (Pediatric Ward)

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

Dr. Atyat Mohammed Hassan Page 6

Pediatric Health Nursing- Clinical (Pediatric Ward Assessment Sheet)

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).

Dr. Atyat Mohammed Hassan Page 7

Pediatric Health Nursing- Clinical (Pediatric Ward Assessment Sheet)

• 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 oropharynx: (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)

Dr. Atyat Mohammed Hassan Page 8

Pediatric Health Nursing- Clinical (Pediatric Ward Assessment Sheet)

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 - Hypospadias -Epispadias-
Circumcision)
• Scrotum: (Wrinkled - Inflammation - Hydrocele)
• 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)

Dr. Atyat Mohammed Hassan Page 9

Pediatric Health Nursing- Clinical (Pediatric Ward Assessment Sheet)

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:

Dr. Atyat Mohammed Hassan Page 10

Pediatric Health Nursing- Clinical (Pediatric Ward Assessment Sheet)

Time Items Nursing remarks

Medications:

Treatment :
 Compresses:
 O2 therapy:
 Dressing:
 Others:
Nursing care:

Dr. Atyat Mohammed Hassan Page 11

Pediatric Health Nursing- Clinical (Pediatric Ward Assessment Sheet)

Health education sheet

Patient's name: Age:

Diagnosis

Topic Item Health teaching

Dr. Atyat Mohammed Hassan Page 12

Pediatric Health Nursing- Clinical (Pediatric Ward Assessment Sheet)

Nursing care plan

Patient's name: Age:

Diagnosis

Nursing Patient
Intervention Evaluation
Diagnosis goal

Dr. Atyat Mohammed Hassan Page 13

Pediatric Health Nursing- Clinical (Pediatric Ward Assessment Sheet)

2- Describe the child's and family's reactions to disease and

hospitalization:
a) Child's reactions to disease and hospitalization:

b) Family's reactions to disease and hospitalization:

3- Describe the available community facilities that help the

family on child's care:

4- List recommendations for any changes or addition in

nursing care of the child:

5- Describe your own feeling and attitude towards caring of

this child:

6- References:

Dr. Atyat Mohammed Hassan Page 14