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ARELLANO UNIVERSITY

COLLEGE OF NURSING

Assessment
In
School-Aged
Child
(3rd year- block 5)

SUBMITTED BY:
DEL ROSARIO, Shiera Marie
MARIANO, Wendel Mark
RAHMAN, Sarah Silvia
SAMSON, Joel
VIAJE, Samantha

SUBMITTED TO:
Dra. Anna Katharina Peña

ASSESSMENT TOOL

1
(SCHOOLER)

GUIDE FOR ASSESSING THE SCHOOLER

Client’s Name: Gabriel Villanueva Age: 10 years old Sex: Male


Date of Birth: March 21, 2000 Place of Birth: Philippine General Hospital
Father’s Name: Joel Villanueva Age: 46
Occupation: Seaman Place of Work:
Mother’s Name: Helen Villanueva Age: 44
Occupation: Housewife

I. PERSONAL HISTORY:
A. FAMILY HISTORY- Family tree

Villanueva
Family

Joel Helen
Villanueva Villanueva
46 yrs. old 44 yrs. old

Bryan Jynine Gabriel


Villanueva Villanueva Villanueva
22 yrs. old 20 yrs. old 10 yrs. old

B. BIRTH/HEALTH HISTORY-
2
: The child is fully immunized.
: Had mumps and chicken fox at 6 years old.
: No history of previous hospitalization and accidental injuries.

II. AREAS OF Growth & Development:


1. PHYSICAL

FINDINGS NORMS INTERPRETATION


A. Measurement
1. Weight 26 kg 34kg The child is
2. Height 4 ft & 5 in. 4ft & 3 in. underweight.

B. Vital Signs
1. Temp. 36.5 °C 36.5 - 37.5 C The child’s vital sign
2. PR 74 bpm 70 – 100 bpm is within the normal
3. RR 25 cpm 20 – 30 cpm range.
4. BP 90/60 mmHg 100/70 mmHg

C. Head-to- Toe Physical Assessment:

BODY PARTS FINDINGS NORMS INTERPRETATION

SKIN Skin color is brown, Uniform color, light The child’s skin is
no allergies and skin brown color and no normal.
returns back quickly allergies noted and
when pinched. warm to touch

HAIR Hair is evenly Thick and evenly Hair distribution is


distributed. distributed. normal.
EYES Eye brows are No edema or The Child’s eyes are
symmetrical, sclera hollowness, color of within the normal
appears white. Pupil the pupil is brown findings.
equally round and her eye lashes
reactive to light and curled outward, her
accomodation. eyebrows are aligned
and it’s symmetrical.

EARS Auricle color is same Ears are The Child’s ears are
as facial skin color. symmetrically within the normal

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Ears are aligned; align with findings.
symmetrically outer cantus of the
aligned. eye.
MOUTH Lips are color pink, Lips are color pink, The child’s mouth is
pink gums, white Gums are slightly pink within the normal
teeth and tounge and her tongue is findings.
move freely. pinkish and no
infection or no
infection and
tonsillitis noted.

NECK No enlargements of Neck is aligned and The Child’s neck is


lympnodes are same color as facial. within the normal
palpated. findings.
THORAX Spine vertically Chest symmetric The Child’s thorax is
aligned. Fully and Spine vertically within the normal
symmetric chest aligned findings.
expansion. Shoulder and Hips are
at the same height.

Extremities (Lower) Equal in size both Equal in size both Both extremities are
sides of the body, no sides of the body, no within the normal
deformities, no deformities, no findings.
contracturs, or contracturs, or
swelling. swelling. With range
Joints are smoothly of motion within
movable. Elbows are normal limits. Joints
symmetrical. are smoothly
moveable and are
easy and has strength
felt on grasp. Elbows
are symmetrical and
movement done with
ease.

Extremities (Upper) Equal in size both Equal in size both


sides of the body, no sides of the body, no
deformities, no deformities, no
contracturs, or contracturs, or
swelling. swelling. With range
Joints are smoothly of motion within
movable. normal limits. Joints
are smoothly

4
moveable and are
easy and has strength
felt on grasp. Elbows
are symmetrical and
movement done with
ease.

D. PHYSIOLOGIC CHANGES

PHYSICAL CHANGES AGE WHEN NORMS INTERPRETATION


OCCURED
FOR BOYS:
1. Increase in Puberty onwards Physical changes
size of occur in puberty age
genitalia because of the
2. Swelling of action of the
the breast hormones released
3. Growth of by that age. Such as
pubic hair testosterone as the
4. Growth of male homone.
axillary hair
5. Growth of
facial hair
6. Growth of
chest hair
7. Voice
changes
8. Nocturnal
emissions
9. Release of
seminal fluid

3. Emotional – Development tasks according to Eric Erickson

5
Central task (+) resolution (-) resolution
Industry vs. inferiority Learns to create, manipulate Loss of hope, sense of being
and develop. mediocre.

Develop sense of competence Withdrawal from school and


and perseverance. peers.

 The child is active physically and verbally, able to make friends and have a lot of
friends in the community.
 The child is receiving an average grades ranging from 77 to 80.
 He is not participating in any extra curricular activities.
 The parent’s states that their son’s teacher does not have any problem with the
child.
 The parent’s states that the child has no special problem.
 The child considers a ghost as his greatest fear.

4. Social – Relations with family, teachers, playmates, schoolmates,


others.
 The child doesn’t belong in any school activities.
 The child usually plays playing cards and computer games on its vacant time.
 The child doesn’t have any play materials appropriate for its age.
 The child is not interested with any play activities.
 The child is allowed to pursue its interest, such as letting it play computer
games.

5. Cognitive – level of development according to Piaget.

Phase Age Description


Concrete operations 7-11 Learns to reason about events
in the here-and-now.

 The child attends to school regularly, and has a perect attendace. Shows interest in
other subjects.
 The child’s concept about life is that “life is hard”.
 The child doesn’t fear death.

6. Language skills

6
 The child is able to communicate with other people.
 Can understand verbal instructions.
 Speaks clearly.

7. Spiritual- Level of development according to Fowler

Stage Characteristics
Mythical- literal Accepts existence of a deity.
Religious and moral beliefs are symbolized by
stories.
Appreciate others’ viewpoints.

8. Moral – Level of Development according to Kohlberg

Level and Stage Description


Level III: Conventional Cordial interpersonal relationships are
mentained. Approval of others is sought
through one’s action.
Stage 3: Interpersonal concordance Authority is respected

Stage 4: Law and order orientation Individual feels “duty bound” to maintain
social order.

Behavior is “right” when it conforms to the


rules.

 The child is being scolded by its parents whenever it commits mistake as a form of
discipline.

9. Body Image / Self – concept

 The child doesn’t have any physical defects or malformities.


 The child verbalize a need of privacy when taking a bath or changing its clothes.

IV Neurological Assessment

7
1. Mental Status – Level of Consciousness

 The child is alert and responsive

2. Intellectual Functions - memory

 Knowledge
 Abstract thinking
 Association
 judgement

3. Cerebellar functions – coordination and balance

 The child has no problem with its body’s coordination and balance, he is able to perform
the heel to toe walking test and other coordination and balance test.

4. Deep tendon reflex

Scores:
0
+ 1 minimal
+ 2 Normal
+ 3 more active
+ 4 maximal

Findings Body reflexes


+2 Tricepts reflex
+2 Brachioradialis reflex
+2 Tricepts reflex
+2 Patellar reflex
+2 Achilles reflex
+2 Plantar reflex

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