POST GRADUATE COLLEGE OF NURSING, HAYATABAD PESHAWAR

PEDIATRICS HISTORY TAKING

HISTORY Finding Nursing Nursing
TAKING diagnosis/ Intervention
Procedure Rational
1. 1PATIENT’S
1) Name
PROFILE
12) Age (Date of Birth)
3) Sex
14) Address of parents
15) Date of admission
2. PRESENTING
COMPLAINTS
(Use parents’ own words +
chronological order)
3. HISTORY OF
PRESENT ILLNESS
1) Enquire as to when patient
was last entirely well?
2) Presenting complaints
a) Time (onset , duration ,
frequency , course)
b) Place (site)
c) Quality (character e.g. of
pain , composition of vomitus)
d) Quantity (severity of pain ,
amount of vomitus)
e) Provocative / alleviative
factors / variations (diurnal or
seasonal)
f) Associated symptoms
g) Treatment if any
Systemic inquiry
4. a) General (weight loss ,
appetite)
b) CVS (shortness of breath on
exertion ,
shortness of breath and sweaty
on feeding, cyanotic spells,
squatting, fainting or syncope,
cyanosis, edema, chest
pain/palpitations)
Respiratory system (sore
5. throat, earache, cough, wheeze,
frequent chest
 infections, history of aspiration,
hemoptysis
Gastrointestinal system
6. (abdominal pain, vomiting,
jaundice,
diarrhea/constipation, blood in
stools)
CNS (fits, syncope/dizziness,
7. headache, visual problems,
numbness/unpleasant
sensations, weakness/frequent
falls, incontinence)
Genitourinary system (stream,
8. dysuria, frequency,
nocturia/enuresis,
incontinence, hematuria)
Rheumatological system
9. (limp, joint swelling, hair loss,
skin rash, dry
mouth/mouth ulcers, dry or sore
eyes, cold extremities)
10.BIRTH HISTORY
(Important in neonatal, genetic
or developmental case)
ANTENATAL HISTORY
(H/O PREGNANCY)
1) H & N status (Health and
nutritional status of mom during
pregnancy)
2) Illness during pregnancy
(HTN, DM, pre-eclampsia,
antepartum
haemorrhage)
3) Infections during
pregnancy (rubella, UTIs,
syphilis, T.B.)
4) Drugs (iron, multivitamin,
other drugs with dose, duration
and at
which time of gestation)
5) X-ray (h/o irradiation in 1st
trimester)
6) TT (maternal vaccination
against tetanus)
7) Past obstetric (problems
with previous pregnancies,
stillbirths,
miscarriages, birth weight of
previous children, prematurity,
blood
transfusions)
NATAL HISTORY (H/O
11. DELIVERY)
1) Place of delivery
(hospital/home)
 2) Conducted by (dai/trained
health visitor/doctor)
4) Gestation time (length)
5) Rupture time (time of
rupture of membranes)
6) Labour time (duration)
7) Presentation and type of
delivery (SVD, forceps,
vacuum extraction
or C-section)
8) Sedation/analgesics during
labour
9) Complications (abnormal
bleeding
POSTNATAL HISTORY
12. 1) 1ST cry
(immediately/cyanosed/apneic)
2) Basic problems (need for
resuscitation, problem with
respiration,
sucking/swallowing)
3) Birth weight
4) Birth injury
5) Convulsions, cyanosis,
jaundice, fever, rash
6) Procedures (exchange
transfusion, umbilical artery
catheterization,
drugs)
13.FEEDING HISTORY
(Significant in child < 2 years ,
anemic or malnourished)
1) Onset of feeding (after how
many hours)
2) Type of feed
Breast-fed (duration)
Bottle-fed (at what age,
composition of formula, amount,
frequency, dilution)
3) Supplements (vitamin, iron)
4) Weaning (when, what,
amount, frequency)
5) Current diet/change in diet
during illness
14.IMMUNIZATION
(check vaccination card * )
1) Types of Vaccinations given
2) Age at which started and by
whom
3) Doses & adverse effects
15.DEVELOPMENTAL
HISTORY
1) Achieving age of various
milestones
 Smiling
Ability to hold neck
Sit
Crawl
Stand
Walk
Talk
Control of bladder and bowel
2) Compared with normal for
this age
16.PAST HISTORY
1) Significant illness in the past
(esp. diarrhea, respiratory
infections, fevers, fits, jaundice)

2) History of similar complaints

in the past
17.
PERSONAL
HISTORY
1) Particular habits of child
2) Details of class, school and
interest in studies
3) Any missed school
attendance
4) Behavior of the child at
school and relationship with
other children
18.DRUG HISTORY
1) Any medications used
(frequency, dose, adverse
effects)
2) Allergy to any drug
3) H/o Mom drug usage ** (in
neonate or breast fed baby)
19.FAMILY HISTORY
(Important in chromosomal,
hereditary, infectious diseases)
1) Age of mother and father?
How long married?
2) Consanguinity ***
3) Parents’ health (present and
past)
4) Siblings
Number
Age and sex
Illness
Any death (cause if known or
symptoms of illness before
death)
Stillbirths, miscarriages
 5) Grand parents’ health (esp. if
living with family)
6) Health of uncles, aunts and
their children (if inherited
disorder suspected)
7) DO MAKE A FAMILY TREE
***
20.SOCIO-ECONOMIC
HISTORY
1) Parents’ education and
occupation
2) Family income
3) House (made of, persons
living, size)
4) Cleanliness and general
hygienic conditions
5) Source of drinking water
6) Any pets at home