HELENE FULD COLLEGE OF NURSING PEDIATRIC ASSESSMENT TOOL Nursing 223 STUDENT: Natalie Misyuk Patientss Name Largo-Zea,

Christopher Age: 13 month old DATE: 06/01/11 Admission Date: 05/20/11

Admitting Diagnosis: croup, pnemonia Allergies: NKA Primary Care Provider: Andre Broussard MD Other Diagnoses: none  CHIEF COMPLAINT/CONCERN: 3 month well baby, breathing heavier after eating noisy HISTORY OF PRESENT ILLNESS: (Include duration of problem, intensity, frequency, description,
associated symptoms, and actions taken/response, and who the historian is).

Christopher is feeding well. No health issues or concerns. Hearing test passed. New born screening is negative. Since birth breathing heavier after eating and noisy. MOTHERS PRENATAL AND OBSTETRICAL HISTORY: CHILDS PAST MEDICAL HISTORY: CHILDHOOD ILLNESSES (Measles, Mumps, Chickenpox): HOSPITALIZATIONS: BLOOD TRANSFUSIONS: MENSTRUAL HISTORY (Age of Menarche): SEXUAL HISTORY (Include any pregnancies- Female only): HISTORY OF ABUSE (Physical, Sexual, Emotional):

Rev. 4/2006

IMMUNIZATION HISTORY
AGE DPT HEPATITIS B POLIO MMR

MEDICATION ADMINISTRATION:
NAME OF MEDICATION DOSAGE ROUTE FREQUENCY

1. 2. 3. 4. 5. 6. INTRAVENOUS FLUIDS IV Fluid 1. PATIENT TREATMENTS: PRIMARY HEALTH CARE PROVIDER: Rate 1.

FAMILY HISTORY FAMILY CONSTELLATION:

PARENT: SIBLING: PARENT: SIBLING: OTHERS: SIBLING:

EXTENDED FAMILY MEMBERS: CHILD CARE PROVIDER: FINANCIAL PROVIDER: RELIGION: CULTURAL BACKGROUND: SPECIAL CULTURAL PRACTICES:

FAMILY HEALTH HISTORY

MOTHER FATHER

Rev. 4/2006

CHILD DAILY ACTIVITIES: PLAY: SLEEP (Any special routine): PERSONAL HYGIENE: EATING HABITS: FAVORITE TOY:

REVIEW OF SYSTEMS
NEUROPSYCHIATRIC EYES EARS Vision Difficulties Hearing Loss Nasal Discharge Cough Mood Disorder Glasses Infections Sinus Pain Hemoptysis Thought Disorder Eye Pain Ear Pain Throat Pain Chest Pain Fast heart beat
Diarrhea

Personality Disorder Eye Discharge Hearing Aid Tooth Pain SOB Slow heart beat
Vomiting

Seizure Disorder Eye Redness Ear Tube (Myringotomy) Braces

NOSE/ MOUTH/ THROAT LUNGS

DOE Chest pain

Nausea

Wheezing

HEART

Palpitations
Stomach pain

LOC
Constipation

Murmur
Loss of appetite

GASTROINTESTINAL

GENITOURINARY

Pain on urination Heat intolerance Bruise easily Joint pain

Frequency Cold intolerance Petechiae

Vaginal or penile discharge Polyuria Anemia

Lesions

Sexual dysfunction Polyphagia Bleeding Disorder

ENDOCRINE HEME EXTREMITIES SKIN

Polydypsia

Muscle pain Rashes Burns

Muscle Weakness Tatoos Body Piercing

Lesions

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PHYSICAL EXAM
GENERAL APPEARANCE: AFFECT: SKIN COLOR: B/P: HR: HT 1. HEENT: 2. 3 4 5 6 7 8 9 CHEST: BREASTS: HEART: BACK: ABDOMEN: GENITALIA: EXTREMITIES: SKIN: HYGIENE LEVEL: TEMP: BMI:

RR:

WT:

10 NEUROLOGICAL FUNCTIONINGS: 11 COORDINATION WALKING, HOPPING ETC.: 12 NEUROPSYCHIATRIC: 13 PSYCHIATRIC: 14 LABORATROY DATA:
Na
+

Cl

BUN GLUCOSE WBC CREAT.

Hb PLATELET HCT

K+

CO2

OTHER DIAGNOSIS: CXR: U/A: CULTURES: 1. SPUTUM: 2. URINE: 3. BLOOD:

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ASSESSMENT/PROBLEM LIST/ NURSING DIAGNOSIS 1. 2. 3. 4. 5. 6. PLAN 1. 2. 3. 4. 5. 6. 7. 8 9 10 ANY REFERRELS: DIETICIAN: SOCIAL SERVICES: PHYSICAL THERAPY: PSYCHIATRY:

Rev. 4/2006

DESCRIBE THE PATHOPHYSIOLOGY OF THE CHILDS ADMITTING DIAGNOSIS? DESCRIBE THE EFFECT OF THE ADMITTING ILLNESS ON THE OTHER CHRONIC ILLNESSES THAT THE CHILD HAS? WHAT IS THE EFECT OF THE CHRONIC ILLNESSES ON THE ADMITTING DIAGNOSIS? DESCRIBE THE CHILDS SOCIAL/FAMILY HISTORY AND ITS IMPACT ON HIS/HER ILLNESS? WHAT IS THE IMPACT OF THE CHILDS ILLNESS ON THE FAMILY? DESCRIBE THE INDICATIONS, EFFECTS, AND SIDE EFFECTS OF EACH MEDICATION FOR THIS CHILD? LIST ALL PRESCRIBED MEDICATIONS FOR THE ASSIGNED CLIENT. A. Calculate the milligrams per Kg of body weight for each medication. B. Calculate the milligrams per Kg per day for each prescribed medication prescribed.. C. Determine if the dosage ordered by the physician in within the safe range. D. Calculate the amount of medication (ie. ml, gm, mg, or micrograms that client should be given for each dose)

Rev. 4/2006