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4 INDEPENDENT - Pediatric Group Project & Presentation
4 INDEPENDENT - Pediatric Group Project & Presentation
Objectives:
1. Define social and cultural factors influencing the care of individuals, families and
communities (competency 1A).
2. Utilize professional behaviors including attention to appearance, demeanor, respect
for self and other and professional boundaries (competency 1E).
3. Explain how care for vulnerable populations is impacted by attitudes, values, and
expectations (competency 1H).
4. Recognize how the nurse impacts positive client outcomes through health
promotion (competency 2E).
5. Define the relationship between theories in arts and sciences and theories in
nursing (competency 3B).
6. Identify the process used to gather the evidence to improve client outcomes
(competency 3D).
7. Identify evidence and client preferences for planning, implementing and evaluating
care (competency 3E).
8. Locate evidence used to guide health teaching, health counseling, and screening
throughout the lifespan (competency 3K).
9. Identify inter-professional resources to promote holistic nursing care (competency
4A).
10. Conduct a holistic health history, wellness assessment, and appropriate screenings
(competency 7A).
11. Correlate specific health problems to genetic links during a health screening
(competency 7B).
12. Develop a holistic plan of care reflecting growth and development, medical
management, and nursing management for identified risk factors (competency 7C).
13. Identify learning needs to provide appropriate teaching materials (competency 7E).
14. Identify complementary and alternative modalities in health care (competency 7K).
PART I: Pediatric Assessment & Teaching-Learning Grid
Directions:
1. Students will work in groups of two to interview and conduct a history and physical
assessment for a child in an assigned age group as identified below.
a. Infant: < 3 months
b. Infant: 3 to 12 months
c. Toddler: 1 to 3 years
d. Preschooler: 3 to 6 years (not yet in school)
e. School-age: 6 to 9 years
f. School-age: 9 to 12 years
g. Adolescent: 13 to 15 years
h. Adolescent: 16 to 17 years
2. You may not interview one of your own children. You may interview one of your
classmate’s children.
3. Arrange to meet the client at their home, and ensure a parent or caregiver is
in the home as well during the visit. Also, both students need to be present
during the entire interview and physical assessment. As indicated in the
Adolescent Assessment, there are interview questions for the adolescent that
the adolescent has the option to excuse their parent/caregiver as they prefer.
4. Obtain parental consent allowing you to conduct an assessment of their child. Have
the parent present for the physical assessment of the infant, toddler, preschooler,
and school age child. Relative to developmental needs, adolescents should be
interviewed and examined privately, with the parent/caregiver in an adjacent room.
See the Pediatric Assessment Consent Form below.
5. Each student pair will complete the assessment using the questions on the
Assessment Template. Type up the data.
6. Each student pair will complete the Pediatric Teaching-Learning Project Grid (last
page of this document) with the learning topic clearly identified, a wellness/health
promotion nursing diagnosis, one goal, one learner outcome in each of the
domains of learning, nursing interventions and anticipated evaluation of your
teaching plan if it had been implemented. All goals, outcomes & interventions are to
relate back to the nursing diagnosis.
7. Submit a PAPER copy of the following immediately prior to the presentation:
a. Assessment Template (one per student pair).
b. Pediatric Teaching-Learning Project Grid (one per student pair)
c. Pediatric Assessment Consent Form, (1 per student pair)
d. Visual presentation (PowerPoint, skit notes, handouts, etc.) (one per large
group)
e. Reference list (one per large group)
8. Upload the completed Pediatric Assessment Group Project Peer Evaluation
Rubric to the D2L Brightspace Assignment area. Evaluate yourself and each person
in your large group.
9. Grading: There are a maximum of 15 points for the completed Assessment Template.
The student pair will receive the same number of points (see the Pediatric
Assessment Grading Rubric).
Directions:
1. Meet with all members of the age group you are assigned to.
a. Effective group process is imperative!
b. Negotiate dates, times, & locations to meet. Meetings may be completed
virtually.
c. Compare and contrast your clients, linking usual principles of growth and
development.
d. Discuss varying cultural beliefs of your client and its impact on health
promotion.
e. Discuss areas of health promotion, including anticipatory guidance, which
you feel are pertinent for your individual clients/family when comparing the
anticipated growth and developmental milestones of the age of your client.
f. Based on this discussion, come to a consensus for the entire group as to
which health promotion topic is the most important for all of the clients
combined. Speak to the instructor regarding your topic of interest. Topics will
be approved on a first come, first approved. Duplicate topics will not be
allowed among groups. This one health promotion topic should then be the
focus of your large group presentation (@ 10 minutes).
2. The presentation needs to contain these 5 elements in a maximum of 20 minutes.
a. Visual presentation that is highly creative, such as skit, game, a home-made
video, etc. Consider how to present multiple groups/ideas into one uniform
presentation demonstrating collaboration.
b. Each pair of students briefly summarizes the Concerns or health promotion
areas of their particular client and the rationale why it is an area of Concern
(@ 2-3 minutes each). Each group should briefly review their Pediatric
Teaching/Learning Project Grid.
c. Each pair of students discusses the impact of culture on health care beliefs
and practices (@2 – 3 minutes each).
d. The entire group needs to present on the one approved health promotion
topic (@ 10 minutes).
e. Provide a list of EBP resources. The majority of the resources need to be
beyond your nursing textbooks/ATI software. They need to be preferably
written by a nurse, from a professional journal, book or website.
3. Other:
a. Imagine yourself presenting to a group of professionals at a conference.
Consider the various elements of a presentation – introduction, development,
and conclusion. Students will wear business attire.
b. No cellphones or electronic devices will be allowed.
4. Grading: A maximum of 15 points for the large group presentation (see the Pediatric
Large Group Presentation Grading Rubric).
a. Group members may receive a maximum 15 points for the presentation
portion. All members will receive the same number of points.
b. Individual group members may receive a maximum of 5 points (2 points for
Professional Appearance & Style; 3 points from the Peer Evaluation).
Part 1: Pediatric Assessment Grading Rubric
15 Points Exemplary Proficient Developing Unacceptable
7 Points 5 Points 3 Points 0 Points
Findings, Expected Findings Expected Findings are Expected Findings are Expected Findings are either
Analysis, & complete, accurate, & incomplete; information incomplete & have multiple incomplete, inaccurate or
Teaching without patient identifiers. presented is generally accurate, inaccuracies. Rarely, patient both. A patient identifier is
Needs Actual Findings & analysis & without patient identifiers. identifier is used. often used.
are complete & show Actual Findings & analysis are Actual Findings & analysis are Actual Findings & analysis are
insight, based on data mostly complete, but lack insight mostly complete, but lack insight. based on personal judgment &
versus personal judgment, in some areas. Personal judgment is evident in values of the interviewer
& show valid links between Some personal judgment is many areas & interferes with rather than on collected data,
the elements. evident & may interfere with data analysis. may be incomplete or lack
Areas for health promotion data analysis. Areas for health promotion insight.
teaching needs for the Areas for health promotion teaching needs are minimally Areas for health promotion
child/family are clearly teaching needs identified & may based on data collected & are teaching needs are not based
identified & are based on be based on individualized data generic to the child’s on data collected & do not
data collected. collected, in addition to generic developmental group & are not reflect the child/family
child/family needs. individualized to family needs. learning needs.
5 Points 4 Points 3 Points 0 Points
Teaching/ GRID complete with all GRID is complete with all GRID is complete with all GRID does not flow logically &
Learning components clearly written components clearly written, components clearly written & more than one of the
(T/L) Plan & plan flows logically. however plan could be clearer & plan flows logically. components are incomplete or
GRID Clear & concise Wellness flow more logically. Components are clear & concise; poorly written.
Nursing Diagnosis, Clear & concise Wellness Nursing 1 of the components (Wellness Knowledge of growth &
Outcomes, Interventions & Diagnosis, Outcomes, Nursing Diagnosis, Outcomes, developmental milestones are
Evaluation. Interventions & Evaluation. Interventions or Evaluation) is unclear & T/L Plan does not
Individualized T/L plan T/L Plan does not always clearly lacking or incomplete reflect anticipated growth &
highly reflects knowledge of reflect anticipated growth & T/L Plan minimally reflects developmental milestones.
growth & development developmental milestones. anticipated growth &
milestones. developmental milestones.
3 Points 2 Points 1 Point 0 Points
Organization, Assessment data is Assessment data is typewritten & Assessment data is typewritten, Assessment typewritten, but
Mechanics, & typewritten & logically generally logical. but may lack organization. there is a lack of organization.
APA presented. Few (3-5) errors in spelling, Occasional (6-10) errors in Many spelling, grammar &
Rare (0-2) errors in grammar, & punctuation. spelling, grammar, & punctuation errors making the
spelling, grammar, & Citations generally in APA format punctuation. document challenging to read.
punctuation. with few (3-5) errors. Citations with an attempt at APA Citations missing or lack of
Citations in APA format format but with occasional (6- attempt at APA formatting.
with rare (0-2) errors. 10) errors.
TOTAL
Part 2: Pediatric Large Group Presentation Grading Rubric
15 Points Exemplary Proficient Developing Unacceptable
8 Points 6 Points 4 Points 0 Points
Content Information presented is Information presented is Gaps in knowledge in some Accuracy of information is
Accuracy, Depth, consistently accurate, current, generally accurate and current of the information questionable. A patient
and Evidence. and without any patient and are without patient presented. Rarely, a identifier is often used.
identifiers. identifiers. patient identifier is used. Minimally reviews client &
Analysis, application, and Analysis and application of Minimal content depth family findings and there is
synthesis of content is effective content is demonstrated and related to the client & a disconnect between
and relates to the client & family relates to the client & family family findings. findings and teaching topic.
findings and teaching areas. findings and teaching areas. Evidence of only one EBP resources are missing,
Evidence of at least three or Evidence of at least two credible and current EBP limited to the current
more credible and current EBP credible and current EBP resource is cited (beyond nursing textbooks and ATI,
resources (beyond the current resources are cited (beyond the the current nursing or EBP resources lack
nursing textbooks and ATI) to current nursing textbooks and textbooks and ATI) to credibility and/or currency.
support the content of the ATI) to support the content of support the content. Lacks the ability to clarify
presentation (< 5 yrs. old, the presentation. Lacks some ability to and respond to audience
written by a nurse(s), from a Attempts to clarify and clarify and respond to questions and/or
nursing journal) responds to questions from the questions from the responses are
Consistently attempts to clarify audience in an appropriate audience appropriately. inappropriate.
and responds to questions from manner.
the audience appropriately and
accurately.
7 Points 5 Points 3 Points 0 Points
Presentation’s Presentation is clear, logical, and Presentation is overall clear Presentation may lack Presentation disorganized.
Organization & organized; clearly evident that and logical with an occasional some clarity, organization, Apparent that the group
Visual Aids the group practiced. lack in development or and transition between did not practice.
Highly apparent introduction, transition between ideas. ideas. Additional practice Lack of or poor
development, and conclusion of Evidence that the group would have been introduction, development
the presentation. practiced. beneficial. and/or conclusion of the
Variety of aids (3 or more) used Overall attempt at Some attempt at presentation.
to enhance and deepen the introduction, development and introduction, development One visual aid.
audience’s understanding of the conclusion of the presentation. and/or conclusion of the Visual presentation
topic. Variety of aids (2) used to presentation, but may have significantly lacks in
Visual presentation highly enhance and deepen the left out a component. professional tact, in
professional & creative audience’s understanding of One visual aid used but did addition to appeal to the
(appropriate font size & text, the topic. not stand out or enhance audience.
image clarity, language Visual presentation generally the delivery of the Many spelling, grammar
appropriate to audience) professional and creative. presentation. and punctuation errors
Part 2: Pediatric Large Group Presentation Grading Rubric
15 Points Exemplary Proficient Developing Unacceptable
Rare (0-2) errors in spelling, Few (3-5) errors in spelling, Visual presentation may making it difficult for the
grammar, and punctuation; grammar, and punctuation; lack in some audience to read.
appropriate use of bullets. appropriate use of bullets. professionalism or appeal Citations missing or there
Citations in APA format with Citations generally in APA to the audience. is a lack of attempt at APA
rare (0-2) errors. format with few (3-5) errors. Occasional (6-10) spelling, formatting.
grammar, and punctuation;
makes an attempt to bullet.
Citations with an attempt
at APA format but with
occasional (6-10) errors.
TOTAL
Group Members:
Self:____________________________________ 3 2 1 0
__________________________________________ 3 2 1 0
__________________________________________ 3 2 1 0
__________________________________________ 3 2 1 0
__________________________________________ 3 2 1 0
__________________________________________ 3 2 1 0
__________________________________________ 3 2 1 0
Pediatric Assessment Consent Form
I give permission to _________________________________________ and ___________________________________________,
students in the North Hennepin Community College Minnesota Alliance for Nursing Education (MANE)
_________________________________. I understand that this is for learning purposes only and it does not replace
a medical evaluation. I understand that I may be with my child during the physical exam, but may be
asked to not be present during the interview portion of the exam, e.g., adolescent. I further understand
that neither my child nor my family will be named in the project, and that the information collected will
not be shared with anyone other than the students and faculty of the North Hennepin Community College
Nursing class.
__________________________________________________.
Date ______________________________________________
Assessment of an Infant (birth to twelve months)
Student(s)
Age of Client
Person(s) _________ child _________ mother _________ father _________ other: _________________________________________
Interviewed
Current Medications
Name Indication
Complementary and Alternative Modalities in Health Care (herbals, supplements, chiropractic, shaman; if none, indicate NONE)
Name Indication
Newborn Course
Findings (bullet findings; do not use ‘normal’, ‘within defined limits’, etc.)
Birth History
(Gestational age and growth
pattern; length & weight)
APGAR
(Apgar score and type of
resuscitation if required)
Neonatal Complications
(Respiratory, infections, feeding,
hyperbilirubinemia, congenital
abnormalities)
Family Detail
Placement in the family
Family structure
Cultural heritage
Family History
Person Age Current medical issues; Person Age Current medical issues;
or cause & age at death or cause & age at death
Mother Father
Maternal grandmother Paternal grandmother
Maternal grandfather Paternal grandfather
Aunt or Uncle (specify) Aunt or Uncle (specify)
Aunt or Uncle (specify) Aunt or Uncle (specify)
Sister Brother
Sister Brother
Sister Brother
Other (specify) Other (specify)
Development
Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the actual *Concern
findings to the expected findings of the child you
assessed)
(bullet findings; do not use ‘normal’, ‘within defined limits’, etc. Place an asterisk if you deem this a ‘Concern’ for this
client)
Development
Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the actual *Concern
findings to the expected findings of the child you
assessed)
How does a child of
this age interact with
their environment?
What are normal play
patterns for children
in this age group?
How do children in
this age group express
anger?
How do children in
this age group express
fear?
In which of Erikson’s
developmental stages
should this child be?
What are the major
tasks of this stage for
the child?
What are the major
tasks/milestones of
this stage for the
family? How should
they demonstrate love
& caring for the child?
What are normal sleep
patterns at this age &
how do these patterns
fit in with the normal
family routine?
What are common
safety
hazards/precautions
for this age group?
What should children
of this age be eating
Development
Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the actual *Concern
findings to the expected findings of the child you
assessed)
and what are their
normal eating
patterns?
Does the parent have
concerns about the
child’s bowel
movements?
Cite resource(s) for
Expected Findings
Physical Assessment
Examination Technique Expected Findings (as found in your Actual Findings (compare and contrast the *Concern
textbooks) actual findings to the expected findings of the
child you assessed)
(bullet findings; do not use ‘normal’, ‘within defined limits’, etc. Place an asterisk if you deem this a ‘Concern’
for this client)
Vital Signs Heart rate:
Respiratory rate:
Height/Weight Ht for 50th percentile: Per caregiver:
Wt for 50th percentile: Ht:
Wt:
Skin:
Inspect skin for coloration,
birthmarks, lesions, turgor.
Hair and Nails
Inspect scalp for texture
and hair distribution.
Head and Neck
Very gently palpate for
symmetry and suppleness.
Very gently palpate
fontanels for concavity.
Eyes, ears, nose, and throat:
Physical Assessment
Examination Technique Expected Findings (as found in your Actual Findings (compare and contrast the *Concern
textbooks) actual findings to the expected findings of the
child you assessed)
Inspect eyes for color and
appearance.
Perform appropriate visual
screening.
Inspect ears for position
and surface characteristics.
Inspect mouth for color,
lesions, and intactness.
Inspect teeth for presence
and characteristics.
Respiratory
Inspect chest for
respiratory effort and
depth.
Auscultate anterior and
posterior chest for lung
sounds.
Cardiovascular
Evaluate pulse for rate,
rhythm, characteristics
(apical for infant, radial for
older child)
Auscultate heart sounds
Abdomen:
Auscultate for bowel sounds
Inspect for symmetry, color,
surface characteristics.
Very gently palpate.
Musculoskeletal:
What should the patient be
doing now?
Inspect development
appropriate for age.
Inspect muscle strength.
Physical Assessment
Examination Technique Expected Findings (as found in your Actual Findings (compare and contrast the *Concern
textbooks) actual findings to the expected findings of the
child you assessed)
Cite Resource(s) for
Expected Findings
Teaching/Learning
Based on findings collected, outline areas of teaching that will promote health for this client/family (focus on *Concern items).
Topic Rationale 1) To whom will you direct the teaching to?
2) What techniques will you use?
3) How will you evaluate if learning has occurred?
Current Medications
Name Indication
Complementary and Alternative Modalities in Health Care (herbals, supplements, chiropractic, shaman; if none, indicate NONE)
Name Indication
Description Date/Year Residual Problems
Previous medical
conditions
Previous hospitalizations
Injuries
Surgeries
Newborn Course
Findings (bullet findings; do not use ‘normal’, ‘within defined limits’, etc.).
Birth History
(Gestational age and growth
pattern; length & weight)
APGAR
(Apgar score and type of
resuscitation if required)
Neonatal Complications
(Respiratory, infections, feeding,
hyperbilirubinemia, congenital
abnormalities)
Family Detail
Placement in the family
Family structure
Cultural heritage
Impact of culture on health care
beliefs and practices (NONE is not
an option)
Family genetic concerns
Family History
Person Age Current medical issues; Person Age Current medical issues;
or cause & age at death or cause & age at death
Mother
Father
Maternal Paternal
grandmother grandmother
Maternal Paternal
grandfather grandfather
Aunt or Uncle Aunt or Uncle
(specify) (specify)
Aunt or Uncle Aunt or Uncle
(specify) (specify)
Sister Brother
Sister Brother
Sister Brother
Other Other
(specify) (specify)
Development
Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the *Concern
actual findings to the expected findings of the
child you assessed)
(bullet findings; do not use ‘normal’, ‘within defined limits’, etc.). Place an asterisk if you deem this a ‘Concern’ for
this client)
How does a child of this
age interact with their
environment?
What are normal play
patterns for children in
this age group?
What is the common
language development
for children age 1 year
compared to age 3 years?
(number of words, use of
phrases, articulation,
ability to convey thoughts
and ideas)
How should the family
communicate with the
toddler?
How do children in this
age group express
negativism and anger?
How should parents cope
with this?
How do children in this
age group express fear?
How should parents cope
with this?
In which of Erikson’s
developmental stages
should this child be?
Development
Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the *Concern
actual findings to the expected findings of the
child you assessed)
What are the major
tasks/milestones of this
stage for the child?
What are the major tasks
of this stage for the
family? How should they
demonstrate love &
caring for the child?
What are normal sleep
patterns at this age &
how do these patterns fit
in with the normal family
routine?
What are common safety
hazards/precautions for
this age group?
Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
Technique in your textbooks) expected findings of the child you assessed)
(bullet findings; do not use ‘normal’, ‘within defined limits’, etc.). Place an asterisk if you deem this a ‘Concern’ for this
client)
Vital Signs Heart rate:
Respiratory rate:
Height/Weight Ht for 50th percentile: Per caregiver:
Wt for 50th percentile: Ht:
Wt:
Skin:
Inspect skin for
coloration,
birthmarks, lesions,
turgor.
Hair and Nails
Inspect scalp for
texture and hair
distribution.
Head and Neck
Inspect and palpate
for symmetry and
suppleness.
Eyes, ears, nose, and
throat:
Inspect eyes for
color and
appearance.
Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
Technique in your textbooks) expected findings of the child you assessed)
Perform appropriate
visual screening.
Inspect ears for
position and surface
characteristics.
Inspect mouth for
color, lesions, and
intactness.
Inspect teeth for
presence and
characteristics.
Respiratory
Inspect chest for
respiratory effort
and depth.
Auscultate anterior
and posterior chest
for lung sounds.
Cardiovascular
Evaluate pulse for
rate, rhythm,
characteristics
(apical for infant,
radial for older child)
Auscultate heart
sounds
Abdomen:
Auscultate for bowel
sounds
Inspect for
symmetry, color,
surface
characteristics.
Very gently palpate.
Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
Technique in your textbooks) expected findings of the child you assessed)
Musculoskeletal:
What should the
patient be doing
now?
Inspect development
appropriate for age.
Inspect muscle
strength.
Inspect symmetry of
movements
Inspect gait and
coordination
Neurological:
Observe gait for
balance and
coordination.
Test extremities for
superficial tactile
sensation.
Evaluate general
mental status.
Cite Resource(s) for
Expected Findings
Teaching/Learning
Based on findings collected, outline areas of teaching that will promote health for this client/family (focus on *Concern items).
Topic Rationale 1) To whom will you direct the teaching to?
2) What techniques will you use?
3) How will you evaluate if learning has occurred?
Self-Evaluation of Therapeutic Communication & Assessment Technique During the Interview
Which therapeutic techniques did
you use to obtain the health
history? Explain if they were
effective or not and any
recommendations you may have?
What techniques did you use to
perform the physical assessment?
Explain if they were effective or
not and any recommendations you
may have?
What techniques did you use to
build trust with the caregiver(s)?
Explain if they were effective or
not and any recommendations you
may have?
Assessment of a Preschool Age Child (age 3-6 years, not enrolled in school)
Student(s)
Age of Client
Person(s) _________ child _________ mother _________ father _________ other: _______________________________________
Interviewed
Current Medications
Name Indication
Complementary and Alternative Modalities in Health Care (herbals, supplements, chiropractic, shaman; if none, indicate NONE)
Name Indication
Description Date/Year Residual Problems
Previous
medical
conditions
Previous
hospitalizations
Injuries
Surgeries
Newborn Course
Findings (Do not use ‘normal’, ‘within defined limits’, etc.)
Birth History
(Gestational age and growth
pattern; length & weight)
APGAR
(Apgar score and type of
resuscitation if required)
Neonatal Complications
(Respiratory, infections, feeding,
hyperbilirubinemia, congenital
abnormalities)
Family Detail
Placement in the family
Family structure
Cultural heritage
Family History
Person Age Current medical issues; Person Age Current medical issues;
or cause & age at death or cause & age at death
Mother
Father
Maternal Paternal
grandmother grandmother
Maternal Paternal
grandfather grandfather
Aunt or Uncle Aunt or Uncle
(specify) (specify)
Aunt or Uncle Aunt or Uncle
(specify) (specify)
Sister Brother
Sister Brother
Sister Brother
Examinations
Date Findings/Comments
Physical exam
Dental exam
Vision exam
Hearing exam
Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
Technique in your textbooks) expected findings of the child you assessed)
(bullet findings; do not use ‘normal’, ‘within defined limits’, etc.). Place an asterisk if you deem this a ‘Concern’ for
this client)
Vital Signs Heart rate:
Respiratory rate:
Height/Weight Ht for 50th percentile: Per caregiver:
Wt for 50th percentile: Ht:
Wt:
Skin:
Inspect skin for
coloration,
birthmarks, lesions,
turgor.
Hair and Nails
Inspect scalp for
texture and hair
distribution.
Head and Neck
Inspect and palpate
for symmetry and
suppleness.
Eyes, ears, nose, and
throat:
Inspect eyes for
color and
appearance.
Perform appropriate
visual screening.
Inspect ears for
position and surface
characteristics.
Inspect mouth for
color, lesions, and
intactness.
Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
Technique in your textbooks) expected findings of the child you assessed)
Inspect teeth for
presence and
characteristics.
Respiratory
Inspect chest for
respiratory effort
and depth.
Auscultate anterior
and posterior chest
for lung sounds.
Cardiovascular
Evaluate pulse for
rate, rhythm,
characteristics
(apical for infant,
radial for older child)
Auscultate heart
sounds
Abdomen:
Auscultate for bowel
sounds
Inspect for
symmetry, color,
surface
characteristics.
Very gently palpate.
Musculoskeletal:
What should the
patient be doing
now?
Inspect development
appropriate for age.
Inspect muscle
strength.
Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
Technique in your textbooks) expected findings of the child you assessed)
Inspect symmetry of
movements
Inspect gait and
coordination
Neurological:
Observe gait for
balance and
coordination.
Test extremities for
superficial tactile
sensation.
Evaluate general
mental status.
Cite Resource(s) for
Expected Findings
Teaching/Learning
Based on findings collected, outline areas of teaching that will promote health for this client/family (focus on *Concern items).
Topic Rationale 1) To whom will you direct the teaching to?
2) What techniques will you use?
3) How will you evaluate if learning has occurred?
Self-Evaluation of Therapeutic Communication & Assessment Technique During the Interview
Which therapeutic techniques did
you use to obtain the health
history? Explain if they were
effective or not and any
recommendations you may have?
What techniques did you use to
perform the physical assessment?
Explain if they were effective or
not and any recommendations you
may have?
What techniques did you use to
build trust with the caregiver(s)?
Explain if they were effective or
not and any recommendations you
may have?
Assessment of a School Age Child (age 6-12 years)
Student(s)
Age of Client
Person(s) _________ child _________ mother _________ father _________ other: ______________________________________
Interviewed
Current Medications
Name Indication
Complementary and Alternative Modalities in Health Care (herbals, supplements, chiropractic, shaman; if none, indicate NONE)
Name Indication
Description Date/Year Residual Problems
Previous
medical
conditions
Previous
hospitalizations
Injuries
Surgeries
Newborn Course
Findings (Do not use ‘normal’, ‘within defined limits’, etc.)
Birth History
(Gestational age and growth
pattern; length & weight)
APGAR
(Apgar score and type of
resuscitation if required)
Neonatal Complications
(Respiratory, infections, feeding,
hyperbilirubinemia, congenital
abnormalities)
Family Detail
Placement in the family
Family structure
Cultural heritage
Family History
Person Age Current medical issues; Person Age Current medical issues;
or cause & age at death or cause & age at death
Mother Father
Maternal Paternal
grandmother grandmother
Maternal Paternal
grandfather grandfather
Aunt or Uncle Aunt or Uncle
(specify) (specify)
Aunt or Uncle Aunt or Uncle
(specify) (specify)
Sister Brother
Sister Brother
Sister Brother
Other (specify) Other (specify)
Development
Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the *Concern
actual findings to the expected findings of the
child you assessed)
(bullet findings; do not use ‘normal’, ‘within defined limits’, etc.). Place an asterisk if you deem this a ‘Concern’
for this client)
How does a child of
this age interact with
their environment?
What is the common
language
development for this
group? (articulation,
ability to convey
thoughts and ideas)
How should the
family evaluate this
child’s language
development?
What are normal
social behaviors
children of this age
exhibit with siblings,
parents and peers?
How do children in
this age group
express their
sexuality?
In which of Erikson’s
developmental stages
should this child be?
What are the major
tasks/milestones of
this stage for the
child?
Development
Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the *Concern
actual findings to the expected findings of the
child you assessed)
What are the major
tasks of this stage for
the family? How
should they
demonstrate love &
caring for the child?
What type of moral
behaviors are
common among
children of this age
group? How should
parents cope with
adverse behavior?
What are normal
sleep patterns at this
age & how do these
patterns fit in with
the normal family
routine?
What bedtime rituals
are recommended for
this age group? What
potentially interferes
with the routines?
What are common
safety
hazards/precautions
for this age group?
Development
Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the *Concern
actual findings to the expected findings of the
child you assessed)
What should children
of this age be eating
and what are their
normal eating
patterns? How should
parents cope with the
child’s eating
patterns?
What
recommendations
should parents
promote regarding:
exercise, TV time,
computer time, social
networking)
Cite Resource(s) for
Expected Findings
Examinations
Date Findings/Comments
Physical exam
Dental exam
Vision exam
Hearing exam
Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the expected *Concern
Technique in your textbooks) findings of the child you assessed)
(bullet findings; do not use ‘normal’, ‘within defined limits’, etc.). Place an asterisk if you deem this a ‘Concern’ for this
client)
Vital Signs Heart rate:
Respiratory rate:
Height/Weight Ht for 50th percentile: Per caregiver:
Wt for 50th percentile: Ht:
Wt:
Skin:
Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the expected *Concern
Technique in your textbooks) findings of the child you assessed)
Inspect skin for
coloration,
birthmarks,
lesions, turgor.
Hair and Nails
Inspect scalp for
texture and hair
distribution.
Head and Neck
Inspect and
palpate for
symmetry and
suppleness.
Eyes, ears, nose,
and throat:
Inspect eyes for
color and
appearance.
Perform
appropriate
visual
screening.
Inspect ears for
position and
surface
characteristics.
Inspect mouth
for color,
lesions, and
intactness.
Inspect teeth for
presence and
characteristics.
Respiratory
Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the expected *Concern
Technique in your textbooks) findings of the child you assessed)
Inspect chest
for respiratory
effort and
depth.
Auscultate
anterior and
posterior chest
for lung sounds.
Cardiovascular
Evaluate pulse
for rate, rhythm,
characteristics
(apical for
infant, radial for
older child)
Auscultate heart
sounds
Abdomen:
Auscultate for
bowel sounds
Inspect for
symmetry,
color, surface
characteristics.
Very gently
palpate.
Musculoskeletal:
What should the
patient be doing
now?
Inspect
development
appropriate for
age.
Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the expected *Concern
Technique in your textbooks) findings of the child you assessed)
Inspect muscle
strength.
Inspect
symmetry of
movements
Inspect gait and
coordination
Neurological:
Observe gait
for balance and
coordination.
Test
extremities for
superficial
tactile
sensation.
Evaluate
general mental
status.
Cite Resource(s)
for Expected
Findings
Teaching/Learning
Based on findings collected, outline areas of teaching that will promote health for this client/family (focus on *Concern items).
Topic Rationale 1) To whom will you direct the teaching to?
2) What techniques will you use?
3) How will you evaluate if learning has occurred?
Self-Evaluation of Therapeutic Communication & Assessment Technique During the Interview
Which therapeutic techniques did
you use to obtain the health
history? Explain if they were
effective or not and any
recommendations you may have?
What techniques did you use to
perform the physical assessment?
Explain if they were effective or
not and any recommendations you
may have?
What techniques did you use to
build trust with the caregiver(s)?
Explain if they were effective or
not and any recommendations you
may have?
Assessment of an Adolescent (age 13-17 years)
Student(s)
Age of Client
Person(s) _________ child _________ mother _________ father _________ other: _________________________________________
Interviewed
Current Medications
Name Indication
Complementary and Alternative Modalities in Health Care (herbals, supplements, chiropractic, shaman; if none, indicate NONE)
Name Indication
Newborn Course
Findings (Do not use ‘normal’, ‘within defined limits’, etc.)
Birth History
(Gestational age and growth pattern;
length & weight)
APGAR
(Apgar score and type of resuscitation if
required)
Neonatal Complications
(Respiratory, infections, feeding,
hyperbilirubinemia, congenital
abnormalities)
Family Detail
Placement in the family
Family structure
Cultural heritage
Development
Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
in your textbooks) expected findings of the child you assessed)
(bullet findings; do not use ‘normal’, ‘within defined limits’, etc.). Place an asterisk if you deem this a ‘Concern’ for
this client)
How does a child of this
age interact with their
environment?
What is the common
language development
for this group?
(articulation, ability to
convey thoughts and
ideas)
How should the family
evaluate this child’s
language development?
What are normal social
behaviors children of
this age exhibit with
siblings, parents and
peers?
Development
Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
in your textbooks) expected findings of the child you assessed)
How do children in this
age group express their
sexuality?
In which of Erikson’s
developmental stages
should this child be?
What are the major
tasks/milestones of this
stage for this child?
What are the major
tasks of this stage for
the family? How should
they demonstrate love
& caring for the child?
What type of moral
behaviors are common
among children of this
age group? How should
parents cope with
adverse behavior?
What are normal sleep
patterns at this age &
how do these patterns
fit in with the normal
family routine?
What bedtime rituals
are recommended for
this age group? What
potentially interferes
with the routines?
What are common
safety hazards/
precautions at this age?
Development
Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
in your textbooks) expected findings of the child you assessed)
What should children of
this age be eating and
what are their normal
eating patterns? How
should parents cope
with the child’s eating
patterns?
What recommendations
should parents promote
regarding: exercise, TV
time, computer time,
social networking)?
Cite Resource(s) for
Expected Findings
Examinations
Date Findings/Comments
Physical
exam
Dental exam
Vision exam
Hearing
exam
Physical Assessment
Examination Technique Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the *Concern
actual findings to the expected findings of the
child you assessed)
(bullet findings; do not use ‘normal’, ‘within defined limits’, etc.). Place an asterisk if you deem this a ‘Concern’ for
this client)
Vital Signs Heart rate:
Respiratory rate:
Height/Weight Ht for 50th percentile: Verbal report
Wt for 50th percentile: Ht: Wt: BMI:
BMI:
Skin:
Inspect skin for
coloration, birthmarks,
lesions, turgor.
Hair and Nails
Inspect scalp for texture
and hair distribution.
Physical Assessment
Examination Technique Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the *Concern
actual findings to the expected findings of the
child you assessed)
Head and Neck
Inspect and palpate for
symmetry and
suppleness.
Eyes, ears, nose, and
throat:
Inspect eyes for color
and appearance.
Perform appropriate
visual screening.
Inspect ears for position
and surface
characteristics.
Inspect mouth for color,
lesions, and intactness.
Inspect teeth for
presence and
characteristics.
Respiratory
Inspect chest for
respiratory effort and
depth.
Auscultate anterior and
posterior chest for lung
sounds.
Cardiovascular
Evaluate pulse for rate,
rhythm, characteristics
(apical for infant, radial
for older child)
Auscultate heart sounds
Abdomen:
Auscultate for bowel
sounds
Inspect for symmetry,
color, surface
characteristics.
Very gently palpate.
Physical Assessment
Examination Technique Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the *Concern
actual findings to the expected findings of the
child you assessed)
Musculoskeletal:
What should the patient
be doing now?
Inspect development
appropriate for age.
Inspect muscle strength.
Inspect symmetry of
movements
Inspect gait and
coordination
Neurological:
Observe gait for
balance and
coordination.
Test extremities for
superficial tactile
sensation.
Evaluate general
mental status.
Cite Resource(s) for
Expected Findings
Teaching/Learning
Based on findings collected, outline areas of teaching that will promote health for this client/family (focus on *Concern items).
Topic Rationale 1) To whom will you direct the teaching to?
2) What techniques will you use?
3) How will you evaluate if learning has occurred?
Teaching Topic (focus on one topic only from your ‘Concern’ column):
Nursing Diagnosis (Wellness/Health Promotion Focus with AEB; relate it to your teaching topic):
2) 2)
Cognitive outcome:
Domain of Learning: 1) 1)
2) 2)
Affective outcome:
Domain of Learning: 1) 1)
2) 2)
Psychomotor outcome:
Cite resources: