MOHAMMAD ALMANA COLLEGE FOR MEDICAL SCIENCES

Division of Nursing

PEDIATRIC NURSING HISTORY & HEALTH ASSESSMENT FORM

NURSING CARE OF CHILDREN (NURS 401)

Name of Student: _________________Dates of Care: __________ Area of Training:__________

Patient's Initials: _____________Age _______ Sex: M F Date Admitted: ___________
Medical Diagnosis _______________________________________________________________

Sources of information:
Parents/ Relatives File Child
Vital Signs:

Chief Complaints:
__________________________________________________________________________________
__________________________________________________________________________________

History of Present illness:

___________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______

Past Health History:

Medical:___________________________________________________________________
__________________________________________________________________________________
________
Surgical:___________________________________________________________________
__________________________________________________________________________________
________

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Hospitalization:______________________________________________________________
__________________________________________________________________________________
_______
Injuries:____________________________________________________________________
__________________________________________________________________________________
_______

Natal History:
Prenatal:___________________________________________________________________________
Natal:_____________________________________________________________________________
Neonatal: __________________________________________________________________________

Family history:
___________________________________________________________________________
__________________________________________________________________________________
_______

Immunization:

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Allergies:
Food:_____________________________________________________________________________
Medication:________________________________________________________________________
Environment:_______________________________________________________________________
Others:____________________________________________________________________________

Current medications if any: (prescribed & OTC)

Growth & development

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 Area Findings in child Normal/ expected growth &
development
Physical

Language

Cognitive

Social

Habits:
Eating:____________________________________________________________________________
Elimination:________________________________________________________________________
Sleep:_____________________________________________________________________________
Behavior:__________________________________________________________________________
Hygiene:___________________________________________________________________________

PHYSICAL ASSESSMENT

General Appearance:
Body: __________________________________________________________________________

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Behavior: ___________________________________ Speech_____________________________
Skin, Hair and Nails:
Skin
Color of skin: ___________________________ Texture & Turgor:
___________________________
Edema: _________________________________ Birth Marks:_______________________________
Pigmentations: ___________________________ Infectious lesions:
___________________________
Capillary bleeding: ________________________ Pruritis:
___________________________________
Trauma:____________________________________________________________________
_______Hair
Distribution________________________ Texture &quality:_________________________________
Infestation: _________________________
Nails
Color:___________________ Shape: _____________________
Condition:_____________________
Nail biting:_______________________________ Infection:_________________________________

Head & Neck: Eyes: Ears: Nose, Face, Mouth & Throat
Head
Head Circumference (HC): ____________ Fontannels: Anterior__________ posterior
___________
Symmetry & shape: _______________________________________ Sinuses: __________________
Eyes
Vision: _____________________________ Irritations & infections:__________________________
Placement of eyes:______________ ۞ PERRLA ۞ sluggish ۞ dilated
۞ Amblyopia (lazy eye): (Cover-uncover test)
Eyelids: _________________________________ Conjunctiva:
______________________________

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Sclera:__________________________________ Cornea:
___________________________________
Ears:
Hearing: ______________________________ external ear canal:____________________________
Nose:
Discharge:_____________________________ Mouth breathing_____________________________
Infection: ________________________ Foreign body:
____________________________________
Excoriation: _________________ ۞ Septal deviation
Mouth & Pharynx
Color of lips:__________________________ Buccal mucosa_______________________________
gingivae:__________________________ Tongue:________________________________________
Teeth: No/ Of teeth:__________________ Type of teeth : ۞ Milk ۞ Permanent
۞ Cleft lip ۞ Cleft palate ۞ oral thrush ۞ oral ulcers
Explain if any:____________________________________________________________________
Neck:
Lymph nodes: ۞ normal ۞ enlarged Thyroid gland: ۞ normal ۞ enlarged
Explain if any:____________________________________________________________________

Thorax & Lungs:

Inspection:
Chest Shape___________________________Symmetry:_________________________________
Symmetry of expansion: ۞ equal ۞ unequal Resp. rate:__________________
۞ Nasal flaring ۞ Dyspnea ۞ Orthopnea
Palpation:
Fremitus: ۞ normal ۞ Increase ۞ Decrease
Percussion:
۞ Resonance ۞ Hyperresonance ۞ Dullness
Auscultation:
۞ Normal Adventitious sounds ۞ Crackles (rales) ۞ Rhonchi ۞ Wheeze
Explain if any:____________________________________________________________________

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________________________________________________________________________________
Cardiovascular
Inspection
Heart rate: ___________BP: ________________ Capillary refill: ۞ immediate ۞ delayed
Palpation
Peripheral pulses: ۞ Present ۞ Absent ۞ Diminished
Auscultation
Heart sounds: ۞ S1 ۞ S2 ۞ Aortic ۞ Pulmonic ۞ Erbs ۞ Tricuspid ۞ Mitral
Explain if any:____________________________________________________________________
________________________________________________________________________________
Abdomen
Inspection:
Scars: ______________ Veins:__________________ Visible peristalsis: _____________________
Contour;_______________________ Hernia: ۞ Umbilicus ۞ inguinal ۞ femoral
Auscultation:
۞ Bowel sounds
Palpation
۞ Tenderness ۞ Rigidity
Percussion
۞ Tympany ۞ dullness
Explain if any:____________________________________________________________________
________________________________________________________________________________
Genitourinary and Reproductive
Female Genitalia
________________________________________________________________________________
Male Genitalia
۞ Hypospadias ۞ Epispadias ۞ Testes descended bilaterally ۞ Phimosis
Explain if any:____________________________________________________________________
________________________________________________________________________________
Musculoskeletal

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Alignment:______________________________ Contour:__________________________________
Strength:_________________________________ weakness & symmetry:_____________________
Joint mobility: ۞ Normal ROM, ۞ Stiffness, ۞ Contractures
Explain if any:____________________________________________________________________
________________________________________________________________________________
Neurological Evaluation
Cerebral Function:
LOC: _________________________________ Orientation: ۞ person ۞ place ۞ time
Social response:________________________________ attention
span;________________________
Cerebellar Function
Balance:________________________ gait & leg coordination:______________________________
Posture:________________________________________ tremors;___________________________
Reflexes
Deep tendon: ۞ Biceps ۞ Triceps ۞ Patellar ۞ Achilles
Infant Reflexes:___________________________________________________________________

Cranial Nerves
۞ C1 Smell
۞ C2 Visual acuity, visual fields, fundus
۞ C3, 4, 6 EOM, 6 fields of gaze
۞ C5 Sensory to face: Motor--clench teeth,
۞ Corneal reflex---is C5 & C7
۞ C7 Raise eyebrows, frown, close eyes tight, show teeth, smile, puff cheeks, Taste--anterior 2/3
tongue
۞ C8 Hearing & equilibrium
۞ C9 "ah" equal movement of soft palate & uvula
۞ C10 Gag, Taste, posterior 1/3 tongue
۞ C11 Shoulder shrug & head turn with resistance
۞ C12 Tongue movement

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 Investigation

SL NO INVESTIGATION FINDINGS NORMAL INTERPRETATION

VALUE

Medications:
NAME OF THE DRUG DOSE/ FREQUENCY/ ACTION
ROUTE

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Pain assessment

Modified FLACC Scale

0 - No particular expression
Face 1 - Occasional grimace, withdrawn, disinterested
2 - Frequent grimace, clenched jaw
0 – Normal position or relaxed

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 Legs 1 – Uneasy, restless, tense
2 – Kicking, or legs drawn up
0 – Lying quietly, normal position, moves easily
Activity 1 – Squirming, shifting back and forth, tense
2 – Arched, rigid or jerking
0 – No cry, whine(awake or asleep)
Cry 1 – Moans or whimpers; occasional yipe
2 - Crying steadily, screams, frequent yipes
0 – Content, relaxed
Consolability 1 – Reassured by occasional touching, hugging or being
/Stress talked to, distractible
2 – Difficult to console or comfort
Total

List of nursing diagnosis

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ASSESSMENT NURSING GOAL / INTERVENTION RATIONALE EVALUATION
DIAGNOSIS OBJECTIVE

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ASSESSMENT NURSING DIAGNOSIS GOAL / INTERVENTION RATIONALE EVALUATION
OBJECTIVE

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