Nursing III Student____________________ Client(s initials__________ Age__________ Date______________________ Admitting diagnosis____________________ PEDIATRIC ASSESSMENT (DATA COLLECTION) PHYSIOLOGICAL OXYGEN Blood Type__________ Rh__________ Skin warm to touch?__________ Cough ( Sputum___________ Skin Color: Normal for ethnic group ( Smokes ( packs per day __________ Abnormal: Pale ( Dusky ( Cyanotic ( Jaundice ( Breath sounds___________________ Color of nailbed: Pink ( Blue or Grey ( Equipment in use: 02 ( Respiratory Rx ( Dyspnea at rest ( on exertion ( Chest pain ( Last menstrual period ___________ *APGAR __________ Problems with menstruation ( Yes ( No Temperature ____________________ Radial pulse: __________ Apical pulse:__________ Comments: ___________________________________________ Blood pressure:__________ Resps/min:__________ Breathing problems? Yes ( No ( Lab data: Adm Hct__________ FLUIDS AND ELECTROLYTES Skin turgor: Elastic ( Loose ( Nausea or vomiting:_______________________________ Fontanelles: Tense ( Flat ( Depressed ( Presence of edema:________________________________ Tongue and lips: Moist ( Dry ( IV: Location_____________________________________ Amount of liquids taken since 7 AM today:___________mL Solution_____________________________________ Medications:_________________________________ Comments:_____________________________________ Lab Data:_____________________________________________ NUTRITION Ordered diet:____________________ Typical diet at home:___________________________________________ Dietary supplement:______________ Appetite in hospital:____________________ % Meal consumed________ Medications:____________________ Lab data:_______________________ Comments:____________________________________________________ ELIMINATION Urinary Bowel Voiding:____________________ Bowel sounds:_______________________________ BM since admission? Yes ( No ( Foley catheter? ( Consistency_________________________________ Lab data:______________________________________ Lab data:___________________________________ Comments:____________________________________ Medications:_________________________________ MOBILITY AND ACTIVITY Type of play observed? ____________________________________ Muscle strength: Handgrips equal ( Footpushes equal ( ROM: Normal ( Limited ( Severely limited ( Ability to ambulate: Assist ( Independent ( Lab data:__________________________________________ Gait____________________ Comments:________________________________________ OOB: Chair ( BRP ( Ad Lib ( Medications:_______________________________________ REST, SLEEP AND PAIN Reported hours of sleep_______________________ c/o fatigue_________________________________________ Naps: Yes ( No ( c/o pain: Yes ( No ( *NIPS scale ______________________ FACES scale _____________________ Location____________________________ Lab data:__________________________________________ Intensity____________________________ Comments:_________________________________________ Duration____________________________ Medications:________________________________________ * For infants * NA � Not Applicable *NO � Not Observed SAFETY AND SECURITY Vision: Skin integrity: Able to see without glasses ( Needs glasses ( Intact ( Hearing: Reddened ( Location___________________________ Responds to normal voice tones ( Rashes ( Acne ( Discharge from ear(s) ( Hearing aid ( Deaf ( Incision ( Location______________________________ Speech: Approx size in cms______________________________ Clear ( Language Barrier ( Appearance____________________________________ Mental Status: Treatment (dressings etc.)________________________ Alert ( Lethargic ( Unresponsive ( Tattoos ( Environment Home/School:______________________ Body piercing ( Location _________________________ Immunizations up to date ( Comments:____________________________ Allergies:_________________________________________ Degree of dependency/independency in caring for self: ____________________________________________ LOVE AND BELONGING Indicators: Cards ( Flowers ( Family pictures ( Toys ( Other___________________________ Care giver�s knowledge of Child Care (safety, feeding, bathing): Ethnic/Religious affiliation_________________________ _________________________________________________ Number and age(s) of siblings_______________________________________________________________________________ Child�s reaction to hospitalization: School ( Grade: _____________ Comments:___________________________________ Social Service consult needed ( SELF-ESTEEM Family role:_____________________________ Parents/SO communication with child (body contact, security, etc): Interest in appearance:_____________________ _____________________________________________________ Comments:______________________________ Child(s reaction to parent/SO:______________________________ _______________________________________ SELF-ACTUALIZATION Child report of satisfaction with life:__________ ________________________________________ Future plans for self:_______________________ Comments:________________________________________ ________________________________________ _________________________________________________ ERIKSON(S STAGE OF DEVELOPMENT What is the stage of development? _________________________________________________________________________ Describe child(s characteristics/behaviors that place him/her in this stage: Is stage appropriate for age? Nsg III Pediatric Assessment 7/07