PEDIATRIC FOCUSED ASSESSMENT.pdf

PEDIATRIC FOCUSED ASSESSMENT
STUDENT’S NAME:
DATE OF CARE:
Pt. initials: Weight: Height:
Pt. age:
Race:
Admission diagnosis:
Secondary diagnosis:
Surgeries (type, reason, and year)
Medical History: (Include what brought the
child to the hospital. If the child is less than
18 months old, include delivery history,
birth weight, Apgar, and gestational age).
Significant Family History:
Name Dosage Times Taken
Current Medications Routinely Taken at Home
Patient’s own words as to why
they take this medication
Alternative
medications
(herbs, solutions,
etc.)

PEDIATRIC FOCUSED ASSESSMENT Page 2
Student’s Name:
What is the most life-threatening problem for this patient (Think ABC’s – this should always be our #1
diagnosis).
What is the most significant emotional issue for this child and/or family
1.
If this patient is experiencing pain, list two ways to provide pain relief without using medications.
2.
Which pain assessment tool did you use
Explain why you chose this pain assessment tool
FLACC 0-5 0-10
Faces NIPS PIPS
Other
What pain medication did you administer, and what was its effect
Procedures/X-rays/Ultrasound/MRI/EKG, etc. while hospitalized, (date and results).

PEDIATRIC FOCUSED ASSESSMENT Page 3
Student’s Name:
Significant lab results with date:
Child’s Values Normal Values Rationale for abnormal values
Equipment used (such as cardiac monitor, pulse OX, etc.):
Fluid Assessment:
IV Fluids: (calculate on all patients, even if they do not have an IV)
Calculating Daily Maintenance Fluid Rates
< 10 kg 100 ml/kg
10 – 20 kg 1000 ml + 50 ml/kg for each additional kg between 10 and 20 kg
20 + kg 1500 ml + 20 ml/kg for each additional kg over 20 kg
Calculated IV fluid intake: Per 24 hours:
Per hour:
Type IVF infusing:
Rate infusing:
Shift intake:
Heplock: Yes No
Central line:
Type:
Site:
Condition of site:
Dressing change:
Diet type:
Formula: Frequency: Shift intake:
NG feedings: Type: Rate: Shift intake:
G Button Feedings: Type: Rate: Shift intake:
Output:
Calculated output (0.5-2 ml/kg/hr or day) Per Day: Per Hour:
Urine: Output Volume ml:
# Diapers:
Sp. Gravity: Protein: Glucose:
Stools: # in last 24 hours:
Guiac:
Other:

PEDIATRIC FOCUSED ASSESSMENT Page 4
Student’s Name:
Medications:
Dose: Route: Times:
Weight of Child in KG:
Calculate dose range: (high and low)
Reference used for dosage range:
Drugs low dose:
Drugs high dose:
Child’s low dose:
Child’s high dose:
Is this a safe dose for this child Yes: No:
Classification of Drug:
Indication of Drug:
Possible adverse reactions:
Drug:
Dose: Route: Times:
Weight of Child in KG:
Calculate dose range: (high and low)
Reference used for dosage range:
Drugs low dose:
Drugs high dose:
Child’s low dose:
Child’s high dose:
Is this a safe dose for this child Yes: No:
Classification of Drug:
Indication of Drug:
Possible adverse reactions:
Drug:
Dose: Route: Times:
Weight of Child in KG:
Calculate dose range: (high and low)
Reference used for dosage range:
Drugs low dose:
Drugs high dose:
Child’s low dose:
Child’s high dose:
Is this a safe dose for this child Yes: No:
Classification of Drug:
Indication of Drug:
Possible adverse reactions:

PEDIATRIC FOCUSED ASSESSMENT Page 5
Student’s Name:
Drug:
Dose: Route: Times:
Weight of Child in KG:
Calculate dose range: (high and low)
Reference used for dosage range:
Drugs low dose:
Drugs high dose:
Child’s low dose:
Child’s high dose:
Is this a safe dose for this child Yes: No:
Classification of Drug:
Indication of Drug:
Possible adverse reactions:
Drug:
Dose: Route: Times:
Weight of Child in KG:
Calculate dose range: (high and low)
Reference used for dosage range:
Drugs low dose:
Drugs high dose:
Child’s low dose:
Child’s high dose:
Is this a safe dose for this child Yes: No:
Classification of Drug:
Indication of Drug:
Possible adverse reactions:
Drug:
Dose: Route: Times:
Weight of Child in KG:
Calculate dose range: (high and low)
Reference used for dosage range:
Drugs low dose:
Drugs high dose:
Child’s low dose:
Child’s high dose:
Is this a safe dose for this child Yes: No:
Classification of Drug:
Indication of Drug:
Possible adverse reactions:

PEDIATRIC FOCUSED ASSESSMENT Page 6
Student’s Name:
Pediatric Growth and Development Assessment
Patient’s age:
Include a brief description of each stage and the patient specific criteria for each stage. (What does the
textbook say and how does your specific patient meet these criteria).
Eriksson’s Stage of Psychosocial development for this child:
Patient’s Stage:
Plaget’s Stage of Cognitive Development:
Patient’s Stage:
Typical fears and/or issues of this age:
Patient’s stage:
Growth Assessment:
(Plot on growth charts in Nursing Care of Children, pages 1069-1072)
Height:
Weight:
What does this assessment indicate
% on growth chart:
% on growth chart:
Gross Motor:
Normal assessment for this age:

PEDIATRIC FOCUSED ASSESSMENT Page 7
Student’s Name:
Observed assessment:
Fine Motor:
Normal Assessment:
Observed Assessment:
Language/Communication:
Normal Assessment:
Observed Assessment:
Socialization:
Normal Assessment:
Observed Assessment:
Characteristics of Play:
Normal Assessment:

PEDIATRIC FOCUSED ASSESSMENT Page 8
Student’s Name:
Observed Assessment:
Appropriate Toys:
List of toys for this age group:
Toys this patient used:
Bibliography:

PEDIATRIC FOCUSED ASSESSMENT Page 8
Student’s Name:
PEDIATRIC
PHYSICAL ASSESSMENT
ASSESSMENT PARAMETERS
A"√” . (check mark) in the box indicates
congruence with
the assessment standards for each system. An "E"
indicates a baseline assessment standard for an
individual patient that reflects an exception to the
assessment standard. An .**(asterisk) in the box
indicates a finding that indicates a deviation from
both
the assessment standard and the patient's baseline
and
requires further elaboration in the boxes to the right.
Neurological Assessment
Alert and/or arouses easily. Oriented to person and
place, no change in usual behavior. No c/o dizziness,
numbness, tingling, pain, headache, seizures, memory
loss, insomnia, loss of consciousness. No paralysis
noted. Pupils equal and react to light. Speech dear for
age. No evidence of hearing or vision loss. Fontanel soft
and flat as appropriate for age.
Cardiovascular Assessment
Blood pressure, heart rate within normal limits for age.
Regular rhythm with no murmur noted. Nail beds pink
without clubbing. Capillary refill time less than or equal
to
3 seconds. No edema or cyanosis noted. No c/o pain.
Peripheral pulses palpable and equal. No history of blood
Transfusions.
Respiratory Assessment
Bilateral breath sounds clear throughout lung fields.
Respirations unlabored, symmetrical and regular with a
rate normal for age. No retractions, nasal flaring,
splinting, dyspnea, stridor or cough. No c/o pain.
Gastrointestinal Assessment
Abdomen soft, non-distended with active bowel sounds
in all quadrants. No c/o nausea, vomiting, diarrhea,
constipation or pain. No blood in stools.
Patient Initials:
AGE:
Diagnosis:
Temp:
Pulse:
Respiratory Rate:
B/P:
Route:
Route:

PEDIATRIC FOCUSED ASSESSMENT Page 9
Student’s Name:
Genitourinary Assessment
External genitalia appropriate for age and without signs
of inflammation, swelling, bleeding, discharge or local
skin changes. Testis descended x2. Amenarchal. If
menarchal, no dysmenorrhea. Able to void without
dysuria. Urine clear and yellow to amber. No c/o
frequency, urgency, pain or changes in urine output.
Integumentary Assessment
Skin color normal for ethnicity. No erythema, jaundice,
pallor, or flusing. Skin warm, dry, intact, firm and elastic.
Normal hair distribution! texture. No evidence of rashes,
petechiae, bruises, lesions, drainage, wounds, incisions, or
lice. Nail beds pink, nails smooth. No c/o pain.
Musculoskeletal Assessment
Full ROM of all joints. No muscle weakness. No evidence
of inflammation, swelling, or pain. Gait and ambulation
appropriate for age.
Eyes, Ears, Nose, Mouth, Throat Assessment
No drainage or bleeding. No c/o hearing or visual
disturbances. Sclera white and clear. Oral mucosa/gums
pink moist, no swelling or lesions. No c/o pain, does not
wear glasses, contacts or hearing aids.
Pain Assessment
Onset, location, duration, symptoms relieved by (i.e.
medication, distraction, etc) Activity: Asleep, restless,
thrashing or rigid, calm/awake; Verbalization: States no
pain, cannot localize pain, can localize pain, cannot
assess; Crying: Not crying, crying but consolable, crying,
inconsolable.
Pain Scale:
Rating: