PEDIATRIC NURSING PROCESS

(FEMALE SURGICAL WARD)

SLR

Ma. Teresa Cercado, RN

RC Amor Vagilidad BSN 4D

West Visayas State University

COLLEGE OF NURSING
 La Paz, Iloilo City

PEDIATRIC NURSING PROCESS

I. VITAL INFORMATION
Name: Date and Time of
Interview:
Sex:
Date of Birth: Name of Informant:
Age: Relationship to the child:
Address:
Date and Time Admitted:
Chief Complaints:
Ward:
Religious Affiliations:
Name of Mother:
Educational Attainment:
Occupation:
Name of Father:
Educational Attainment:
Occupation:
Approximate monthly income of the family:
Mother
Father
TOTAL
Physician:
Impression/Diagnosis:

II. CLINICAL ASSESSMENT

A. Nursing History
History of present illness
a. Usual Health Status

b. Chronologic Story
 A. Past Medical History
_____Parasitism _____BPN
_____AGE _____Accidents
_____AGN _____Anemia
_____Allergy (specify): _____Seizures
_____Tuberculosis _____Emotional
Disorders
_____Measles _____Others

Number of previous hospitalizations:

Date of last confinement:
Where:
Reasons for confinement:
1. Family History
Birth order of patient:
Total number of siblings:
Number of living siblings:
Serious diseases/illnesses of siblings:
Causes of death/serious illnesses of siblings:

Heredo-familial diseases:

Disease Maternal/Paternal Specific Family

Member
Tuberculosis
Diabetes Mellitus
Asthma
Hypertension
Cancer
Genetic Disorders
Others

2. Maternal and prenatal History

Maternal age when the child was born:
Age of gestation and birth 9 months (37 weeks), 8.5 lbs.
weight
Pre-term
Full term
Post term
Complications related to pregnancy:
Parental views of pregnancy:

Patient’s problems (1st month):

Child’s ability to get along with people as viewed by

parents:
 Early behavior patterns as viewed by parents:

Parent’s attitude towards child rearing:

I. PATTERNS OF FUNCTIONING
Nutritional History and Eating Patterns
A. Infants up to 1 year
TYPE OF FEEDING AGE DURATION INTERVAL
STARTED
1. Breastfed
2. Bottlefed
3. Mixed
4. Type and Brand of
Milk
a. Evaporated
b. Condensed
c. Powdered
d. Others

Approximate intake per 24 hours:

Problems during weaning:
Vitamins and minerals supplement:
Type:
Dosage/Amount:

For children 1 year and above:

Meal Type and amount of foods
usually taken
Breakfast

Morning snacks

Lunch

Afternoon snacks

Supper

Food likes:
Food dislikes:
Allergies:
Problems related to nutrition:
Supplementary foods:
Age Started Kind/type and Frequency
amount
1-3
4-6
7-9
10-13

Elimination
Frequency Problem/difficulti Usual
es remedy
Bowel
Movement

Urination

Toilet Training
Age in month Found in As seen in the Significance
started textbook patient and/or
verbalized by
significant
person

Bowel:

Bladder:

Sleeping Patterns:
Usual Usual Approxima Sleeping Special Problem
patter time te total arrangeme rituals s with
ns number of nts sleeping
sleep/24
hours
Immunization Status:
Type 1st Ag 2nd Ag 3rd Ag Boost Ag Boost Ag
dos e dos e dos e er 1 e er 2 e
e e e

BCG

DPT

OPV

Hepa B

Measle
s/ MMR

Play:
a. Appropriateness of available toys

b. Availability and safety of play areas

c. Favorite toys and activities

d. Child initiative and amount of creative play

e. Preferred play: Solitary:________

Parallel:_________
Cooperative: _________
f. Peer interaction
I. DEVELOPMENTAL ASSESSMENT
A. Developmental History
Applicable during infancy (1-12 months)
Patterns of Age in Age in As seen in Significanc
developmen months months the patient e
t when found in and/or
manifested textbook verbalized
by the
informant
Smiles and
regards
Holds up
head when
prone
Follows
objects with
eyes
Turned self
form prone
to supine
First
eruption of
tooth
Sat with
support
Crawls/cruis
es
Stands alone

I. PRESENT MEDICAL HISTORY

A. Measurements:
Weight:
Height:
Head circumference:
Chest circumference:

B. Clinical Inspection:
Date and time taken:
Vital Signs:
Temperature: _______
Respiratory rate: ________
Pulse rate: _________
Blood pressure: _________

C. Reflexes:

a. Sucking Reflex:
b. Plantar Grasp Reflex:
c. Babinski Reflex:
d. Moro Reflex:
e. Stepping Reflex:
 f. Palmar Plantar Grasp:

II. PHYSICAL ASSESSMENT

General Appearance:

A. Integumentary System

B. Neurologic System

C. Respiratory System

D. Cardiovascular/ Circulatory System

E. Genito-urinary System
F. Gastrointestinal System

G. Reproductive System

H. Endocrine System

I. Musculoskeletal System

J. Lymphatic System

K. Hematopoietic System