Você está na página 1de 7

PEADIATRIC HISTORY TAKING

PATIENT IDENTIFICATION:

1. PATIENT NAME………………………………………
2. AGE & SEX………………………………………
3. FATHER’S NAME………………………………………
4. CHIEF COMPLAINT………………………………………
5. FAMILY INCOME…………………………………………
6. DATE OF ADMISSION……………………………………
7. O. P. D. No.………………………………………………
8. I. P. D. No. ………………………………………………….
9. BED No.…………………………………………………….
10. UNIT………………………………………………………
11. WARD………………………………………………………
12. HOSPITAL………………………………………………
13. DIAGNOSIS………………………………………………
14. NAME OF SURGERY…………………………………….
15. ADDRESS.…………………………………………………

PRENATAL HISTORY
1. COMPLICATION DURING PREGNANCY
………………………………………………………………
2. ULTRA SOUND DURING PREGNANCY
………………………………………………………………
3. MEDICATION USED DURING PREGNANCY
………………………………………………………………..
4. CIGARETTE/ALCOHOL USED DURING PREGNANCY
………………………………………………………………
5. ANY HEALTH PROBLEM
………………………………………………………………

BIRTH HISTORY

1. WAS THE DELIVERY VAGINAL OR CESARIEAN


…………………………………………………………………
2. BABY BIRTH WEIGHT (IN KG.) ……………………………
3. BABY LENGTH AT BIRTH (IN CM.)
(i) HEAD TO TOE………………………………………………
(ii) CROWN TO RUMP………………………………………...
4. ANY HEALTH PROBLEM AT BIRTH ………………………

1
DEVELOPMENTAL HISTORY
AT WHAT AGE CHILD ABLE TO

1. RESPOND TO SOUND …………………………………………


2. HOLD HEAD UP………………………………………………..
3. STAND ALONE …………………………………………………
4. WALK ALONE…………………………………………………..
 IMMUNIZATION
……………………………………………………………
 PAST MEDICAL HISTORY
……………………………………………………………
 PAST SURGICAL HISTORY
……………………………………………………………
 MATERNAL HEALTH IN PREGNANCY
……………………………………………………………
 GASTRITIONAL AGE OF DELIVERY TIME
…………………………………………………………….
 TYPE & PERIOD OF DELIVERY
……………………………………………………………

NEONATAL PERIOD

 BIRTH PROBLEM
…………………………………………………………
 FEEDING PROBLEM
…………………………………………………………
 WEIGHT AT BIRTH
…………………………………………………………

APGAR SCORING

CRITERIA 0 1 2
RESPIRATION

HEART RATE

MUSCLE TONE

REFLEX RESPONSE

SKIN COLOR

2
FAMILY & SOCIAL HISTORY

1. ILLNESS IN FAMILY
………………………………………………………
2. CONGENITAL DISEASE IN FAMILY
…………………………………………………………………..
3. LIVING CONDITION OF FAMILY
…………………………………………………………………...
4. COMPOSITION OF FAMILY
……………………………………………………………………
5. OCCUPATION OF FAMILY
…………………………………………………………………….

PHYSICAL EXAMINATION
(A) VITAL SIGNS

 TEMPERATURE………………………………………………
 PULSE ………………………………………………………..
 RESPIRATION ……………………………………………….
 BLOOD PRESSURE ...…………………………………

(B) GENERAL EXAM

 HYDRATION LEVEL………………………………………………
 LOOK…………………………………………………………………
 SPEECH ………………………………………………………………
 DRESS………………………………………………………………….
 BODY CURVE…………………………………………………………
 HEIGHT ………………………………………………………………
 WEIGHT………………………………………………………………
 NUTRITIONAL LEVEL………………………………………………
 CONSCIOUSNESS LEVEL………………………………………….
 CYANOSIS LEVEL……………………………………………………
 MATERNAL CONDITION……………………………………………

(C) HEAD

 SHAPE AND SIZE…………………………………………………


 FONTANELLES ……..…………………………………………….
 SUTURES…………….…………………………………………….
 HAIR DISTRIBUTION………………………………………………
 SCALP INJURY…………………………………………………………

(D) SKIN & LYMPH

 RASHES ………………………………………………………………
 COLOR ………….…………………………………………………….
 VASCULARITY ………………………………………………………
 PIGMENTATION ……………………………………….……………
 MOISTURE ………………………………………………………….…

3
 TEMPRETURE …………………………………………………………
 TURGOR ………………………………………………………….……
 LESIONS ………………………………………………………….……
 EDEMA ………………………………………………………….………
 HAIR DISTRIBUTION …………………………………………………
 INJURY ………………………………………………………….………
 BIRTH MARKS …………………………………………………………
 LYMPH NODE ENLARGEMENT ……………………………………

(E) EYES EXAM

 COLOR OF SCLERA …………………………………………………….


 STRABISMUS…………………………………………………………….
 CONJUCTIVA …...…….…………………………………………………
 VISUAL FIELD……………………………………………………………
 EYE BROWS ……………………………………………………………..
 EYE POSITION…….…………………………………………………….
 EYE LASHES……………………………………………………………
 EYE BALL….. .……………………………………………………………
 LENS ……………………………………………………………………….
 EYE MOVEMENT …………………………………………………………
 PUPILS …………………………………………………………………….

(F) EAR

 POSITION OF EAR ………………………………………………………..


 TYMPENIC MEMBRANE …………………………………………………
 HEARING………………………………………………………..………….
 DISCHARGE ………………………………………………………….……
 EAR CANAL………………………………………………….……………

(G) NOSE

 SIZE & SHAPE …………………………………………………………..


 NASAL SEPTUM …………………………………………………………
 MUCOSA OF NOSE ………………………………………………..……
 NOSTRILS………………………………………………………………..
 SINUSES……………………………………………………………………
 SECRETIONS ………………………………………………………………

(H) MOUTH & THROAT

 LIPS CONDITION……………………………………………….
 TEETH CONDITION……………………………………………
 GUM COLOR & BLEEDING……………………………………
 TONGUE COLOR & POSITION………………………………
 TONSIL SIZE & COLOR ………………………………………
 GAG REFLEX……………………………………………………
 ODOUR OF MOUTH ……………………………………………
 PHARYNX ……………………………………………………..

4
 VOICE…………………………………………………………….
 THYROID GLAND……………………………………………..
 TRACHEA POSITION……………………………………………
 STIFFNESS OF NECK ……………………………….…………..
 MOVEMENT ……………………………………………………
 LYMPH NODES…………………………………………………..
 EXTERNAL JUGULAR VEIN……………………………………
 CAROTID ARTERY……………………………………………….

(I) LUNG & THOREX

 INSPECTION ……………………………………………………..
 BREATHING PATTERN …………………………………………
 RESPIRATION RATE…………………………………………….
 SHAPE ……………………………………………………………
 BREATHING SOUND ……………………………………

(J) BREAST

 APPEREANCE…………………………………………………….
 SYMMETERY …………………………………………………….
 AXILLIRIES LYMPH NODES …………………………………

(K) CARDIO VASCULAR

 HEART SOUND ………………………………………………….


 RHYTHM………………………………………………………….
 PULSE……………………………………………………………..

(L) ABDOMEN

 INSPECTION…………..………………………………………….
 APPEARANCE …………………………………………………..
 POSITION OF UMBLICUS ………………………………………
 PALPITATION…………………………………………………….
 PERCUSSION …………………………………………………….
 AUSCULTATION/…………………………………………………
 BOWL SOUND……………………………………………………

(M) MUSCULOSKELETON

 BACK……………………………………………………………
 JOINT TENDERNESS….………………………………………
 DEFORMITY….…………………………………………………
 SYMMETRY…….………………………………………………

5
(N) NEUROGENIC

 REFLEX…………………………………………………………
 SENSATION …….……………………………………………
 CONVULSION …….……………………………………………
 COMA …….………………………………………………………

(O) GENITO URINARY EXAM

MALE-

 EXTERNAL GENITAL AREA …….………………..……………


 ENLARGEMENT…….……………………………………………
 ABNORMILITY …….………………………………………………
 PENIS…….…………………………………………………………
 SCROTUM …….……………………………………………………
 TESTES…….………………………………………………………
 HERNIA …….………………………………………………………
 RECTUM …….…………………………………………………..…
FEMALE-
 ENLARGEMENT OF CLITORIS……………………………………
 LABIA MAJORA……………………………………………………
 LABIA MINORA……………………………………………………..
 PATENCY OF ANUS………………………………………………..

(P) INVESTIGATION

Sr. No. INVESTIGATION FINDING NORMAL RATE

1
2
3
4

(Q) Medication Chart

Sr. No. Name of Medication Dose Route Time Remark


1
2
3
4
5
6
7

6
(R) NURSING MANAGEMENT

ASSESSMENT NURSING GOAL/PLANNING INTERVENTION EVALUATION


DIAGNOSIS

(S) HEALTH EDUCATION