Suffolk County Community College - DOC by 6Ru726Y

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									                        Suffolk County Community College
                                 School of Nursing
                            Pediatric Assessment Guide
                                     NUR 246

Name _____________________________         Date submitted ______________________

Patient Profile

Initials of Patient ________ Age _________ Sex ________ Grade __________________

Height ________ % Height ________        Weight ________ %Weight________ BMI______
(plot on appropriate graph from http://www.cdc.gov/growthcharts and Child and Teen BMI
Calculator on CDC website and submit with NCP)

Date of patient care ___________________

Reason for Admission to Hospital
(Subjective)______________________________________________________________
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Ethnic Background ________________________________________________________

Culture / Pertinent Cultural Practices / Religion
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Type of dwelling patient lives in _____________________________________________

Family Constellation (members living with child)
       Relationship                                             Age
       1. ________________________________________              ______________
       2. ________________________________________              ______________
       3. ________________________________________              ______________
       4. ________________________________________              ______________
       5. ________________________________________              ______________

Past History – response to any previous hospitalizations
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Immunizations: List all immunizations applicable to the child’s age.
(See Recommended Childhood Immunization Schedule http://www.cdc.gov/nip/acip and submit
with NCP)
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Present Health

Allergies to: medications, foods, environment, include reaction
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Sleep Routine ____________________________________________________________

Bowel Routine: state usual pattern (diapers, toilet trained, incontinence, methods/supplies)
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Nutrition: identify the expected caloric intake for a child of your patient’s age.
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For children 2 years of age and older, using a typical 24 hour recall compare the child’s diet to
the recommended diet on the food pyramid @ www.mypyramid.gov and submit with NCP.
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For children < 2 years of age, state a typical 24 hour recall compare the child’s diet to the
textbook.
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State food preferences (uses cup, finger foods, feeds self, food jags)
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Dentition (primary or secondary teeth, daily oral health care, cavities, dentist visits, orthodontics)
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Favorite toy, interests, hobbies:
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Home medications (include herbs, minerals, vitamins)
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Developmental Assessment- Complete either page 9 or 10 depending on your patient’s age

Complete the Denver II if your patient is between the ages of 0 and 6 years. This is a tool for
screening the apparently normal child. This screen identities those children who may have
developmental delays. Further evaluation is needed for a definite diagnosis.

Directions:
   1. Print out the Denver II on page 11 of this packet
   2. Age Calculation: Draw a vertical line for the age of the child. For children born before 38
       weeks’ gestation, age should be corrected for prematurity, up to 2 years of age. Each item
       that intersects or is just adjacent to the age line should be scored.

   3. Scoring
             Advanced: Child passes item that falls completely to the right of age line.
             Normal: Child passes, fails, or refuses item on which the age line falls between
                   the 25th and 75th percentiles
             Caution: Child passes, fails, or refuses item on which the age line falls between
                   the 75th and 90th percentiles
             Delayed: Child passes, fails, or refuses item that falls completely to the left of age
                   line
             Assessment: Child fails if two or more delays are noted. Child passes with no
                   delays and a maximum of one caution

   4. Based on the result of your Denver Development II, what are the results? What is the
      approximate developmental age of your patient? Be specific.

Personal – Social _________________________________________________________
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Fine Motor – Adaptive ____________________________________________________
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Language _______________________________________________________________
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Gross Motor ____________________________________________________________
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Development Milestones: If the patient you are providing care for is over 6 years of age
                        do not use the Denver Development II.

Instead, compare/contrast developmental tasks/needs stated in the textbook (include physical,
gross motor, sensory, language, socialization)

Textbook                             Patient
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Nursing Care-

How did you approach this patient to provide nursing care, based on your patient’s
developmental age?
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How did you incorporate therapeutic play into the care of your patient? Remember all pediatric
patients play, this does not refer to the use of toys only! See text for description of play in all
aged children and the value to nursing care.

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              Teaching Plan regarding Developmental Level of Child includes:

Anticipatory Guidance: based on the developmental age of the patient

Nutrition ________________________________________________________________
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Elimination ______________________________________________________________
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Sleep Patterns ____________________________________________________________
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Social/Family Relationships _________________________________________________
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Parenting Practices ________________________________________________________
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Injury Prevention _________________________________________________________
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Behavioral Development ___________________________________________________
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Discharge Planning /Anticipated Home Care Needs
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Journal Summary:
Review the sections of your nursing text and select a current nursing/professional journal that
relates to problems similar to those of the child you are taking care of.
This review of one nursing/professional journal article must be typed on a separate piece of
paper.

References:
Using APA format identify texts, journals and other relevant sources used when writing
NCP. Dictionaries and medical “manuals” are not acceptable references. Submit this
reference information on a separate sheet of paper. Reference page must be typed.

								
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