ASSIGNMENT: Pediatric Group Project & Presentation

Assessment of a Preschool Age Child (age 3-6 years, not enrolled in school)
Student(s)
Age of Client
Person(s) _________ child _________ mother _________ father _________ other: _______________________________________
Interviewed

Current Medical History (list, if any; if none, indicate NONE)

Allergies (medications, food, other; if none, indicate NKA)

Substance Reaction

Current Medications
Name Indication

Complementary and Alternative Modalities in Health Care (herbals, supplements, chiropractic, shaman; if none, indicate NONE)
Name Indication
 Description Date/Year Residual Problems
Previous
medical
conditions
Previous
hospitalizations
Injuries
Surgeries

Current Immunization Status

Are immunizations up-to-date?
(If No, explain parent’s rationale)
Reactions to vaccines (list, if any
and to which one(s); if none, put
NONE

Newborn Course
Findings (Do not use ‘normal’, ‘within defined limits’, etc.)
Birth History
(Gestational age and growth
pattern; length & weight)
APGAR
(Apgar score and type of
resuscitation if required)
Neonatal Complications
(Respiratory, infections, feeding,
hyperbilirubinemia, congenital
abnormalities)
 Family Detail
Placement in the family

Family structure

Cultural heritage

Impact of culture on health care

beliefs and practices (NONE is not
an option)
Family genetic concerns

Family History
Person Age Current medical issues; Person Age Current medical issues;
or cause & age at death or cause & age at death
Mother
Father
Maternal Paternal
grandmother grandmother
Maternal Paternal
grandfather grandfather
Aunt or Uncle Aunt or Uncle
(specify) (specify)
Aunt or Uncle Aunt or Uncle
(specify) (specify)
Sister Brother

Sister Brother

Sister Brother

Other Other (specify)

(specify)
 Development
Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the *Concern
actual findings to the expected findings of the
child you assessed)
(bullet findings; do not use ‘normal’, ‘within defined limits’, etc.). Place an asterisk if you deem this a ‘Concern’ for
this client)
How does a child of They are pursuing interests and independent
this age interact with activities. They explore their environment and use
their environment? imaginative play, they learn to cooperate with
others and lead
What is the common -3 years = The child comprehends up to 4200 -
language 5600 w0rds.- Uses 900-1000 words
development for expressively. use three- to four-word
children age 3 years sentences, Complex sentences and good at
compared to age 6
introducing new topics but not sustaining
years? (number of
topic.
words, use of phrases,
articulation, ability to
convey thoughts and -6 years = 8000 to 14000 words. Tells long
ideas) stories; retells tales of past and present events.
Understands concepts such as yesterday-
tomorrow, more-less- Can state similarities
and differences of objects.

How should the By asking the child to follow simple directional

family evaluate this commands such as “put the ball on the chair”
child’s language They can answer questions like “what do you
development? do when you’re hunger”
-the pattern of asking questions is at its peak
children usually repeat question until they get
a answer.
What are normal -Stranger anxiety and fear of separation from
social behaviors parents are overcome
children of this age -Parental security and guidance are still needed
exhibit with siblings, -Security is derived from familiar objects
parents and peers? -Play therapy is beneficial for working through
fears, anxieties, and fantasies
 Development
Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the *Concern
actual findings to the expected findings of the
child you assessed)
How do children in They forms strong attachment to opposite-sex
this age group parent while identifying with same-sex parent
express their -Modesty becomes a concern
sexuality? -Child evinces sex role limitation, "dressing up like
Mommy or Daddy"
-Sexual exploration is more pronounced
-Questions arise about sexual reproduction

In which of Erikson’s They are in the initiative vs guilt stage.

developmental stages Developing sense of initiative
should this child be?
What are the major - 3 years old
tasks/milestones of •Gross motor: jump forward, ride tricycle
this stage for the •Verbal: understandable
child? •Fine motor: copy circle or dash
•Self-care: play board games, dress, brush teeth,
make bowl of cereal
- 4 years old
•Gross motor: hop on 1 foot
•Verbal:
•Fine motor: copy a cross (+), draw a stick figure
•Self-care: button clothes
- 5 years old
•Gross motor: tie shoes
•Verbal: identify colors and coins, count to 5
•Fine motor: copies square and triangle
•Self-care: ties shoe strings
- 6 years old
•Logical thinking begins
What are the major Parental awareness of signs of stress
tasks of this stage for in child's life
the family? How -Stressors
should they Birth of a sibling
Divorce or separation
 Development
Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the *Concern
actual findings to the expected findings of the
child you assessed)
demonstrate love & Relocation
caring for the child? Illness
What are normal -12hrs a night
sleep patterns at this
-nightmares
age & how do these -20% REM
patterns fit in with -by age 5 rarely takes naps
the normal family
-difficulty relaxing/whining down
routine?
problems with bedtime fears, waking during
the night, or nightmares. Partial wakening
followed by normal return to sleep is frequent.
In the waking period children exhibit brief
crying, walking around, unintelligible speech,
sleepwalking, or bedwetting
What bedtime rituals -encourage and engage children is quit
are recommended for activities before bed time maintain specific
this age group? rituals that signal bedtime
-story telling
What are common -Increase in pedestrian-motor vehicle accidents
safety -Education concerning safety and potential
hazards/precautions hazards
for this age group? -Appropriate protection
Bicycle helmets
Protective equipment

What should children -Caloric requirements: approximately 1400-

of this age be eating 1600 calories per day
and what are their -Fluid requirements: approximately 100
normal eating mL/kg, depending on activity and climate
patterns? How should
-Food fads, strong tastes: common
parents cope with the
-Amount of food: varies greatly from day to
child’s eating
patterns? day
 Development
Expected Findings (as found in your textbooks) Actual Findings (compare and contrast the *Concern
actual findings to the expected findings of the
child you assessed)
-Obesity in young children: has increased
dramatically

What is typical for physical ability

bladder and bowel independent toileting
control and training? guidance: washing hands and flushing toilet
preschooler responsible for changing clothes
handle in gentle and encouraging ways.
Cite Resource(s) for Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2014). Maternal child nursing care. St. Louis, MO:
Expected Findings Mosby.

Child Interview *Concern

Who are your heroes?
What types of activities
(sports, church, etc.)
do you engage in?
How do you balance
this with school?

Parent Interview *Concern

How do you feel
about competition?
How do you
anticipate your child
will perform in school
or challenges your
child may
experience?
What role do you
assume in assisting
your child to be
successful
academically?

Examinations
Date Findings/Comments
Physical exam
Dental exam
Vision exam
Hearing exam

Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
Technique in your textbooks) expected findings of the child you assessed)
(bullet findings; do not use ‘normal’, ‘within defined limits’, etc.). Place an asterisk if you deem this a ‘Concern’ for
this client)
Vital Signs Heart rate:
Respiratory rate:
Height/Weight Ht for 50th percentile: Per caregiver:
Wt for 50th percentile: Ht:
Wt:
Skin:
 Inspect skin for
coloration,
birthmarks, lesions,
turgor.
Hair and Nails
 Inspect scalp for
texture and hair
distribution.
Head and Neck
 Inspect and palpate
for symmetry and
suppleness.
 Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
Technique in your textbooks) expected findings of the child you assessed)
Eyes, ears, nose, and
throat:
 Inspect eyes for
color and
appearance.
 Perform appropriate
visual screening.
 Inspect ears for
position and surface
characteristics.
 Inspect mouth for
color, lesions, and
intactness.
 Inspect teeth for
presence and
characteristics.
Respiratory
 Inspect chest for
respiratory effort
and depth.
 Auscultate anterior
and posterior chest
for lung sounds.
Cardiovascular
 Evaluate pulse for
rate, rhythm,
characteristics
(apical for infant,
radial for older child)
 Auscultate heart
sounds
Abdomen:
 Auscultate for bowel
sounds
 Physical Assessment
Examination Expected Findings (as found Actual Findings (compare and contrast the actual findings to the *Concern
Technique in your textbooks) expected findings of the child you assessed)
 Inspect for
symmetry, color,
surface
characteristics.
 Very gently palpate.
Musculoskeletal:
 What should the
patient be doing
now?
 Inspect development
appropriate for age.
 Inspect muscle
strength.
 Inspect symmetry of
movements
 Inspect gait and
coordination
Neurological:
 Observe gait for
balance and
coordination.
 Test extremities for
superficial tactile
sensation.
 Evaluate general
mental status.
Cite Resource(s) for
Expected Findings

Teaching/Learning
Based on findings collected, outline areas of teaching that will promote health for this client/family (focus on *Concern items).
Topic Rationale 1) To whom will you direct the teaching to?
2) What techniques will you use?
3) How will you evaluate if learning has occurred?
 Self-Evaluation of Therapeutic Communication & Assessment Technique During the Interview
Which therapeutic techniques did
you use to obtain the health
history? Explain if they were
effective or not and any
recommendations you may have?
What techniques did you use to
perform the physical assessment?
Explain if they were effective or
not and any recommendations you
may have?
What techniques did you use to
build trust with the caregiver(s)?
Explain if they were effective or
not and any recommendations you
may have?
 Pediatric Teaching/Learning Project GRID
Students:

Teaching Topic (focus on one topic only from your ‘Concern’ column):

Nursing Diagnosis (Wellness/Health Promotion Focus with AEB; relate it to your teaching topic):

Goal (relate it to your teaching topic):

Learner Objectives/Outcomes Nursing Interventions Anticipated Evaluation of Learning

(Include methods of instruction) (How will you know that the
client met the outcome?)
Domain of Learning: 1) 1)

2) 2)
Cognitive outcome:

Domain of Learning: 1) 1)

2) 2)
Affective outcome:

Domain of Learning: 1) 1)

2) 2)
Psychomotor outcome:

Cite Resources: