Pediatric Assessment: School-Age Child (Name: [Child’s Initials], Date of Birth: [DOB], Current Age: [Years and Months])

QUESTION

PEDIATRIC ASSESSMENT

 *This project must be entered in Session 9*

It must type neatly this assessment and orderly, with a cover page that includes the following information:

1. Title: Pediatric Assessment (with applicable age group-e.g., School-Age Child)
2. Date
3. Your name, Student RN

There are three parts to any “intake assessment” Part IV is a student-driven component of the Assessment and should be on a separate page of the document.

1. The Interview & Health History 
2. Patient Profile:

Include the child’s initials, date of birth, and current age (years and months)

Record apparent/subjective information on interaction with family and peers.

For older children, ask about school performance: grades, achievements, and general progress.

Note habits-thumb sucking, nail-biting, hobbies, sports participation, activities (fishing, hunting, reading, travel, other)

If relevant, include peer group activities and employment performance for teens. (For this assignment, we will not analyze sexual activity, drug use, or parent-child disputes, however, they are part of the health history in a professional evaluation.)

1. Developmental Profile:

Note Erikson’s stage of development-document examples of how the patient evidences the characteristics of this stage.

(Example: a nine-year-old male stage of Industry vs. Inferiority: describes school experiences with enthusiasm, enjoys math and science classes, plays on a basketball team with classmates. The stage of Industry is apparent. If the child presents with a negative resolution of inferiority, what steps might you take to help them reach a positive resolution?)

1. Nutritional Status:

Infants: feeding (breast/bottle) if on the bottle what type of formula, frequency, and duration of feedings, use of supplemental iron or fluoride, types of solid foods fed, and when introduced.

Children’s eating patterns, preferences, particular foods consumed, and vitamin supplements?

1. Elimination Pattern:

Bladder habits-voiding frequency, presence of enuresis, burning or pain

Bowel habits-assess for the existence of constipation, bleeding, and complaint of pain with defecation (and yes, you will need to ask specifically about “peeing and pooping” as defecation, enuresis, and voiding, are not in everyone’s vocabulary) and what is the average bowel frequency for this child?

1. Sleep/Rest Pattern:

Typical bedtime, average hours of sleep, number and length of daily naps

1. Sensory-Perceptual Pattern:

The child wears corrective lenses, hearing aids, or other special medical equipment.

1. Value-Belief Pattern:

Include religious affiliation if applicable (consider how this information plays a part in the care of the child in the stressed situation)

1. Childhood Illnesses/Accidents/Injuries/Operations/Hospitalizations
2. Current Health Status 
3. Allergies/Sensitivities
4. Current Medications
5. Immunization Status-next due?
6. Reason for Exam: Wellness Exam
7. Physical Assessment* (8 points)
8. General Appearance and assessment findings:
9. General Physical Survey to include available vital signs
10. Skin, hair, nails
11. Head and neck
12. Eyes
13. Ears
14. Nose and sinuses
15. Mouth and pharynx
16. Cardiac and peripheral vascular system
17. Thorax and lung
18. Abdomen
19. Musculoskeletal
20. Neurologic

*Note: use your Pediatric text for help

For your selected patient: 

1. Identify two priority nursing diagnoses.
2. Identify two measures for injury prevention in this age group (remember to consider injury prevention for the specific needs of a handicapped/special needs child relative to their developmental stage)

ANSWER

Pediatric Assessment: School-Age Child (Name: [Child’s Initials], Date of Birth: [DOB], Current Age: [Years and Months])

Date: [Date]
Student RN: [Your Name]

Patient Profile

[Child’s Initials] is a [age]-year-old school-age child who presents with apparent positive interactions with family and peers. He/she is thriving in school, achieving good grades, and actively participating in extracurricular activities, such as basketball and reading. [Child’s Initials] has developed several hobbies, including fishing and travel, which contribute to his/her overall well-being.

Developmental Profile

[Child’s Initials] is currently in Erikson’s stage of Industry vs. Inferiority. He/she demonstrates characteristics of this stage by enthusiastically describing school experiences, excelling in math and science classes, and actively participating in team sports with classmates. The child’s resolution of industry is apparent, fostering a sense of competence and accomplishment. In the rare case of a negative resolution, steps to encourage a positive resolution would involve providing support, positive reinforcement, and opportunities for skill-building to boost self-confidence and competence.

Nutritional Status:
[Child’s Initials] is breastfed and introduced to solid foods at the appropriate developmental stages. His/her eating patterns include a diverse diet, with a preference for fruits and vegetables. There are no vitamin supplements in his/her diet, as [Child’s Initials] receives essential nutrients through balanced meals.

Elimination Pattern

[Child’s Initials] has regular bladder habits, with no enuresis or complaints of pain or burning during voiding. Bowel habits are regular, and the average bowel frequency is [number] times per day. [Child’s Initials] has no complaints of constipation or bleeding during bowel movements.

Sleep/Rest Pattern:
[Child’s Initials] typically goes to bed at [time] and sleeps an average of [number] hours per night. He/she does not take daily naps.

Sensory-Perceptual Pattern:
[Child’s Initials] does not require corrective lenses, hearing aids, or other special medical equipment.

Value-Belief Pattern:
[Child’s Initials] identifies with the [religious affiliation] faith, which may play a role in providing comfort and support during stressful situations.

Childhood Illnesses/Accidents/Injuries/Operations/Hospitalizations:
[Child’s Initials] has no significant past medical history of illnesses, accidents, injuries, operations, or hospitalizations.

Current Health Status:
[Child’s Initials] is currently in good health, with no known medical conditions or chronic illnesses.

Allergies/Sensitivities:
[Child’s Initials] has no known allergies or sensitivities.

Current Medications:
[Child’s Initials] is not taking any medications at present.

Immunization Status:
[Child’s Initials] is up-to-date with all immunizations. The next due immunization is [next due date].

Reason for Exam: Wellness Exam

Physical Assessment

[Use the pediatric textbook for guidance]

Priority Nursing Diagnoses:
Impaired Physical Mobility related to [specific condition or factor], as evidenced by [specific observations or patient statements].
Risk for Injury related to [specific risk factors], as evidenced by [specific potential hazards].

Injury Prevention Measures for this Age Group:
Encourage parents and caregivers to implement age-appropriate safety measures at home and during activities, such as using child safety locks, securing furniture to the wall, and using helmets during sports and cycling.
Educate the child and parents on the importance of pedestrian safety, including using crosswalks, looking both ways before crossing the road, and being mindful of traffic signals and signs.

Conclusion

The pediatric assessment of [Child’s Initials] indicates a healthy and active school-age child with positive interactions in family and peer settings. By prioritizing nursing diagnoses and implementing injury prevention measures, healthcare providers can ensure [Child’s Initials]’ well-being and contribute to fostering a safe and nurturing environment for optimal growth and development.