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ASSESSMENT OF CHILDREN IN CRITICAL CARE UNIT (NURSE PRACTITIONER).docx

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PGIMS Rohtak
PGIMS Rohtak

Assessment of Children

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ASSESSMENT ON CHILDREN 2022-2024 Submitted By: Submitted To: Komal Mrs. Rajpati Roll no. 402 Lecturer Npcc 1st year College of Nursing
A. HISTORY TAKING 1. Patient profile: Name:- Diksha Father Name:- Mr. Sataywan Age:- 2 year Sex:- Female Marital Status:- Unmarried Religion:- Hindu Residence:- Dharodi, Jind Haryana Occupation:- Nil Date of Admission:- 24/07/2023 at 03:55pm Mode of Admission:- Emergency(trauma traige) C.R NO.:- PGIMS/23/65218 Comorbidities:- NO Unit:- General surgery ward 6(Neuro-surgery) 2. Chief Complains : Increase in head size vomiting Irritability 3. History of presenting complain: Parents of the patient first noticed the Increase in head size at the age of 3 months and Since then, the deformity gradually increased. Patient was operated at the age of 6 months for hydrocephalus and was discharged. 2 months back patient came with complains of fever and irritability. Infection was found at shunt site and shunt removed. Head size again increased from 5-7 days before admission which was associated with c/o vomiting and irritability. Patient was diagnosed with hydrocephalus and was decided to be operated for shunt surgery again 4. Past medical history No history of TB, DM , Asthma, convulsion 5. Drug history no history of any drug allergy. 6. Family history- not significant No history of congenital disease H/O Full term normal delivery 7. Personal history: Normal bowel and bladder habits Average built and nourished, proper breast feeding, normal developmental milestones 8. Allergic history : No any drug allergy or food allergy. 9. Blood transfusion history:No any history of blood transfusion. 10. Socioeconomic history: Urban Good sanitation facility. Good water supply.
Good eletrical supply. 11. Developmental history:- Language and communication:- by syllables( Amma) Social:- no social smile Does not recognise mother Immunized for age 12. Dietary history:- Exclusive breast feeding till the age of 5 months. Weaning :- 5 months Presently eat with family 13. Developmental goals which includes smiling, crawling, walking, being able to roll over,palmer grisp and pincer grisp are developed acc.to age B. General Physical Examination:- 1) Vital signs and baseline measurements Temprature:- 38.8属c ( rectal) Heart rate:-160 bpm B.P:- 98/52mm/hg Height:-57cm Weight:-4.5kg 2) Skin, hair and nails Skin is smooth and no lesion is present on body. Little body or facial hairs are present. Nails are intact and smooth C. Systemic Examination : 1. HEENT Head is enlarged. Assessment of eye and vision is appropriate for the developmental stage and age of child. 2. Lungs and Respiratory system Respiratory rate:- 40bpm Palpate the chest with 2-3 fingers. On Palpation bilateral sounds are equal and clear. Spo2 :- 95% on room air. 3. Heart and Peripheral vascular system Auscultate heart with Bell of stethoscope at supraclavicular space . Child's heart rate and rhythm are normal. 4. Musculoskeletal system Patient is able to move all four limbs well.
5. Abdomen and GI system Emesis is present during examination. 6. Neurologic system Patient is irritable , awake , fussy and difficult to console. Anterior fontanel is slightly bulging Pt is conscious Average built and nourished Afebrile Pallor- / Icterus-/ Cyanosis-/ clubbing- Neck veins not engorged Pulse 110/min, regular, normal volume , all peripheral pulses palpable 7. Respiratory examination Chest movements symmetric. B/L equal air entry,no added sounds No abnormality detected 8. Cardiovascular examination S1, S2 Sounds are normal. No murmur, No abnormality detected No history of any cardiovascular disorders includes vessels diseased, structure problems, blood clots, valvular defects , patent ductus arteriosus etc. 9. Central nervous examination Conscious , Motor function muscle tone, power and DTR within normal limits Sensory function within normal limits No history of central nervous system disorders includes coma,paralysis,meningitis. 10. Head examination:- Large head (increased circumference) Shiny scalp with dilated veins Fullness of the ant.fontanele Sun set appearance of the eyes. Eye exam. And reflexes are normal 11. Urinary system :No history of any urinary system disorder includes kidney stones,kidney infection 12. Genital system : No history of any genital disorder includes sexually transmitted disorders C. Physical examination 1. Inspection : Head is enlarged Bulged parietal bone area. No pallor, jaundice. 2. Auscultation:
Patient is intubated on ventilator Bilateral lung entry is equal Heart sounds are normal . Lungs sounds are normal. 3. Palpation : No organomegaly. No temperature. 4. Percussion : Lungs sound hollow on percussion. Bones,joints and solid organs such as the liver Sound solid. The abdomen sound likes a hollow organ filled With air,fluid or solids.

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ASSESSMENT OF CHILDREN IN CRITICAL CARE UNIT (NURSE PRACTITIONER).docx

  • 1. ASSESSMENT ON CHILDREN 2022-2024 Submitted By: Submitted To: Komal Mrs. Rajpati Roll no. 402 Lecturer Npcc 1st year College of Nursing
  • 2. A. HISTORY TAKING 1. Patient profile: Name:- Diksha Father Name:- Mr. Sataywan Age:- 2 year Sex:- Female Marital Status:- Unmarried Religion:- Hindu Residence:- Dharodi, Jind Haryana Occupation:- Nil Date of Admission:- 24/07/2023 at 03:55pm Mode of Admission:- Emergency(trauma traige) C.R NO.:- PGIMS/23/65218 Comorbidities:- NO Unit:- General surgery ward 6(Neuro-surgery) 2. Chief Complains : Increase in head size vomiting Irritability 3. History of presenting complain: Parents of the patient first noticed the Increase in head size at the age of 3 months and Since then, the deformity gradually increased. Patient was operated at the age of 6 months for hydrocephalus and was discharged. 2 months back patient came with complains of fever and irritability. Infection was found at shunt site and shunt removed. Head size again increased from 5-7 days before admission which was associated with c/o vomiting and irritability. Patient was diagnosed with hydrocephalus and was decided to be operated for shunt surgery again 4. Past medical history No history of TB, DM , Asthma, convulsion 5. Drug history no history of any drug allergy. 6. Family history- not significant No history of congenital disease H/O Full term normal delivery 7. Personal history: Normal bowel and bladder habits Average built and nourished, proper breast feeding, normal developmental milestones 8. Allergic history : No any drug allergy or food allergy. 9. Blood transfusion history:No any history of blood transfusion. 10. Socioeconomic history: Urban Good sanitation facility. Good water supply.
  • 3. Good eletrical supply. 11. Developmental history:- Language and communication:- by syllables( Amma) Social:- no social smile Does not recognise mother Immunized for age 12. Dietary history:- Exclusive breast feeding till the age of 5 months. Weaning :- 5 months Presently eat with family 13. Developmental goals which includes smiling, crawling, walking, being able to roll over,palmer grisp and pincer grisp are developed acc.to age B. General Physical Examination:- 1) Vital signs and baseline measurements Temprature:- 38.8属c ( rectal) Heart rate:-160 bpm B.P:- 98/52mm/hg Height:-57cm Weight:-4.5kg 2) Skin, hair and nails Skin is smooth and no lesion is present on body. Little body or facial hairs are present. Nails are intact and smooth C. Systemic Examination : 1. HEENT Head is enlarged. Assessment of eye and vision is appropriate for the developmental stage and age of child. 2. Lungs and Respiratory system Respiratory rate:- 40bpm Palpate the chest with 2-3 fingers. On Palpation bilateral sounds are equal and clear. Spo2 :- 95% on room air. 3. Heart and Peripheral vascular system Auscultate heart with Bell of stethoscope at supraclavicular space . Child's heart rate and rhythm are normal. 4. Musculoskeletal system Patient is able to move all four limbs well.
  • 4. 5. Abdomen and GI system Emesis is present during examination. 6. Neurologic system Patient is irritable , awake , fussy and difficult to console. Anterior fontanel is slightly bulging Pt is conscious Average built and nourished Afebrile Pallor- / Icterus-/ Cyanosis-/ clubbing- Neck veins not engorged Pulse 110/min, regular, normal volume , all peripheral pulses palpable 7. Respiratory examination Chest movements symmetric. B/L equal air entry,no added sounds No abnormality detected 8. Cardiovascular examination S1, S2 Sounds are normal. No murmur, No abnormality detected No history of any cardiovascular disorders includes vessels diseased, structure problems, blood clots, valvular defects , patent ductus arteriosus etc. 9. Central nervous examination Conscious , Motor function muscle tone, power and DTR within normal limits Sensory function within normal limits No history of central nervous system disorders includes coma,paralysis,meningitis. 10. Head examination:- Large head (increased circumference) Shiny scalp with dilated veins Fullness of the ant.fontanele Sun set appearance of the eyes. Eye exam. And reflexes are normal 11. Urinary system :No history of any urinary system disorder includes kidney stones,kidney infection 12. Genital system : No history of any genital disorder includes sexually transmitted disorders C. Physical examination 1. Inspection : Head is enlarged Bulged parietal bone area. No pallor, jaundice. 2. Auscultation:
  • 5. Patient is intubated on ventilator Bilateral lung entry is equal Heart sounds are normal . Lungs sounds are normal. 3. Palpation : No organomegaly. No temperature. 4. Percussion : Lungs sound hollow on percussion. Bones,joints and solid organs such as the liver Sound solid. The abdomen sound likes a hollow organ filled With air,fluid or solids.