• PEDIATRIC INITIAL

    NURSING ASSESSMENT

  • SESSION WAS NOT INITIALIZED PROPERLY. YOU CAN NOT USE THIS FORM. MAKE SURE THIS DOCUMENT HAS BEEN OPENED DIRECTLY FROM THE SOURCE PROVIDED TO YOU.

    • Visit Information  
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    • Time In - Time Out  
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    • Visit End Date/Time is on the last page along with signatures

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  • DIAGNOSIS

  • 0 - No treatment needed

    1 - Symptoms well controlled

    2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring

    3 - Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring

    4 - Symptoms poorly controlled; history of re-hospitalizations

  • CHILDCARE ARRANGEMENTS

  • LIVING ARRANGEMENTS

  • MEDICAL HISTORY

  • RELATIONSHIP

  • NEWBORN / INFANT SECTION

  • Infant Motor Skills:

  • CHILDHOOD HISTORY

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  • VITAL SIGNS


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  • ALLERGIES

  • IMMUNIZATIONS

  • RESPIRATORY

  • Oxygen Therapy:

  • Trach:

  • PAIN


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  • ABILITIES

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  • NEUROLOGICAL

  • Growth and Development:

  • Mental Status:

  • Seizures:

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  • SENSORY STATUS

  • Eyes:


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  • Ears:


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  • Nose:


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  • CARDIOVASCULAR

  • GASTROINTESTINAL/NUTRITIONAL

  • Bowel Sounds:

  • Last BM:

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  • Mouth:


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  • Throat:


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  • Colostomy/Ileostomy:

  • TUBE FEEDINGS


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  • INTEGUMENTARY

  • Skin:


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  • Pressure Ulcers:

  • Mucus Membranes:

  • ENDOCRINE / HEMATOLOGY

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  • GENITOURINARY

  • Catheter:

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  • Urination:


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  • Dialysis:

  • FALL RISK ASSESSMENT

  • If the total score of the items above is 3 or greater, or based on clinical judgement, initiate the Fall Prevention Program in the Plan of Care.

  • Scoring Criteria:

    1. Clinical Judgement Patient diagnosis or condition warrants fall prevention program.
    2. Mobility Uses assistive devices or needs assitance for ambulance/transfer. Evidence of generalized weakness or decreased mobility in lower exremities, poor balance and dizziness.
    3. Mentation Patient is developmentally delayed or is disoriented.
    4. Elimination Has need to get to toilet frequently or urgently. Needs assistance with toileting.
    5. History of Falls related to Illness Has the patient fallen within the last year related to illness, including falls at home or a previous admission or during this admission? (refer to inpatient admission assessment).
    6. Current Medications Anticonvulsants, opiods, benzodiazepines. Also consider diuretics, antihypertensives, and analgesics, bowel preps.

     

  • SAFETY MEASURES


  • MUSCULOSKELETAL / FUNCTIONAL

  • Homebound Status:

  • Limited ROM:

  • MEDICATIONS


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  • INSTRUCTIONS

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  • INTERVENTIONS

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  • Rehabilitation Potential/Goals:

     

    Nursing:


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  • Home Health Aide:


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  • Physical Therapy:


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  • Speech Therapy:


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  • Occupational Therapy:


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  • Medical Social Services:


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  • SUPERVISORY

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  • DISCHARGE PLANS


  • OVERALL COMMENTS

  • SIGNATURES

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