Pedia Assessment Example

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Pediatric Assessment

I. Physical growth and development

Patient JJ is 7 months/old boy. His weight is 17.6 lbs and his height is 68 centimeters with a head circumference of 44 cm and chest circumference of 44 cm using tape measure. His abdominal circumference is 40 cm. He has 4 teeth, 2 upper teeth and 2 lower teeth, both in central and lateral incisors.

II. Motor skills

• Gross motor

Client JJ can sit alone without assistance, he can also roll front to back and crawl on his own.

• Fine motor

Client JJ can grasp his toy. He can transfer his toys from left to right.

III. Language development

Client JJ can only speak words like “wowa” and “ah”. We observed that whenever we call his name, he will respond by looking at us.

IV. Play and activity

According to client JJ’s grandmother, his favorite toy is mobile. During our assessment, he was playing a soft rattle.

V. Nutrition and diet

According to Client JJ’s grandmother, he did not breast fed by his mother because his mother said she has no breast milk. He is fed by formula milk since birth. He starts supplemental feeding when he was in 5 months old consist of cerelac and soft food. He also takes vitamin C.

VI. Reflexes

We test the sucking reflex of Client JJ by placing gloved finger on his mouth and we found out that he still have a sucking reflex. We hold client JJ’s foot and stroke up the lateral edge and across the ball and we find out that he still have a babinski reflex.

VII. Elimination pattern

Client JJ’s grandmother said that her grandson consumed 3 diapers a day before her grandson was admitted. But during our assessment, client JJ has not yet consumed a diaper the day of our assessment.

According to Client JJ’s grandmother, the color of his stool was dark yellow and it was unformed. The color of his urine is light yellow.

VIII. Other areas of...
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