TRINITY VALLEY COMMUNITY COLLEGE
ASSOSCIATE DEGREE NURSING
PEDIATRIC ASSESSMENT CRITERIA SHEET – LEVEL III
Student Name: ________________________________
Patient’s Initials: ____Age: _____ Sex: _______
Due Date: _____________________
# - Maximum points available for each criterion
 - Self check column
#

G
Course: _________________
Date of Contact: ________________
Submission Date: _____________________
G - Assigned grade (increments of 0.25)
C - Corrections required
C
I.
3.0
BIOPHYSICAL
A. GROWTH AND DEVELOPMENT
Compare and contrast the normal growth/development of your pediatric patient to the
“textbook picture” of the specific age group including activity restrictions.
1. Gross motor
2. Fine motor
3. Language
4. Socialization
5. Cognition
6. Sensory (Discuss all 5 senses - tactile, auditory, etc.)
1.0
B.
GROWTH CHARTS
Complete growth charts (available on-line) (stature for age, weight for age,
stature for weight or BMI) and analyze
0.5
C.
VITAL SIGNS
Compare and analyze patient’s vital signs, height, weight with “normal” vital
signs for a child of the same age.
1.0
D.
NUTRITIONAL INTAKE
Describe the nutritional intake including calories of your pediatric patient.
Compare routine diet with requirements for age group and write analysis of
findings.
0.5
E.
IMMUNIZATIONS
Identify and discuss primary caregiver’s knowledge of immunizations to
include side effects, adverse effects and safety measures for patient and patient
contacts and analyze knowledge and teaching needs.
1.0
F.
ILLNESS
Compare signs and symptoms of illness of your pediatric patient to the
“textbook picture”. List medications the child is receiving for this condition.
Discuss rationales and effectiveness.
II.
PSYCHOSOCIOCULTURAL
0.5
A. INTERPERSONAL INTERACTIONS
1. Describe interactions between:
a. Child, primary caregiver and nursing student
0.5
B. ERICKSON’S STAGES OF DEVELOPMENT
Major developmental task (Erikson). Meeting/not meeting-explain.
0.5
C. PLAY ACTIVITIES
Identify play/activities and toys that would be appropriate for your patient
according to the developmental level and physical condition/illness.
0.5
D. EVIDENCE-BASED PRACTICE
Discuss one evidence-based nursing practice guideline related to health
promotion of children this age.
1.0
E. HEALTH PROMOTION
Identify health promotion activities and safety precautions appropriate for this
child/family.
OTHER
A. Is typed and referenced with accurate spelling.
B. Completed self-check column before submitting for evaluation and criteria
sheet is included.
10
VI.
TOTALS
COMMENTS:
Unsatisfactory -- Corrections due: _______________ Return to: ___________________
Accepted as satisfactory
Instructor’s Signature
N:\Syllabus\Core\Pediatric Assess Criteria Sheet
Date
Revised 04/13
TRINITY VALLEY COMMUNITY COLLEGE
ASSOSCIATE DEGREE NURSING
PEDIATRIC ASSESSMENT – LEVEL III
Student Name: ________________________________
Patient’s Initials: ____Age: _____ Sex: _______
Course: _________________
Date of Contact: ________________
Chronic/Acute Diagnosis: _______________________________________
I.
Biophysical
A. Growth & Development
Instructions:
1. Complete expected levels of development for this age child from a textbook.
2. Assess your patient and document observed levels of development in each area.
3. Compare and contrast expected versus observed development.
4. Write a summary of analysis.
Component Area
Gross motor
Fine motor
Language
Socialization
Cognition
Sensory - Vision
Sensory – Auditory
Sensory – Tactile
Sensory – Taste
Sensory – Smell
Textbook – What is
Expected for Age
Client – What Client
Demonstrated
Analysis – Compare
& Contrast
Reference:
Summary of Analysis:
B. Growth Charts
Instructions
1. Measure client’s height and weight
2. Calculate client’s BMI
3. Download growth charts from CDC
a. Height for age
b. Weight for age
c. BMI (if over 2) or Head Circumference (if under 2)
4. Graph client information on the growth chart and submit. Do not submit computer
generated results
5. Analyze results and write summary – include description of percentiles
Client Height:
Client Weight:
Client BMI or Head Circumference:
Summary of analysis of results:
C. Vital Signs
Instructions:
1. Document normal vital signs for this age child.
2. Assess patient’s vital signs.
3. Analyze results.
4. Summarize analysis.
Age Appropriate
Pulse
Respirations
Temperature
Blood Pressure
Reference:
Summary of analysis of results:
Client’s Results
Analysis
D. Nutritional Intake
Instructions:
1. Ask primary caregiver to describe average intake for child for a day or ask them to write
down intake for a typical day.
2. Go to choosemyplate.gov and find out the recommended number of servings in each food
group for this child
3. Determine the number of servings and calories the patient consumed
4. Determine the difference between the actual intake and the recommended intake
5. Write an analysis of the nutritional intake.
Breakfast:
Snacks:
Lunch:
Snacks:
Dinner:
Snacks:
Food Group
# Servings
Recommended for this
age child
# Servings Patient
Consumed in average
day
Difference
(+ or -)
Grains
Proteins
Fruits
Vegetables
Dairy
Reference:
Analysis of results and recommendations:
E. Immunizations
Discuss primary caregiver’s knowledge of immunizations including side effects, adverse effects,
and safety measures for patient and patient contacts and analyze teaching needs:
F. Illness Signs & Symptoms
Instructions:
1. Document expected signs and symptoms for this medical diagnosis.
2. Assess patient for signs and symptoms.
3. Compare signs and symptoms of illness of your pediatric patient to the “textbook
picture”.
4. Summarize analysis.
5. List medications the child is receiving for this condition. Discuss the rationale for
receiving and their effectiveness.
Signs & Symptoms
Expected S & Sx
Client
Analysis – Compare
& Contrast
Signs
Symptoms
Reference:
Summary of Analysis:
Medications:
II. Psychosociocultural
A. Interpersonal Interactions
Directions:
1. Describe interactions.
Between child and primary
caregiver
Between primary caregiver
and the nursing student
Between child and the
nursing student
B. Erickson Stages of Development
Major developmental task
Examples that show patient is meeting or not
meeting the task
C. Play Activities
Instructions:
1. Identify play activities and toys that would be appropriate for this age child
a. Play activities
b. Toys
Reference:
D. Evidence-based Nursing Practice
Instructions:
1. Discuss one evidence-based nursing practice guideline related to pediatric nursing
related to health condition
Evidence-based Nursing Practice Guideline:
Reference:
E. Health Promotion
Instructions:
1. Identify health promotion activities and safety precautions that would be appropriate for
this age child
a. Health Promotion Activities
b. Safety precautions
Reference:
N:\Syllabus\Core syllabus\Pediatric Assessment
Revised 04/13