COMPREHENSIVE PEDIATRIC NURSING ASSESSMENT

1 Primary Diagnosis/Reason for Home CareICD Code(Locator #11)a. _____ ( _____ ) Date _____ O EOther Diagnosis/ReasonsICD Code(Locator #13)b. _____ ( _____ ) Date _____ O Ec. _____ ( _____ ) Date _____ O Ed. _____ ( _____ ) Date _____ O Ee. _____ ( _____ ) Date _____ O Ef. _____ ( _____ ) Date _____ O EHistory/Surgical ProcedureICD Code(Locator #12)_____ ( _____ ) Date _____ O E_____ ( _____ ) Date _____ O EPatient s HI Claim No.: (Locator #1) Same as Medicaid CHIP (Childrens Health Insurance Program) Self or family pays full or partial costs Other_____Gender: (Locator #9) 1-Male 2-FemaleEthnicity and Race: American Indian or Alaska Native Native Hawaiian or AsianPacific Islander Black or African-American White Hispanic or Latino OtherMedicaid Provider Number: (Locator #5) _____Patient ID / Medical Record Number: (Locator #4)_____ Start of Care Date: (Locator #2) _____month/day/yearCertification Period: (Locator #3) (if applicable)From _____ To _____Patient s Name: (Locator #6)_____ ____ (First)(MI)_____(Last)(Suffix)Patient Phone: _____ - _____ - _____Patient Address: (Locator #6)_____(Street/Apt.)

2 No.)_____(City)Patient State of Residence: (Locator #6)_____Patient Zip Code: (Locator #6) _____ _____Email Address:_____Birth Date: (Locator #8) _____month/day/yearMedicaid/Waiver Number: NA-No Medicaid(specify waiver)_____PATIENT REPRESENTATIVE INFORMATION (see page 8) COMPREHENSIVE PEDIATRICNURSING ASSESSMENTWITH PLAN OF TREATMENT/485 INFORMATIONPATIENT NAME Last, First, Middle InitialID# COMPREHENSIVE PEDIATRICNURSING ASSESSMENTPage 1 of 14 DATE OF SERVICE _____TIME IN _____ OUT _____ALLERGIES:(Locator #17) None known Aspirin Penicillin Sulfa Pollen Eggs Milk products Insect bites Other_____IMMUNIZATIONS (check if current) DPT Measles Polio DT Mumps HBV MMR Rubella HibIs the patient from birth to 18 years currentwith the recommended CDC immunizationschedule? Yes No UnknownIf no, (specify) _____ Other (specify)_____PERTINENT BACKGROUND INFORMATION PRIMARY REASON FOR HOME HEALTH: _____PERTINENT HISTORY AND / OR PREVIOUS OUTCOMES_____ _____HOSPITALIZATIONS: No hospitalization within 90 days Yes Number of times _____ Hospitalization: 31-90 days 15-30 days 8-14 days In the last 7 daysReason(s)_____WELL CHILD CARE (if applicable)_____ _____ Clinic last visit _____ Next visit _____Form 3547 RPRev.

3 4/18 2002 BRIGGS, Des Moines, IA (800) 247-2343 Unauthorized copying or use violates copyright law. Referring Physician / Pediatrician NPI: UK-Unknown or Not Available_____Phone: (Locator #24) _____ - _____ - _____Name: (Locator #24) _____ ____(First)(MI)_____ (Last)(Suffix)Address: (Street/Apt. No.) (Locator #24)_____City: (Locator #24)_____ State: (Locator #24)Zip Code: (Locator #24)_____ _____Complete upper section according to organization guidelines Private insurance Qualified health planEMERGENCYPREPAREDNESSPRIORITY CODE:Does the patient have an Advance Directives order? No Ye s Address the patient s individualized emergency plan for emergencycontact information. (Briggs form 3556)PATIENT NAME Last, First, Middle InitialID# COMPREHENSIVE PEDIATRICNURSING ASSESSMENTPage 2 of 14 PERTINENT BACKGROUND INFORMATION (Cont d.)SKILLED OBSERVATION / ASSESSMENT (Cont d.)SKILLED OBSERVATION / ASSESSMENTCONDITIONHNPCONDITIONHNP*Thrus h*ApneaConjunctivitisCroupPicaRubellaRub eolaScarlet FeverMumpsChickenpoxHepatitisSickle CellLead poisoningHIVP neumoniaAsthmaFrequent coldsStrep throatSinusitisNosebleedsFracture(s)Burn (s)Otitis mediaFrequent ear infectionTonsillitisFrequent sore throatBleeding problemsRheumatic feverHeadachesSeizures grand malSeizures petit malOther (specify)CHILDHOOD HISTORY(H - History of; N - Negative; P - Present problem)Newborn screen results_____Gestational age at birth _____ weeksBirth weight less than 1500 g: Yes NoBirth wt.

4 _____lb. _____oz. Length circumference_____ Chest circumference_____Fontanels: Anterior PosteriorUmbilicus: Healed Hernia Inverted EvertedMaternal health problem during pregnancy: Yes No (if known,specify)_____NOTE:Additional newborn/infant related ASSESSMENT criteria are identified by an asterisk (*) throughout the remainder of this all applicable:Mental Status:(Locator #19) Oriented Comatose Forgetful Depressed Hyperactive Disoriented Lethargic Agitated Other_____Vitals: Temperature_____ F C Oral Axillary Tympanic Rectal Pulse:_____ Radial Apical Brachial Carotid Regular Irregular Heart Sounds: Regular IrregularBlood Pressure: Arm Leg Lying Sitting Standing Right_____ Left_____ Weight:_____ Actual ReportedLength/Height:_____ Actual ReportedRespirations_____ Regular Irregular Breath Sounds: Clear Crackles Rales Rhonchi Wheeze Other_____ Diminished Absent Location _____O2saturationat _____%COGNITIVE STATUS/ABILITYUses language to communicate?

5 Yes No Understood Usually understood (has trouble finding words but if given time little orno prompting needed) Often understood (Difficulty finding words and needs lots of prompting) Sometimes understood (has limited ability but is able to make understandable request such as food, drink, toilet) Rarely or never understood Communication device (specify)_____ Not applicable (specify)_____EYES /EARS Glasses Contacts: R L Prosthesis R L Jaundice Blurred vision Legally blind Sunset sign Tracks with eyes Drainage: R L(specify)_____ Most recent eye exam (date)_____ Infections _____ Other (specify, incl. history)_____ NO PROBLEM HOH: R L Deaf: R L Hearing aid: R L Ear device (cochlear implant) R L Vertigo Tinnitus Most recent hearing exam (date)_____Infections: Yes No If yes, frequency_____ tubes present: Yes No R L Other _____ NO PROBLEMHEAD /NECK6 months and Under: Bulging Fontanel Depressed Fontanel Hydrocephaly Separated Sagittal Suture Microcephaly6 months and Over: Head Asymmetry Head lag Enlarged Head Other_____ Injuries /Wounds (specify)_____ Masses Nodes: Site_____Size_____ Other (specify, incl.)

6 History) _____ NO PROBLEMNEWBORN / INFANT (Complete if applicable)SCREENING / EARLY DETECTIONDid the newborn have a state specific Recommended UniformScreening Panel (RUSP)? Yes No UnknownDid the RUSP identify any significant organic conditions or disorders? Yes No Unknown(specify)_____TB skin test: No Yes, if yes,date_____ results_____Lead screening: No Yes, if yes,date_____ results_____Other (specify)_____PROGNOSIS (Locator #20) 1-Poor 2-Guarded 3-Fair 4-Good 5-Excellent PATIENT NAME Last, First, Middle InitialID# COMPREHENSIVE PEDIATRICNURSING ASSESSMENTPage 3 of 14 NOSE / THROAT / MOUTHCARDIOPULMONARY (Cont d.) Accessory muscles used Retractions O2@ _____ LPM per _____ O2saturation _____% Concentrator Liquid Other_____Trach? No Yes, Brand_____ Size_____ Who manages? Self RN Caregiver Family Cuffed: _____mL s Cuffless Disposable Reusable Fenestrated Non-fenestrated inner cannula Speaking valve Humdivent Cap N/AComment_____Ventilator?

7 No Yes, Continous IntermittentVent type_____Settings_____Comment_____ Cough: Dry Acute Chronic Productive: Thick ThinColor _____Amount_____ Unable to cough up secretions Dyspnea: Rest Exertion Ambulation _____feet During ADL s Orthopnea Other_____ Chest Pain:Associated with: Shortness of breath Activity SweatsFrequency/duration_____ Palpitations FatigueForm 3547RP 2002 BRIGGS, Des Moines, IA (800) 247-2343 Unauthorized copying or use violates copyright law. REQUIREMENTS FOR AGE (diet) (Locator #16)_____For Newborn to 3 years: Number of bottles of formula 24 hours _____ Name/Type of formula_____Breast fed: Yes NoCombination Breast fed/bottle: Yes NoWhat percent of both: breast _____% bottle _____%MEAL PATTERNS _____Appetite: Good Fair Poor NPO Hydration adequate: Yes NoEATING BEHAVIORS_____ Eating disorder: Anorexia Bulimia Other (specify)_____ Weight change: Gain Loss _____ lb.

8 X _____ wk. mo. yr. Increase fluids_____amt. Restrict fluids_____amt. Nausea Vomiting: Frequency_____ Continent Incontinent Controlled with ostomy Occasionally incontinent less than daily Frequently incontinent daily but some controlLAST BM: _____ Frequency of stools_____ Bowel sounds: active_____absent_____hypoactive_____hyp eractive_____ Bowel regimen/program _____ Diarrhea (describe)_____ Constipation: Chronic Acute Occasional Flatulence Abdominal distentionGirth _____ inches Firm Tender Laxative Enema use: Daily Weekly Monthly PRN Other_____ Diapers/other _____ Ileostomy Colostomy site (describe skin around stoma):_____Ostomy care managed by: Self Caregiver Family Other_____ NO PROBLEMCARDIOPULMONARY Congestion Dysphagia Hoarseness Lesions Sore throat Masses Tumors Nasal flaring Drainage Nose bleeds Sucking swallowing deficit Palate intact Teeth present: Yes NoOral hygiene practices _____Dentist visits.

9 Frequency_____ Other (specify, incl. history)_____ NO PROBLEMENDOCRINE Hypothyroidism Hyperthyroidism Fatigue Intolerance to heat Intolerance to cold Diabetes: Ty p e 1 Type 2 Date of onset_____ Insulin dependent? Yes No Insulin dose / frequency (specify)_____ _____On insulin since_____ Diabetic diet Oral medication_____ Hyperglycemia: Glycosuria Polyuria Polydipsia Hypoglycemia: Sweats Polyphagia Weak Faint StuporBlood Sugar:_____ Actual Reported Blood sugar ranges_____ Patient Caregiver ReportMonitored by: Self Caregiver Nurse Other_____Frequency of monitoring _____Competency with use of Glucometer _____ Self-care/self observational tasks (specify) _____ Abnormal growth pattern Abnormal sexual development Other (specify incl. history) _____ NO PROBLEMGASTROINTESTINAL Edema:Pedal Right: Non-pitting Pitting: +1 +2 +3 +4 Pedal Left: Non-pitting Pitting: +1 +2 +3 +4 Sacral: Non-pitting Pitting: +1 +2 +3 +4 Site_____ Cyanosis (site) _____ Capillary refill: Less than 3 seconds Greater than 3 seconds Skilled intervention (specify)_____ Other_____ NO PROBLEMGENITALIA Angry Flat affect Discouraged Withdrawn Difficulty coping Disorganized Recent family change: Birth Death Moved Divorce Other (specify) _____ Suicidal: Ideation Verbalized Depressed: Recent Long termDue to (if known) _____ Substance use: Drugs Alcohol Tobacco Evidence of abuse: Potential Actual Verbal Emotional Physical FinancialDescribe objective/subjective findings _____DESCRIBE RELATIONSHIPS WITH THE FOLLOWING.

10 Parents, Siblings, Peers_____USUAL SLEEP/REST PATTERN_____SLEEPING ARRANGEMENTS_____ Other (specify, incl. pertinent history) _____ NO PROBLEMPATIENT NAME Last, First, Middle InitialID# COMPREHENSIVE PEDIATRICNURSING ASSESSMENTPage 4 of 14 PSYCHOSOCIALHEMATOLOGY Anemia Bilirubin, results_____ Other (specify, incl. pertinent history) _____ NO PROBLEM Circumcised Uncircumcised Precocious pubertyScrotum: WNL SwollenTestes: Descended Undescended: Right Left Bilateral Puberty Menarche, if checked, age_____ LMP_____Pregnancy: Gravida_____ Para _____ Estimated Date of Delivery_____ Discharge (describe)_____ Other (specify, incl. pertinent history) _____ NO PROBLEM N/A Nasogastric - Size_____ Gastrostomy - Size_____ Jejunostomy - Size_____ PEG - Size_____ Other (specify)_____Pump:(type/specify)_____Fe edings: Bolus ContinuousFlush Protocol: ( )_____Performed by: Self RN Caregiver Other_____Dressing /Site care: (specify)_____Interventions /Instructions / Comments_____GENITOURINARY Continent - complete control, does not use any type of catheter or other urinary collection device Complete control with any catheter or ostomy Occasionally incontinent but less than daily Frequently incontinent - Daily Incontinent - No control present Diapers /day_____Urine: Color_____ Odor_____Frequency_____ Burning Itching Toilet trained: Day Night Both Bladder Bowel Both Enuresis; bedtime ritual _____ Catheter type/brand: _____ Foley Straight catheter External Other (specify, incl.)