Far Eastern University

Institute of Nursing

Assessment Guide for the Pre-Schooler

Informant :- Relationship to Client : -

Client’s Name : Yves Dominic Pacia Date of Birth : Aug. 5, 2005
Address : 2241 Alabastro st. San Andres Bukidnon Manila
Age : 4 years old
Sex : Male
Name of Father : Joco Pacia
Occupation : Cook Place of Work : Malate, Manila
Name of Mother : Malou Pacia
Occupation : Teacher Place of Work : Manila

I. Personal History
a. Birth and Maternal History
The mother of the child was not interviewed about this matter.

II. Areas of Growth and Development

a. General Appearance

The pre-schooler appears slender with erect posture. He is active and friendly during the
interview. Though he kips on working on other things, yet he seems to be interested in the
conversation.

b. Head-to-Toe Assessment

Body Parts Actual Findings Normal Findings Analysis

A. Head

1. Skull Generally round, with Generally round, with Normal

prominences in the frontal prominences in the frontal
and occipital area. and occipital area.
(Normocephalic). (Normocephalic).

No tenderness noted upon No tenderness should be

palpation. noted upon palpation.
2. Scalp Lighter in color than the Lighter in color than the Normal
complexion. complexion.
It is moist. Can be moist or oily.
No scars noted. No scars noted.
Free from lice, nits and Free from lice, nits and
dandruff. dandruff.
No lesions noted. No lesions should be noted.
No tenderness or masses on No tenderness or masses on
palpation. palpation.

3. Hair Hair is color black Can be black, brown or Normal

burgundy depending on the
race.
Evenly distributed and covers Evenly distributed and covers
the whole scalp.(No the whole scalp.(No
Alopecia). evidences of Alopecia)
It is thin and smooth. Neither Maybe thick or thin, coarse or
brittle nor dry. smooth.
Neither brittle nor dry.
4.Face Face is oval in shape. Oblong or oval or round or Normal
square or heart-shaped.
Symmetrical. Symmetrical
Smooth and free from Should smooth and free from
wrinkles. wrinkles
No involuntary muscle No involuntary muscle
movements. movements.
5. Eyes Evenly placed and in line Evenly placed and in line Normal
with each other. with each other.
Non-protruding. Non-protruding.
Equal palpebral fissure. Equal palpebral fissure.

5.1 Eyebrows Symmetrical and in line with Symmetrical and in line with Normal
each other. It is black and each other.
evenly distributed. Maybe black, brown or blond
depending on race.
Evenly distributed.

5.2 Eyelashes Color is black. Evenly Color dependent on race. Normal

distributed. Turned outward. Evenly distributed.
Turned outward.

Upper eyelids cover the small Eyelids:

5.3 Eyelids and portion of the iris, cornea, andUpper eyelids cover the small Normal
Lacrimal Apparatus sclera when eyes are open. portion of the iris, cornea, and
No PTOSIS.(drooping of sclera when eyes are open.
upper eyelids). Meets No PTOSIS.(drooping of
completely when eyes are upper eyelids).
closed. Symmetrical. Meets completely when eyes
are closed.
Symmetrical

Lacrimal gland is non Lacrimal Apparatus:

palpable.No tenderness on
palpation.No regurgitation
from the nasolacrimal duct.
Both conjunctivae are
pinkish in color. With
5.4 Conjunctivae presence of many minute
capillaries.
Moist and no ulcers.
No foreign objects.
Lacrimal gland is normally
non-palpable. Normal
No tenderness on palpation.
No regurgitation from the
nasolacrimal duct.
Both conjunctivae are pinkish
or red in color. Normal
With presence of many
minute capillaries.
Moist .No foreign objects.

Sclerae is white in color

(anicteric sclera). Sclerae is white in color
5.5 Sclerae No yellowish discoloration (anicteric sclera). Normal
(icteric sclera). No yellowish discoloration
Some capillaries are visible. (icteric sclera).
 Some capillaries maybe
visible.
Some people may have
pigmented deposits.
No irregularities on the
surface. There should be no
5.6 Cornea Looks smooth. irregularities on the surface. Normal
The cornea is clear and Looks smooth.
transparent. The cornea is clear and
The features of the iris are transparent.
fully visible through the The features of the iris should
cornea. be fully visible through the
cornea.
The anterior chamber is
transparent. The anterior chamber is
5.7 Anterior Chamber No noted visible materials. transparent. Normal
and Iris Iris is black. No noted visible materials.
Color of the iris depends on
From side view, it appears the person’s race.
flat and no bulging forward. From the side view, the iris
should appear flat and should
not be bulging forward.
No crescent shadow casted on There should NO crescent
the other side. shadow casted on the other
side when illuminated from
one side.
Pupillary size is from 3-7 Pupillary size ranges from 3-
mm, and is equal in size. 7 mm, and are equal in size.
5.8 Pupils Equally round. Normal
Equally round. Constrict Constrict briskly/ sluggishly
briskly/ sluggishly when light when light is directed to the
is directed to the eye, both eye, both directly and
directly and consensual. consensual.
Pupils dilate when looking at Pupils dilate when looking at
distant objects, and constrict distant objects, and constrict
when looking at nearer when looking at nearer
objects. objects.
6. Ears The ear lobes are bean The ear lobes are bean Normal
shaped, parallel, shaped, parallel,
and symmetrical. and symmetrical
The upper connection of the The upper connection of the
ear lobe is parallel with the ear lobe is parallel with the
outer canthus of the eye. Skin outer canthus of the eye.
is the same in color as in the Skin is the same in color as in
 complexion. the complexion.
No lesions noted on No lesions noted on
inspection. inspection.
The auricles are has a firm The auricles are has a firm
cartilage on palpation. cartilage on palpation.
The pinna recoils when The pinna recoils when
folded. folded.
There is no pain or tenderness There is no pain or tenderness
on the palpation of the on the palpation of the
auricles and mastoid process. auricles and mastoid process.
The ear canal has normally The ear canal has normally
had some cerumen of some cerumen of inspection.
inspection. No discharges or lesions
No discharges or lesions noted at the ear canal.
noted at the ear canal.

7. Nose and Paranasal Nose in the midline.
Sinuses No discharges and no flaring
of alae nasl.
Both nares are patent.
No bone and cartilage
deviation noted on palpation.
No tenderness noted on
palpation.
Nasal septum is in the
midline and not perforated.
The nasal mucosa is pinkish
to red in color.
No tenderness noted on
palpation of the paranasal
sinuses.
Nose in the midline. Normal
No discharges and no flaring
of alae nasl.
Both nares are patent.
No bone and cartilage
deviation noted on palpation.
No tenderness noted on
palpation.
Nasal septum is in the
midline and not perforated.
The nasal mucosa is pinkish
to red in color.
No tenderness noted on
palpation of the paranasal
sinuses.

8. Mouth and With visible margin. Visible margin. Normal

Oropharynx Symmetrical in appearance Symmetrical in appearance
Lips and movement. and movement.
Pinkish in color. Pinkish in color.
No edema. No edema.

Temporo-mandibular Moves smoothly no crepitus. Moves smoothly no crepitus.

No deviations noted. No deviations noted.
No pain or tenderness on No pain or tenderness on
palpation and jaw movement. palpation and jaw movement.

Pinkish in color. Pinkish in color.

 No gum bleeding. No gum bleeding.
Gums No receding gums. No receding gums.

He has 19 teeth. 28 for children and 32 for

adults.
Teeth White to yellowish in color. White to yellowish in color.
He has dental carries. With or without dental caries
and/or dental filings.
No malocclusions With or without
malocclusions.
No halitosis No halitosis.

Pinkish with white taste buds
on the surface. No lesions
Tongue noted.
No varicosities on ventral
surface.
Frenulum is thin attached to
the posterior 1/3 of the
ventral aspect of the tongue.
Gag reflex is present.
Able to move the tongue
freely and with strength.
Surface of the tongue is
rough.
Pinkish with white taste buds Abnormal
on the surface.
No lesions noted. Normal
No varicosities on ventral
surface.
Frenulum is thin attaches to
the posterior 1/3 of the
ventral aspect of the tongue.
Gag reflex is present.
Able to move the tongue
freely and with strength.
Surface of the tongue is
rough.

Positioned in the midline. Positioned in the midline.

Pinkish to red in color and no Pinkish to red in color and no
swelling or lesion noted. swelling or lesion noted.
Uvula Normal
Pinkish, non-inflamed. Pinkish, non-inflamed.
No hoarseness and wall No hoarseness and wall
modulated. modulated.
Tonsils Normal

9. Neck Proportional to the size of Proportional to the size of Normal

Inspection the body and head, the body and head,
symmetrical and straight symmetrical and straight.

Palpation: No palpable lumps, masses or No palpable lumps, masses or

areas of tenderness. areas of tenderness.
Range of Motion Freely movable without Freely movable without
difficulty. difficulty.

SOURCE: Fundamentals of Nursing, Kozier 7th Edition

c. Nutritional Pattern

He prefers food with like adobo, isda, hotdog and sinigang. .He is not fond of eating
vegetables and fruits but sometimes he eats banana, as stated by him. He does not have any kind
of food allergies.
The table below shows his food recall.

Food Recall
Cupcake
Breakfast Chuckie
1 cup if rice
Lunch I serving of isda
water
1 pc. Turon
Snack Orange juice
½ cup of rice
Dinner 1 serving of adobo

Interpretation:
Insufficient requirement of food intake. Inadequate intake of fruits and vegetables.

Analysis:
The preschooler eats adult food and should have the required amounts from the four
food groups. Weight gain preschool children are generally slow. They have added only another 3
to 5 kg. (7 to 12 lb) to their 3-year-old weight, increasing it to somewhere between 18 and 20 kg
(40 and 45 lb). Preschool children grow about 5 to 6.25 cm (2.0 to 2.5 in0 in each year). Thus by
5 years of age they double the birth length and measure 100 cm (40 in).

Fundamentals of Nursing
Kozier et.al, 5th edition,
pg. 597, 602
f. Elimination Pattern
 The preschooler verbalizes that whenever he wants to urinate or do bowel movement he
is able to go to the comfort room by his own.

Interpretation:
He was able to do the normal responsibilities of a preschooler for an independent
toileting.

Analysis:
The preschooler is able to take responsibility for independent toileting. The child
can control his bowel movement, some control of defecation starts at 11/2 to 2 years of age.
Characteristics of normal feces: color-brown, odor-aromatic, consistency-formed, soft,
semisolid, moist. Excretion of urine for 3 to 5 years is 600-700 mL.

Fundamentals of Nursing
Kozier et.al, 5th edition,
pg. 602,1183,1225

d. Rest and Sleep

The child takes naps during the day about 2-3 hours. The preschooler goes to bed at
exactly 8 o’clock in the evening. The child sleeps about 10 hours on an average night.

Interpretation:
The preschooler gets enough amount of sleep due to his 10 hours of sleep at night
and at least 3-4 hours of sleep during afternoon.

Analysis:
Preschoolers sleep about 11 hours at night; 20% REM sleep; second nap eliminated
by most at age 3. During REM sleep, the brain is highly active, and brain metabolism may
increase as much as 20%. When a person is very tired, the duration of each REM sleep is very
short or even absent. As the person becomes more rested through the night, the duration of REM
sleep increases.

Fundamentals of Nursing
Kozier et.al, 5th edition,
pg. 602, 954-956

III. Emotional Development

The preschooler verbalizes that whenever he felt rejected or he is scolded he just sits in a
corner and quietly cries.

Interpretation:
 An actual finding conforms to norms.

Analysis:
Preschoolers learn about their feelings: they know the words "cry," "sad," "laugh,"
and the feelings related to them. They also begin how to control their feelings and behavior. The
preschooler uses the same types of coping mechanisms in response to stress as the toddler does,
although protest behavior (kicking, screaming) is less likely to occur in the older preschoolers
usually have greater ability to verbalize stress.

IV. Body Image/Self Concept Development

Analysis:

Preschoolers also become increasingly aware of themselves. They play with their bodies
largely about curiosity. Guidance and discipline are important parts of the parental role during
the preschool years.

Fundamentals of Nursing
Kozier et.al, 5h edition
pg. 599

V. Social Development

According to the preschooler, he spends his time playing with his baby sister. He
sometimes goes out to play with others. He has his own toys like; sword and car.

Interpretation:

The preschooler seems to be friendly and take part in some activities that is appropriate in
his age.

Analysis:

Preschoolers enjoy playing with their peers and can even take part in some activities with
older children. Social interaction is important for this age group. It provides them with
opportunities to learn the rules of play and cooperation such as taking turns and following
directions. Parents should be encouraged to provide these situations for the preschoolers in order
to enhance social development and foster school
readiness.

Fundamentals of Nursing
Kozier et.al 5th edition
Pg. 600

VI. Cognitive Development

The preschooler verbalized that he was entertained in watching his favorite television
shows. He often asks to his mother things that confuses him. He is aware of his birthday and
age.

Interpretation:
There were no deviations; therefore actual findings conform to norms

Analysis:
The preschooler cognitive development, according to Piaget is the phase of
intuitive thought. Children are still egocentric, but egocentrism gradually subsides as they
encounter wider experiences. Preschoolers learn through trial and error and they think of only
one idea at a time. They do not understand relationships such as those between mother and father
or sister and brother. Children start to form concepts in late toddler hood or early preschool
years. Preschoolers become concerned about death as something inevitable but they do not
explain it. They also associated death with others rather than themselves.
Most children at the age of 5 years can count pennies however, the opportunity to
spend money usually does not occur until they attend school. Reading skills also start to develop
at this age. Young children like fairy tales and books about animals and other children

Fundamentals of Nursing
Kozier et.al 5th edition
Pg. 600

VII. Religious/ Spiritual Development

Their family goes to church every. He does not make noise when he’s inside the church,
he just sit beside his parents or walk on the kneeler back and forth. He imitates religious gestures
like the sign of the cross.

Interpretation:
Religious or spiritual activities conform to norms.

Analysis:
Many preschoolers enroll in Sunday school or faith oriented classes. At this stage is
primarily a result of the teaching of significant others, such as parents and teachers. Children
learn to imitate religious behavior for example, bowing the head in prayer although they
dontunderstand the meaning of the behavior. Preschoolers require simple explanations such as
those in picture books of spiritual matters. Children at this age use their imagination to envision
such ideas as angles or the devil
Fundamentals of Nursing
Kozier et.al 5th edition
Pg. 601

VIII. Language and Speech Development

The preschooler speaks what is in his mind and people easily can understand it. He can
already talk in complete sentences. He talks with a moderate voice without shouting.

Interpretation:
An actual finding conforms to norms.

Analysis:
The preschoolers use language to express ideas. Parents can facilitate improved
language skills by encouraging the child to tell stories.Never criticizing the child speech and
remaining patient if the child stumbles over words. Playing word games to teach the child new
objects or names and reading and discussing stories with the child.

Fundamentals of Nursing
Kozier et.al 5th edition

IX. Moral Development

He can pick simple instructions as evidenced by his physical examination.

Interpretation:
Moral activities conforms to norms.

Analysis:
Preschoolers are capable of pro social behavior, that is, any action that a person
takes to benefit someone else. At this stage of development preschoolers do not have fully
formed consciences; however they do develop some internal controls. Moral behavior is largely
learned by modeling, initially after parents and later significant others. The preschooler usually
behaves well in social settings. Preschoolers usually control their behavior because they want
love and approval from their parents. Moral behavior to a preschooler may mean taking turns at
play or sharing. Nurses can assist parents by discussing moral development and encouraging
parents to give preschoolers recognition for actions such as sharing. It is also important for
parents to answer preschooler “why?” question and discuss values with them.
Fundamentals of Nursing
Kozier et.al 5th edition