PEDIATRIC NURSING ASSESSMENT

(Gordons Functional Health Pattern)

A. Name:
Preferred to be called:
Age:
Sex:
ime of Arri!al to "nit:
#ode of Admission:
#others Name:
$ccu%ation:
Age:
Address:
el. No.:
Fathers Name:
$ccu%ation:
Age:
Address:
el. No:
&eligion:
Primar' (anguage:
Nationalit':
).
*. +hilds A%%earance , )eha!ior
-. Parent.child interaction
/. Siblings and other famil' members
0. Home en!ironment
+. +hief +oncern (Narrati!e of Present 1llness)
2. 3t
Ht:
em%: 4444 (oral5axilla5rectal)
Pulse 44444 (regular6irregular)
&es% 44444 (regular6irregular)
)P
7. Past Histor'
*. )irth Histor'
a. #others health during %regnanc'
b. (abor and deli!er'
c. 1nfants condition immediatel' after birth
(APGA&)
-. Pregnanc'5 (abor and 2eli!er'
a. $bstetric histor' (GP5 PA()
b. +risis during %regnanc'
c. Prenatal attitude to8ard fetus
/. Perinatal Histor'
a. 3t and Ht at birth
b. (oss of 8t follo8ing birth and time of
regaining birth 8t
c. APGA& score5 le!el of acti!it'
d. Problem if an' (birth in9ur'5 congenital
anomalies)
0. 2ietar' Histor' (Feeding Histor')
:. 1mmuni;ation and boosters
<. 2e!elo%mental milestones (gro8th %attern)
a. A%%rox 8t at < mos5 * 'r5 - 'rs5 : 'rs
b. A%%rox ht at * 'r5 - 'rs5 / 'rs5 0 'rs
c. 2entition (including age of onset5
number of teeth and s'm%toms during
teething)
d. Hold head steadil'
e. Sitting alone 8ithout su%%ort
f. 3al=s 8ithout assistance
g. Sa's first 8ords
F. Functional Health Pattern Assessment
*. Health Perce%tion.Health #anagement Pattern
3h' has 'our child been admitted>
Ho8 has 'our childs general health been>
3hat does 'our child =no8 about this
hos%itali;ation>
As= the child 8h' he came to the hos%ital
1f ans8er is ?For o%eration or for tests@5
as= child to tell 'ou about 8hat had
ha%%ened before5 during and after the
o%eration or tests
Has 'our child e!er been in the hos%ital
before>
Ho8 8as the hos%ital ex%erience>
3hat things 8ere im%ortant to 'ou and
'our child during that hos%itali;ation> Ho8
can 8e be most hel%ful no8>
3hat medications does 'our child ta=e at
home>
3h' are the' gi!en>
3hen are the' gi!en>
Ho8 are the' gi!en (if a liAuid5 8ith a
s%oon5 if a tablet5 s8allo8ed 8ith 8ater or
other)>
2oes he ha!e an' trouble ta=ing
medication> 1f so5 8hat hel%s>
2oes he ha!e an' allergies to
medications>
3hat does 'our child =no8 about this
hos%itali;ation>
As= the child 8h' he came to the hos%ital
-. Nutritional and #etabolic Pattern
3hat are the famil's usual meal times>
2o famil' members eat together or at se%arate
times>
3hat are 'our childs fa!orite foods5
be!erages and snac=s>
A!erage amounts consumed or usual si;e
%ositions
S%ecial cultural %ractices5 such as famil'
eats onl' ethnic food
3hat goods and be!erages does 'our child
disli=e>
3hat are his feeding habits (bottle5 cu%5
s%oon5 eats b' seld5 needs assistance5 an'
s%ecial de!ices)>
Ho8 do8s the child li=e his food ser!ed
(8arm5 cold5 one at a time>
Ho8 8ould 'ou describe his usual a%%etite>
(heart' eater5 %ic=' eater)
Has his being sic= affected 'our childs
a%%etite>
Are there an' feeding %roblems (excessi!e5
fussiness5 s%itting u%5 colic)5 an' dental or
gum %roblems that affect feeding>
3hat do 'ou do 8ith these %roblems>
/. 7limination Pattern
3hat are 'our childs toilet habits> (dia%er5
toilet trained Bda' onl' or da' and nightC5 use
of 8ords to communicate urination and
defecation5 %ott' chair5 regular toilet5 other
routines)>
3hat is his usual %attern of elimination (bo8el
mo!ements)
2o 'ou ha!e an' concerns about elimination
(bed 8etting5 consti%ation5 diarrhea)
3hat do 'ou do for these %roblems>
Ha!e 'ou e!er noticed that 'our child s8eats a
lot>
0. Slee%.&est Pattern
3hat is 'our childs usual hour of slee% and
a8a=ening>
3hat is his schedule for na%s6length of na%s>
1s there a s%ecial routine before slee%ing
(bottle5 drin= of 8ater5 bedtime stor'5 nightlight5
fa!orite blan=et5 or to' or %ra'ers)
1s there a s%ecial routine during slee% time
such as 8al=ing to go to the bathroom>
3hat t'%e of bed does he slee% on>
2oes he ha!e his o8n room or share a room:
if he shares a room5 8ith 8hom>
3hat are the home slee%ing arrangements
(along or 8ith others5 such as sibling %arent or
other %erson)>
3hat is his fa!orite slee%ing %osition>
Are there an' %roblems a8a=ening and getting
read' in the morning>
3hat do 'ou do for these %roblems>
:. Acti!it'.7xercise Pattern
3hat is 'our childs schedule during the da'>
(nurser' school5 da'care center5 regular
school5 extracurricular acti!ities)
3hat are his fa!orite acti!ities or to's (both
acti!e and Auiet interests)
3hat is his usual tele!ision.!ie8ing schedule
at home>
3hat are his fa!orite %rograms>
Are there an' tele!ision restrictions>
2oes 'our child ha!e an' illness or disabilities
that limit his acti!it'> 1f so5 ho8>
3hat are his usual habits and schedule for
bathing> (bath in the tub or sho8er5 s%onge
bath5 sham%oo>
3hat are his dental habits (brushing5 flossing5
fluoride su%%lements or rinses5 fa!orite
tooth%aste5 schedule of dail' dental care)
2oes 'our child need hel% 8ith dressing or
grooming such as hair combing>
Are there an' %roblems 8ith the abo!e (disli=e
or refusal to bathe5 sham%oo hair or brush
teeth)
3hat do 'ou do 8ith these %roblems>
Are there s%ecial de!ices that 'our child
reAuires hel% in managing (e'eglasses5
contact lenses5 hearing aid5 orthodontic
a%%liance5 artificial elimination a%%liances5
ortho%edic de!ices)
Note: "se the follo8ing code to assess
functional self care le!el for feeding5
bathing6h'giene5 dressing6grooming5 toileting:
D E full self care
* E reAuires use if eAui%ment or de!ice
- E reAuires assistance or su%er!ision
from another %erson and eAui%ment or
de!ice
1s de%endent and does not %artici%ate
<. +ogniti!e.Perce%tual Pattern
2oes 'our child ha!e an' hearing difficult'>
2oes he use hearing aid>
Ha!e tubes been %laced in 'our childs
ears>
2oes 'our child ha!e an' !ision %roblems>
2oe she 8ear e'eglasses or lenses>
2oes 'our child ha!e an' learning difficulties>
3hat is his grade in school>
F. Self Perce%tion.Self.+once%t Pattern
Ho8 8ould 'ou describe 'our child (ta=es time
to ad9ust5 settles in easil'5 sh'5 friendl'5 Auiet5
tal=ati!e5 serious5 %la'ful5 stubborn5 eas'
going)>
3hat =inds of things ma=e 'our child angr'5
anno'ed5 anxious or sad> 3hat hel%s>
Ho8 does 'our child act 8hen he is anno'ed
or u%set>
3hat ha!e been 'our childs ex%eriences 8ith
and reactions to tem%orar' se%aration from
'ou (%arent)>
2oes 'our child ha!e an' fears (%laces5
ob9ects5 animals5 %eo%le5 situations)> Ho8 do
'ou handle them>
2o 'ou thin= 'our childs illness has changed
the 8a' he thin=s about himself (more sh'5
embarrassed about a%%earance5 less
com%etiti!e 8ith friends5 sta's home more)>
G. &ole &elationshi% Pattern
2oes 'our child ha!e a nic=name he 8ishes to
be called>
3hat are the names of other famil' members
or others 8ho li!e in the home (relati!es5
friends5 %ets)>
3ho usuall' ta=es care of 'our child during
the da'6night (es%eciall' if other than %arent5
such as bab'sitter5 relati!e)
3hat are the %arents occu%ations and 8or=
schedule>
Are there an' s%ecial famil' considerations
(ado%tion5 foster child5 ste% %arent5 di!orce5
single %arent)>
Ha!e an' ma9or changes in the famil'
occurred latel'> (death5 di!orce5 se%aration5
birth of a sibling5 loss of 9ob5 financial strain5
mother beginning a career5 other)> 7x%lain
childs reaction.
3ho are 'our childs %la' com%anions or
social grou% (%eers5 'oung or older children5
adults5 %refer to be alone)>
2o thing generall' go 8ell for 'our child in
school or 8ith friends>
2oes 'our child ha!e securit' ob9ects at home
(%acifier5 thumb5 bottle5 blan=et5 stuffed animal
or doll)> 2id 'ou bring an' of these to the
hos%ital>
Ho8 do 'ou handle disci%line %roblems at
home> Are these methods al8a's effecti!e>
2oes 'our child ha!e an' s%eech or hearing
%roblems> 1f so5 8hat are 'our suggestions for
communicating 8ith him>
3ill 'our childs hos%itali;ation affect famil's
financial su%%ort or care of other famil'
members5 such as other children>
3hat concerns do 'ou ha!e about 'our childs
illness and hos%itali;ation>
3ho 8ill be sta'ing 8ith 'our child 8hile he is
in the hos%ital>
Ho8 can 8e contact 'ou or another close
famil' member outside of the hos%ital>
H. Sexualit'.&e%roducti!e Pattern
(Ans8er Auestions that a%%l' to childs age.
grou%)
Has 'our child begun %ubert' (de!elo%ing
%h'sical5 sexual characteristics5
menstruation)> Ha!e 'ou or 'our child had
an' concerns>
2oes 'our daughter =no8 ho8 to do )S7>
2oes 'our child =no8 ho8 to do S7>
Ha!e 'ou a%%roached to%ics of sexualit' 8ith
'our child> 2o 'ou feel 'ou might need some
hel% 8ith some to%ics>
Has 'our childs illness affected the 8a' he or
she feels about being a male or female> 1f so5
ho8>
2o 'ou ha!e an' concerns 8ith beha!iors in
'our child such as masturbation5 as=ing man'
Auestions or tal=ing about sex5 nit res%ecting
others %ri!ac'5 or 8anting too much %ri!ac')>
1nitiate a con!ersation about adolescents
sexual concerns 8ith o%en.ended to more
direct Auestions and using the terms ?friends@
or ?%artners@ rather than girlfriend or bo'friend
ell me about 'our social life
3ho are 'our closest friends> (if one
friend is identified5 could as= more about
that relationshi%5 such as ho8 much time
the' s%end together5 ho8 serious the' are
about each other5 if the relationshi% is
going that 8a' the teenager ho%ed it
8ould)
#ight as= about dating and sexual issues5
such as the teenagers !ie8s on sex
education5 ?going stead'@5 li!ing together
or %remarital sex
3hich friends 8ould 'ou li=e to ha!e !isit
in the hos%ital>
*D. +o%ing Stress olerance Pattern
1f 'our child is tired or u%set5 8hat does he do>
1f he is u%set5 doe she ha!e a s%ecial
%erson or ob9ect he 8ants>
1f 'our child has tem%er tantrums5 8hat causes
them and ho8 do 'ou handle them>
3ho does 'our child tal= to 8hen something is
8orr'ing him>
Ho8 does 'our child usuall' handle %roblems
or disa%%ointments>
Has there been an' big changes or %roblems
un 'our famil' recentl'> Ho8 did 'ou handle
them>
Has 'our child e!er ha d a %roblem 8ith drugs
or alcohol or tried suicide>
2o 'ou thin= 'our child is accident %rone> 1f
so5 ex%lain>
**. Ialue.)elief Pattern
3hat us 'our religion>
Ho8 is religion or faith im%ortant in 'our childs
life>
3hat religious %ractices 8ould 'ou ha!e
continued in the hos%ital such as %ra'ers
before meals6bedtime5 !isit b' minister5 %riest5
or rabbi5 %ra'er grou%>
G. Ph'sical Assessment
1N7G"#7N E intact5 h'giene5 rashes5
abrasions
77N
7'es E %ale5 con9ucti!a5 P7&(A
7ars E hearing5 s'mmetr'5 discharge5 %ain
Nose E nasal flaring5 e%istaxis5 stuff' nose
hroat E dental condition5 %har'ngitis
#outh E mouth breathing5 gum bleeding
N7+J E %ain5 limitation of mo!ement
+H7S E breast enlargement5 masses
&7SP1&A$&K E chronic cough5 freAuent colds
(L6'r)
+A&21$IAS+"(A& E c'nosis5 fatigue on
exertion5 anemia5 blood t'%e5 +)+5 rate and r'thim
of heart
G" E freAuenc'5 d'suria5 descent of testes
G1 E food intolerance5 eating and elimination
habits5 !omiting
GKN7+$($G1+ E menarche5 regularit'5 !aginal
discharge
#"S+"($SJ7(7A( E 8ea=ness5 clumsiness5
lac= of coordination5 abnormal gait5 deformities5
fractures
N7"&$($G1+A( E head5 fontanels5 sutures5
circumference5 orientation to time %lace and
alertness5 res%onsi!eness to reflexes
H. +urrent 2e!elo%mental (e!el
*. Gross #otor S=ills
-. Frame #otor Ado%ti!e S=ills
/. (anguage S=ills
0. Personal.Social