PEDIATRIC NURSING ASSESSMENT(Gordon’s Functional Health Pattern)

A. Name: Preferred to be called: Age: Sex: Time of Arrival to Unit: Mode of Admission: Mother’s Name:

Occupation: Age:Address: Tel. No.:

Father’s Name:Occupation:Age:Address:Tel. No:

Religion:Primary Language:Nationality:

B. 1. Child’s Appearance & Behavior2. Parent-child interaction3. Siblings and other family members4. Home environment

C. Chief Concern (Narrative of Present Illness)

D. WtHt:Temp: ____ (oral,axilla,rectal)Pulse _____ (regular/irregular)Resp _____ (regular/irregular)BP

E. Past History1. Birth History

a. Mother’s health during pregnancyb. Labor and deliveryc. Infant’s condition immediately after birth

(APGAR)

2. Pregnancy, Labor and Deliverya. Obstetric history (GP, TPAL)b. Crisis during pregnancyc. Prenatal attitude toward fetus

3. Perinatal Historya. Wt and Ht at birthb. Loss of wt following birth and time of

regaining birth wtc. APGAR score, level of activityd. Problem if any (birth injury, congenital

anomalies)

4. Dietary History (Feeding History)

5. Immunization and boosters

6. Developmental milestones (growth pattern)a. Approx wt at 6 mos, 1 yr, 2 yrs, 5 yrsb. Approx ht at 1 yr, 2 yrs, 3 yrs, 4 yrsc. Dentition (including age of onset,

number of teeth and symptoms during teething)

d. Hold head steadilye. Sitting alone without supportf. Walks without assistanceg. Says first words

F. Functional Health Pattern Assessment

1. Health Perception-Health Management Pattern Why has your child been admitted? How has your child’s general health been? What does your child know about this

hospitalization? Ask the child why he came to the hospital If answer is “For operation or for tests”,

ask child to tell you about what had happened before, during and after the operation or tests

Has your child ever been in the hospital before? How was the hospital experience? What things were important to you and

your child during that hospitalization? How can we be most helpful now?

What medications does your child take at home? Why are they given? When are they given? How are they given (if a liquid, with a

spoon, if a tablet, swallowed with water or other)?

Does he have any trouble taking medication? If so, what helps?

Does he have any allergies to medications?

What does your child know about this hospitalization? Ask the child why he came to the hospital

2. Nutritional and Metabolic Pattern What are the family’s usual meal times? Do family members eat together or at separate

times? What are your child’s favorite foods,

beverages and snacks?

Average amounts consumed or usual size positions

Special cultural practices, such as family eats only ethnic food

What goods and beverages does your child dislike?

What are his feeding habits (bottle, cup, spoon, eats by seld, needs assistance, any special devices)?

How dows the child like his food served (warm, cold, one at a time?

How would you describe his usual appetite? (hearty eater, picky eater) Has his being sick affected your child’s

appetite? Are there any feeding problems (excessive,

fussiness, spitting up, colic), any dental or gum problems that affect feeding?

What do you do with these problems?

3. Elimination Pattern What are your child’s toilet habits? (diaper,

toilet trained [day only or day and night], use of words to communicate urination and defecation, potty chair, regular toilet, other routines)?

What is his usual pattern of elimination (bowel movements)

Do you have any concerns about elimination (bed wetting, constipation, diarrhea)

What do you do for these problems? Have you ever noticed that your child sweats a

lot?

4. Sleep-Rest Pattern What is your child’s usual hour of sleep and

awakening? What is his schedule for naps/length of naps? Is there a special routine before sleeping

(bottle, drink of water, bedtime story, nightlight, favorite blanket, or toy or prayers)

Is there a special routine during sleep time such as walking to go to the bathroom?

What type of bed does he sleep on? Does he have his own room or share a room:

if he shares a room, with whom? What are the home sleeping arrangements

(along or with others, such as sibling parent or other person)?

What is his favorite sleeping position? Are there any problems awakening and getting

ready in the morning? What do you do for these problems?

5. Activity-Exercise Pattern

What is your child’s schedule during the day? (nursery school, daycare center, regular school, extracurricular activities)

What are his favorite activities or toys (both active and quiet interests)

What is his usual television-viewing schedule at home?

What are his favorite programs? Are there any television restrictions? Does your child have any illness or disabilities

that limit his activity? If so, how? What are his usual habits and schedule for

bathing? (bath in the tub or shower, sponge bath, shampoo?

What are his dental habits (brushing, flossing, fluoride supplements or rinses, favorite toothpaste, schedule of daily dental care)

Does your child need help with dressing or grooming such as hair combing?

Are there any problems with the above (dislike or refusal to bathe, shampoo hair or brush teeth)

What do you do with these problems? Are there special devices that your child

requires help in managing (eyeglasses, contact lenses, hearing aid, orthodontic appliance, artificial elimination appliances, orthopedic devices)

Note: Use the following code to assess functional self care level for feeding, bathing/hygiene, dressing/grooming, toileting: 0 – full self care 1 – requires use if equipment or device 2 – requires assistance or supervision

from another person and equipment or device

Is dependent and does not participate

6. Cognitive-Perceptual Pattern Does your child have any hearing difficulty?

Does he use hearing aid? Have tubes been placed in your child’s

ears? Does your child have any vision problems?

Doe she wear eyeglasses or lenses? Does your child have any learning difficulties?

What is his grade in school?

7. Self Perception-Self-Concept Pattern How would you describe your child (takes time

to adjust, settles in easily, shy, friendly, quiet, talkative, serious, playful, stubborn, easy going)?

What kinds of things make your child angry, annoyed, anxious or sad? What helps?

How does your child act when he is annoyed or upset?

What have been your child’s experiences with and reactions to temporary separation from you (parent)?

Does your child have any fears (places, objects, animals, people, situations)? How do you handle them?

Do you think your child’s illness has changed the way he thinks about himself (more shy, embarrassed about appearance, less competitive with friends, stays home more)?

8. Role Relationship Pattern Does your child have a nickname he wishes to

be called? What are the names of other family members

or others who live in the home (relatives, friends, pets)?

Who usually takes care of your child during the day/night (especially if other than parent, such as babysitter, relative)

What are the parent’s occupations and work schedule?

Are there any special family considerations (adoption, foster child, step parent, divorce, single parent)?

Have any major changes in the family occurred lately? (death, divorce, separation, birth of a sibling, loss of job, financial strain, mother beginning a career, other)? Explain child’s reaction.

Who are your child’s play companions or social group (peers, young or older children, adults, prefer to be alone)?

Do thing generally go well for your child in school or with friends?

Does your child have security objects at home (pacifier, thumb, bottle, blanket, stuffed animal or doll)? Did you bring any of these to the hospital?

How do you handle discipline problems at home? Are these methods always effective?

Does your child have any speech or hearing problems? If so, what are your suggestions for communicating with him?

Will your child’s hospitalization affect family’s financial support or care of other family members, such as other children?

What concerns do you have about your child’s illness and hospitalization?

Who will be staying with your child while he is in the hospital?

How can we contact you or another close family member outside of the hospital?

9. Sexuality-Reproductive Pattern(Answer questions that apply to child’s age-group) Has your child begun puberty (developing

physical, sexual characteristics, menstruation)? Have you or your child had any concerns?

Does your daughter know how to do BSE? Does your child know how to do TSE? Have you approached topics of sexuality with

your child? Do you feel you might need some help with some topics?

Has your child’s illness affected the way he or she feels about being a male or female? If so, how?

Do you have any concerns with behaviors in your child such as masturbation, asking many

questions or talking about sex, nit respecting others privacy, or wanting too much privacy)?

Initiate a conversation about adolescent’s sexual concerns with open-ended to more direct questions and using the terms “friends” or “partners” rather than girlfriend or boyfriend Tell me about your social life Who are your closest friends? (if one

friend is identified, could ask more about that relationship, such as how much time they spend together, how serious they are about each other, if the relationship is going that way the teenager hoped it would)

Might ask about dating and sexual issues, such as the teenager’s views on sex education, “going steady”, living together or premarital sex

Which friends would you like to have visit in the hospital?

10. Coping Stress Tolerance Pattern If your child is tired or upset, what does he do?

If he is upset, doe she have a special person or object he wants?

If your child has temper tantrums, what causes them and how do you handle them?

Who does your child talk to when something is worrying him?

How does your child usually handle problems or disappointments?

Has there been any big changes or problems un your family recently? How did you handle them?

Has your child ever ha d a problem with drugs or alcohol or tried suicide?

Do you think your child is accident prone? If so, explain?

11. Value-Belief Pattern What us your religion? How is religion or faith important in your child’s

life? What religious practices would you have

continued in the hospital such as prayers before meals/bedtime, visit by minister, priest, or rabbi, prayer group?

G. Physical Assessment INTEGUMENT – intact, hygiene, rashes,

abrasions EENT

Eyes – pale, conjuctiva, PERLA Ears – hearing, symmetry, discharge, pain Nose – nasal flaring, epistaxis, stuffy nose

Throat – dental condition, pharyngitis Mouth – mouth breathing, gum bleeding

NECK – pain, limitation of movement CHEST – breast enlargement, masses RESPIRATORY – chronic cough, frequent colds

(#/yr) CARDIOVASCULAR – cynosis, fatigue on

exertion, anemia, blood type, CBC, rate and rythim of heart

GUT – frequency, dysuria, descent of testes GIT – food intolerance, eating and elimination

habits, vomiting GYNECOLOGIC – menarche, regularity, vaginal

discharge MUSCULOSKELETAL – weakness, clumsiness,

lack of coordination, abnormal gait, deformities, fractures

NEUROLOGICAL – head, fontanels, sutures, circumference, orientation to time place and alertness, responsiveness to reflexes

H. Current Developmental Level1. Gross Motor Skills2. Frame Motor Adoptive Skills3. Language Skills4. Personal-Social