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 & Behavior
2. Parent-child interaction
3. Siblings and other family members
4. Home environment
C. Chief Concern (Narrative of Present Illness)
D. Wt
Ht:
Temp:____ (oral,axilla,rectal)
Pulse__ ___ (regular/irregular)
Resp_____ (regular/irregular)
BP
E. Past History
1. Birth History
a. Mother’s health during pregnancy
b. Labor and delivery
c. Infant’s condition immediately after birth
(APGAR)
2. Pregnancy, Labor and Delivery
a. Obstetric history (GP, TPAL)
b. Crisis during pregnancy
c. Prenatal attitude toward fetus
3. Perinatal History
a. Wt and Ht at birth
b. Loss of wt following birth and time of
regaining birth wt
c. APGAR score, level of activity
d. 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 yrs
b. Approx ht at 1 yr, 2 yrs, 3 yrs, 4 yrs
c. Dentition (including age of onset,
number of teeth and symptoms during
teething)
d. Hold head steadily
e. Sitting alone without support
f. Walks without assistance
g. 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 atseparate 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 andawakening?
•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 dentalcare)
•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)?
2. 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?
3. 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?
4. 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?
5. 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?
D. 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
E. Current Developmental Level
1. Gross Motor Skills
2. Frame Motor Adoptive Skills
3. Language Skills
4. Personal-Social
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