(Gordon’s Functional Health Pattern) D. Wt A. Name: Ht: Preferred to be called: Temp: ____ (oral,axilla,rectal) Age: Pulse _____ (regular/irregular) Sex: Resp _____ (regular/irregular) Time of Arrival to Unit: BP Mode of Admission: Mother’s Name: E. Past History Occupation: 1. Birth History Age: a. Mother’s health during pregnancy Address: b. Labor and delivery Tel. No.: c. Infant’s condition immediately after birth Father’s Name: (APGAR) Occupation: Age: 2. Pregnancy, Labor and Delivery Address: a. Obstetric history (GP, TPAL) Tel. No: b. Crisis during pregnancy Religion: c. Prenatal attitude toward fetus Primary Language: Nationality: 3. Perinatal History a. Wt and Ht at birth B. b. Loss of wt following birth and time of 1. Child’s Appearance & Behavior regaining birth wt 2. Parent-child interaction c. APGAR score, level of activity 3. Siblings and other family members d. Problem if any (birth injury, congenital 4. Home environment anomalies) 4. Dietary History (Feeding History) Has your child ever been in the hospital before? 5. Immunization and boosters How was the hospital experience? What things were important to you and 6. Developmental milestones (growth pattern) your child during that hospitalization? How a. Approx wt at 6 mos, 1 yr, 2 yrs, 5 yrs can we be most helpful now? b. Approx ht at 1 yr, 2 yrs, 3 yrs, 4 yrs What medications does your child take at c. Dentition (including age of onset, home? number of teeth and symptoms during Why are they given? teething) When are they given? d. Hold head steadily How are they given (if a liquid, with a e. Sitting alone without support spoon, if a tablet, swallowed with water or f. Walks without assistance other)? g. Says first words Does he have any trouble taking medication? If so, what helps? F. Functional Health Pattern Assessment Does he have any allergies to medications? 1. Health Perception-Health Management Pattern What does your child know about this Why has your child been admitted? hospitalization? How has your child’s general health been? Ask the child why he came to the hospital What does your child know about this hospitalization? 2. Nutritional and Metabolic Pattern Ask the child why he came to the hospital What are the family’s usual meal times? If answer is “For operation or for tests”, Do family members eat together or at separate ask child to tell you about what had times? happened before, during and after the What are your child’s favorite foods, operation or tests beverages and snacks? Average amounts consumed or usual size What is his usual pattern of elimination (bowel positions movements) Special cultural practices, such as family Do you have any concerns about elimination eats only ethnic food (bed wetting, constipation, diarrhea) What goods and beverages does your child What do you do for these problems? dislike? Have you ever noticed that your child sweats a What are his feeding habits (bottle, cup, lot? spoon, eats by seld, needs assistance, any special devices)? 4. Sleep-Rest Pattern How dows the child like his food served What is your child’s usual hour of sleep and (warm, cold, one at a time? awakening? How would you describe his usual appetite? What is his schedule for naps/length of naps? (hearty eater, picky eater) Is there a special routine before sleeping Has his being sick affected your child’s (bottle, drink of water, bedtime story, nightlight, appetite? favorite blanket, or toy or prayers) Are there any feeding problems (excessive, Is there a special routine during sleep time fussiness, spitting up, colic), any dental or such as walking to go to the bathroom? gum problems that affect feeding? What type of bed does he sleep on? What do you do with these problems? Does he have his own room or share a room: if he shares a room, with whom? 3. Elimination Pattern What are the home sleeping arrangements What are your child’s toilet habits? (diaper, (along or with others, such as sibling parent or toilet trained [day only or day and night], use other person)? of words to communicate urination and What is his favorite sleeping position? defecation, potty chair, regular toilet, other Are there any problems awakening and getting routines)? ready in the morning? What do you do for these problems? 5. Activity-Exercise Pattern appliance, artificial elimination appliances, What is your child’s schedule during the day? orthopedic devices) (nursery school, daycare center, regular school, extracurricular activities) Note: Use the following code to assess What are his favorite activities or toys (both functional self care level for feeding, active and quiet interests) bathing/hygiene, dressing/grooming, toileting: What is his usual television-viewing schedule 0 – full self care at home? 1 – requires use if equipment or device What are his favorite programs? 2 – requires assistance or supervision Are there any television restrictions? from another person and equipment or Does your child have any illness or disabilities device that limit his activity? If so, how? Is dependent and does not participate What are his usual habits and schedule for bathing? (bath in the tub or shower, sponge 6. Cognitive-Perceptual Pattern bath, shampoo? Does your child have any hearing difficulty? What are his dental habits (brushing, flossing, Does he use hearing aid? fluoride supplements or rinses, favorite Have tubes been placed in your child’s toothpaste, schedule of daily dental care) ears? Does your child need help with dressing or Does your child have any vision problems? grooming such as hair combing? Doe she wear eyeglasses or lenses? Are there any problems with the above (dislike Does your child have any learning difficulties? or refusal to bathe, shampoo hair or brush What is his grade in school? 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 7. Self Perception-Self-Concept Pattern Who usually takes care of your child during How would you describe your child (takes time the day/night (especially if other than parent, to adjust, settles in easily, shy, friendly, quiet, such as babysitter, relative) talkative, serious, playful, stubborn, easy What are the parent’s occupations and work going)? schedule? What kinds of things make your child angry, Are there any special family considerations annoyed, anxious or sad? What helps? (adoption, foster child, step parent, divorce, How does your child act when he is annoyed single parent)? or upset? Have any major changes in the family What have been your child’s experiences with occurred lately? (death, divorce, separation, and reactions to temporary separation from birth of a sibling, loss of job, financial strain, you (parent)? mother beginning a career, other)? Explain Does your child have any fears (places, child’s reaction. objects, animals, people, situations)? How do Who are your child’s play companions or you handle them? social group (peers, young or older children, Do you think your child’s illness has changed adults, prefer to be alone)? the way he thinks about himself (more shy, Do thing generally go well for your child in embarrassed about appearance, less school or with friends? competitive with friends, stays home more)? Does your child have security objects at home (pacifier, thumb, bottle, blanket, stuffed animal 8. Role Relationship Pattern or doll)? Did you bring any of these to the Does your child have a nickname he wishes to hospital? be called? How do you handle discipline problems at What are the names of other family members home? Are these methods always effective? or others who live in the home (relatives, Does your child have any speech or hearing friends, pets)? problems? If so, what are your suggestions for communicating with him? Will your child’s hospitalization affect family’s questions or talking about sex, nit respecting financial support or care of other family others privacy, or wanting too much privacy)? members, such as other children? Initiate a conversation about adolescent’s What concerns do you have about your child’s sexual concerns with open-ended to more illness and hospitalization? direct questions and using the terms “friends” Who will be staying with your child while he is or “partners” rather than girlfriend or boyfriend in the hospital? Tell me about your social life How can we contact you or another close Who are your closest friends? (if one family member outside of the hospital? friend is identified, could ask more about that relationship, such as how much time 9. Sexuality-Reproductive Pattern they spend together, how serious they are (Answer questions that apply to child’s age- about each other, if the relationship is group) going that way the teenager hoped it Has your child begun puberty (developing would) physical, sexual characteristics, Might ask about dating and sexual issues, menstruation)? Have you or your child had such as the teenager’s views on sex any concerns? education, “going steady”, living together Does your daughter know how to do BSE? or premarital sex Does your child know how to do TSE? Which friends would you like to have visit in the hospital? Have you approached topics of sexuality with your child? Do you feel you might need some 10. Coping Stress Tolerance Pattern help with some topics? If your child is tired or upset, what does he do? Has your child’s illness affected the way he or If he is upset, doe she have a special she feels about being a male or female? If so, person or object he wants? how? If your child has temper tantrums, what causes Do you have any concerns with behaviors in them and how do you handle them? your child such as masturbation, asking many Who does your child talk to when something is Nose – nasal flaring, epistaxis, stuffy nose worrying him? Throat – dental condition, pharyngitis How does your child usually handle problems Mouth – mouth breathing, gum bleeding or disappointments? NECK – pain, limitation of movement Has there been any big changes or problems CHEST – breast enlargement, masses un your family recently? How did you handle RESPIRATORY – chronic cough, frequent colds them? (#/yr) Has your child ever ha d a problem with drugs CARDIOVASCULAR – cynosis, fatigue on or alcohol or tried suicide? exertion, anemia, blood type, CBC, rate and rythim Do you think your child is accident prone? If of heart so, explain? GUT – frequency, dysuria, descent of testes GIT – food intolerance, eating and elimination 11. Value-Belief Pattern habits, vomiting What us your religion? GYNECOLOGIC – menarche, regularity, vaginal How is religion or faith important in your child’s discharge life? MUSCULOSKELETAL – weakness, clumsiness, What religious practices would you have lack of coordination, abnormal gait, deformities, continued in the hospital such as prayers fractures before meals/bedtime, visit by minister, priest, NEUROLOGICAL – head, fontanels, sutures, or rabbi, prayer group? circumference, orientation to time place and alertness, responsiveness to reflexes G. Physical Assessment INTEGUMENT – intact, hygiene, rashes, H. Current Developmental Level abrasions 1. Gross Motor Skills EENT 2. Frame Motor Adoptive Skills Eyes – pale, conjuctiva, PERLA 3. Language Skills Ears – hearing, symmetry, discharge, pain 4. Personal-Social