GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC CLIENTS

GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC

CLIENTS
PEDIATRIC NURSING ASSESSMENT

A. Initial Database
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. General Assessment

1. Child’s Appearance & Behavior

2. Parent-child interaction

3. Siblings and other family members

4. Home environment

MANUAL OF PATIENT ASSESSMENT TOOL

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 GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC CLIENTS

C. Chief Concern (Narrative of Present Illness)

__________________________________________________________________________________________
_____________________________________________

D. Vital Signs
Wt__________

Ht:__________

Temp: ____ (oral,axilla,rectal)

Pulse _____ (regular/irregular)

Resp _____ (regular/irregular)

BP__________

E. Past Health 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)

____________________________________________________________________________________
____________________________________________________________________
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 GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC CLIENTS

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. Gordon’s 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 does 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?

MANUAL OF PATIENT ASSESSMENT TOOL

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 GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC CLIENTS

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?
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MANUAL OF PATIENT ASSESSMENT TOOL

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● 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
A. Tell me about your social life
B. 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)
C. Might ask about dating and sexual issues, such as the teenager’s views on sex education,
“going steady”, living together or premarital sex
D. 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

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MANUAL OF PATIENT ASSESSMENT TOOL

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 GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC CLIENTS

● 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. Current Developmental Level

Gross Motor Skills

Frame Motor Adoptive Skills

Language Skills

Personal-Social

H. Behavioral Checklist for Pediatric Patients

Scoring is a point system:
0 – never
1 – sometimes
2 – often
Scores between 15 and 22 indicate closer following; scores above 22 warrant psychiatric evaluation.
This checklist is applicable for school-age children, ages 7-11.

0 1 2 Behaviors (mood, play, school, friends, family relations)

1. Prefers to play alone
2. Gets hurt in major accidents
3. Does he or she ever play with fire?
4. Has difficulties with teacher?
5. Gets poor grades in school?
6. Is absent from school?
7. Becomes angry easily?
8. Daydreams
9. Feels unhappy
10. Acts younger than other children his/her age
11. Does not listen to parents
12.Does not tell the truth
13. Unsure of himself or herself
14. Has trouble sleeping
15. Seems afraid of someone or something
16. Is nervous and jumpy
17. Has a nervous habit
18. Does not show feelings
19. Fight with other children
Note: Reverse the score for numbers 20 and 26
20. Is understanding of other peoples feelings
21. Refuses to share
22. Shows jealously
23. Takes things that are not his or hers
24. Blames others for his or her troubles
25. Prefers to play with children no his/her age
26. Gets along well with grown-ups.
27. Teases others

Total Score:____________________________
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MANUAL OF PATIENT ASSESSMENT TOOL

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 GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC CLIENTS

Interpretation:  Normal  Needs closer following  Needs Psychiatric Evaluation

I. Denver II Developmental Screening Test

● This tool may determine relative areas of advancement and areas of delay in the development of
children. Frequently, this is used as an excellent way to begin health appraisal because it is non-
threatening, requires no painful or unfamiliar procedures, and capitalizes on the child’s natural activity
of play.
● Used with children from birth to six years of age.

Directions for Administration:

1. Try to get the child to smile by smiling, talking, or waving. Do not touch him or her.
2. The child must stare at hand several seconds.
3. Parent may help guide toothbrush and put toothpaste on brush.
4. Child does not have to be able to tie shoes or button/zip in the back.
5. Move yarn slowly in an arc from one side to the other, about 8 “ above child’s face.
6. Pass if the child grasps rattle when it is touched to the back or tips of fingers.
7. Pass if child tries to see where the yarn went. Yarn should be dropped quickly from sight from tester’s hand
without arm movement.
8. Child must transfer cube from hand to hand without help of the body, mouth or table.
9. Pass if the child picks up raisin with any part of thumb and finger.
10. Line can vary only 30 degrees or les from tester’s line.
11. Make a fist with thumb pointing upward and wiggle only the thumb. Pass if child imitates and does not mive
any fingers other than the thumb.
12. Pass any enclosed form. Fail continuous round motion.

13. Which line is longer? (Not bigger). Turn paper upside down and repeat (pass 3 of 3 or 5 of 6).

14. Pass any lines crossing midpoint.

15. Have the child copy first. If failed, demonstrate.

When giving items 12, 4 and 15, do not name the forms. Do not demonstrate 12 and 14.
16. When scoring, each pair (2 arms, 2 legs, etc.) Count as one part.
17. Place one cube in cup and shake gently near child’s ear, but out of sight. Repeat for other ear.
18. Point to picture and have child name it. (No credit is given for sounds only). If less than 4 pictures are named
correctly, have child point picture as each is named by tester.

MANUAL OF PATIENT ASSESSMENT TOOL

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 GORDON’S FUNCTIONAL HEALTH PATTERN FOR PEDIATRIC CLIENTS

19. Using doll, tell child: show me the nose, eyes, ears, mouth, hands, feet, tummy, hair. Pass 6 out of 8.
20. Using pictures, ask child; which one flies? Says meow? Talks? Used to play? Used as a clothing? Pass 2 of
3 or 4 out of 5.
21. Ask child: What do you do when you are cold? Tired? Hungry? Pass 2 of 3, 3 of 3.
22. Ask child; what do you do with a cup? What is a chair used for? What is a pencil used for? Action words
must be included in the answer.
23. Pass if child correctly places and says how many blocks are there on paper (1,5).
24. Tell child; Put block on the table; under table; in front of me, behind me. Pass 4 of 4. (Do not help child by
pointing, moving head or eyes).
25. Ask child what is a ball? Lake? Desk? House? Banana? Curtain? Fence? Ceiling? Pass if defined in terms
of use, shape, what is it made from or general category (such as banana as fruit, not just yellow). Pass 5 of
8, 7 of 8.
26. Ask child: if a horse is big, a mouse is ________? If fire is hot, ice is _______?If the sun shines during the
day, the moon shines during________?Pass 2 out of 3.
27. Child may use wall or rail only, not person. May not crawl.
28. Child must throw ball overhand 3 feet to within arm’s reach of tester.
29. Child must perform standing broad jump over width of test sheet (8 1/2 inches).
30. Tell child to walk forward, Heel within 1 inch of toe. Tester may demonstrate. Child must walk 4 consecutive
steps.
31. In the second year, half of children are non-compliant.

Observations:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Denver II Scoring
Interpretation of Denver II scores

Advanced – Passed an item completely to the right of the age line (passed by less than 25% of children at an
age older than the child).
OK- Passed, failed, or refused an item intersected by the age line between the 25 th and 75th percentiles.
Caution- Failed, or refused item s intersected by the age line on or between the 75 th and 90th percentiles.
Delay – Failed an item completely to the left of the age line; refusals to the left of the age line may also be
considered delays, since the reason for the refusal may be inability to perform the task.

Interpretation of Test

Recommendations for referral for suspect and untestable test

Normal – No delays and a maximu of one caution
Suspect – one or more delays and/or two or more cautions.
Untestable – Refusals on one or more items completely left of the age line or on more than one item intersected
by the age line in the 75% to 90% area.

Recommendations for referral for suspect and untestable test

Rescreen in 1 to 2 weeks to rule out temporary factors.
If rescreen is suspect or untestable, use clinical judgement based on the following; number of cautions and
delays; which items are cautious and delays; rate of past development; clinical examination and history; availabilty
of referral resources.

MANUAL OF PATIENT ASSESSMENT TOOL

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