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ALL THINGS RN
these are my projects, research, reviewers, study guides i used during my college years. hope this will guide/help you through your nursing life, research, assignment, or your curious minds.:) .im sorry if there are any mistakes, wrong grammar or spelling.
ALL THINGS RN
these are my projects, research, reviewers, study guides i used during my college years. hope this will guide/help you through your nursing life, research, assignment, or your curious minds.:) .im sorry if there are any mistakes, wrong grammar or spelling.
ALL THINGS RN
these are my projects, research, reviewers, study guides i used during my college years. hope this will guide/help you through your nursing life, research, assignment, or your curious minds.:) .im sorry if there are any mistakes, wrong grammar or spelling.
(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) d. Hold head steadily When are they given? e. Sitting alone without support How are they given (if a liquid, with a f. Walks without assistance spoon, if a tablet, swallowed with water or g. Says first words other)? Does he have any trouble taking F. Functional Health Pattern Assessment medication? If so, what helps? Does he have any allergies to 1. Health Perception-Health Management Pattern medications? • Why has your child been admitted? • What does your child know about this • How has your child’s general health been? hospitalization? • What does your child know about this Ask the child why he came to the hospital 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”, ask child to tell you about what had • Do family members eat together or at happened before, during and after the separate times? operation or tests • What are your child’s favorite foods, defecation, potty chair, regular toilet, other beverages and snacks? routines)? Average amounts consumed or usual size • What is his usual pattern of elimination positions (bowel 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 • What are his feeding habits (bottle, cup, sweats a 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 (hearty eater, picky eater) naps? Has his being sick affected your child’s • Is there a special routine before sleeping appetite? (bottle, drink of water, bedtime story, • Are there any feeding problems (excessive, nightlight, favorite blanket, or toy or prayers) fussiness, spitting up, colic), any dental or • Is there a special routine during sleep time gum problems that affect feeding? such as walking to go to the bathroom? • What do you do with these problems? • What type of bed does he sleep on? • Does he have his own room or share a 3. Elimination Pattern room: if he shares a room, with whom? • What are your child’s toilet habits? (diaper, • What are the home sleeping arrangements toilet trained [day only or day and night], use (along or with others, such as sibling parent of words to communicate urination and or other person)? • What is his favorite sleeping position? • Are there any problems with the above • Are there any problems awakening and (dislike or refusal to bathe, shampoo hair or getting ready in the morning? brush teeth) • What do you do for these problems? • What do you do with these problems? 5. Activity-Exercise Pattern • Are there special devices that your child • What is your child’s schedule during the requires help in managing (eyeglasses, day? (nursery school, daycare center, contact lenses, hearing aid, orthodontic regular school, extracurricular activities) appliance, artificial elimination appliances, • What are his favorite activities or toys (both orthopedic devices) active and quiet interests) • Note: Use the following code to assess • What is his usual television-viewing functional self care level for feeding, schedule at home? bathing/hygiene, dressing/grooming, • What are his favorite programs? toileting: • Are there any television restrictions? 0 – full self care • Does your child have any illness or 1 – requires use if equipment or device disabilities that limit his activity? If so, how? 2 – requires assistance or supervision • What are his usual habits and schedule for from another person and equipment or bathing? (bath in the tub or shower, sponge device bath, shampoo? Is dependent and does not participate • What are his dental habits (brushing, flossing, fluoride supplements or rinses, 6. Cognitive-Perceptual Pattern favorite toothpaste, schedule of daily dental • Does your child have any hearing difficulty? care) Does he use hearing aid? • Does your child need help with dressing or Have tubes been placed in your child’s grooming such as hair combing? ears? • Self Perception-Self-Concept Pattern Does your child have any vision problems? Doe she wear eyeglasses or lenses? • How would you describe your child (takes • Does your child have any learning time to adjust, settles in easily, shy, friendly, difficulties? quiet, talkative, serious, playful, stubborn, What is his grade in school? easy going)? • What kinds of things make your child angry, 7. 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 • Does your child have any speech or hearing the day/night (especially if other than parent, problems? If so, what are your suggestions such as babysitter, relative) for communicating with him? • What are the parent’s occupations and work • Will your child’s hospitalization affect family’s schedule? financial support or care of other family • Are there any special family considerations members, such as other children? (adoption, foster child, step parent, divorce, • What concerns do you have about your single parent)? child’s illness and hospitalization? • Have any major changes in the family • Who will be staying with your child while he occurred lately? (death, divorce, separation, is in the hospital? birth of a sibling, loss of job, financial strain, • How can we contact you or another close mother beginning a career, other)? Explain family member outside of the hospital? child’s reaction. • Who are your child’s play companions or 3. Sexuality-Reproductive Pattern social group (peers, young or older children, (Answer questions that apply to child’s age- adults, prefer to be alone)? group) • Do thing generally go well for your child in • Has your child begun puberty (developing school or with friends? physical, sexual characteristics, • Does your child have security objects at menstruation)? Have you or your child had home (pacifier, thumb, bottle, blanket, any concerns? stuffed animal or doll)? Did you bring any of • Does your daughter know how to do BSE? these to the hospital? • Does your child know how to do TSE? • How do you handle discipline problems at • Have you approached topics of sexuality home? Are these methods always effective? 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 4. Coping Stress Tolerance Pattern so, how? • If your child is tired or upset, what does he • Do you have any concerns with behaviors in do? your child such as masturbation, asking If he is upset, doe she have a special many questions or talking about sex, nit person or object he wants? respecting others privacy, or wanting too • If your child has temper tantrums, what much privacy)? causes them and how do you handle them? • Initiate a conversation about adolescent’s • Who does your child talk to when something sexual concerns with open-ended to more is worrying him? direct questions and using the terms • How does your child usually handle “friends” or “partners” rather than girlfriend problems or disappointments? or boyfriend • Has there been any big changes or Tell me about your social life problems un your family recently? How did Who are your closest friends? (if one you handle them? friend is identified, could ask more about • Has your child ever ha d a problem with that relationship, such as how much time drugs or alcohol or tried suicide? they spend together, how serious they are • Do you think your child is accident prone? If about each other, if the relationship is so, explain? going that way the teenager hoped it would) 5. Value-Belief Pattern Might ask about dating and sexual issues, • What us your religion? such as the teenager’s views on sex education, “going steady”, living together • How is religion or faith important in your or premarital sex child’s life? Which friends would you like to have visit • What religious practices would you have in the hospital? continued in the hospital such as prayers before meals/bedtime, visit by minister, • MUSCULOSKELETAL – weakness, clumsiness, priest, or rabbi, prayer group? lack of coordination, abnormal gait, deformities, fractures D. Physical Assessment • NEUROLOGICAL – head, fontanels, sutures, • INTEGUMENT – intact, hygiene, rashes, circumference, orientation to time place and abrasions alertness, responsiveness to reflexes • EENT Eyes – pale, conjuctiva, PERLA E. Current Developmental Level Ears – hearing, symmetry, discharge, pain 1. Gross Motor Skills Nose – nasal flaring, epistaxis, stuffy nose 2. Frame Motor Adoptive Skills Throat – dental condition, pharyngitis 3. Language Skills Mouth – mouth breathing, gum bleeding 4. Personal-Social • 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