Functional Health Pattern Assessment: Infant and Early Childhood

Patients Name: Age: Birthdate: Address: Religion: Address: Occupation: Room and bed number: Doctors in charge: Educational Attainment: Nationality: Date and Time of Admission: Source of Information: Chief Complaints: History of Present Illness General Impression of Client: 1) Health Perception- Health management Patter A. Parents Report Pregnancy/labor/delivery history (this baby, child) Health status since birth Adherence to routine health checks? Immunization? Infections? Frequency? Absence from school? If applicable: Medical problem, treatment and prognosis If applicable: Action taken when signs/symptoms perceived? If appropriate: Been easy to follow things, doctors or nurses suggest?

Preventive health practices (diaper change, utensils, clothes, etc) Parents smoke? around baby Accidents Frequency? Crib toys (safety) carrying safety? car safety? Safety practices (household products, medicines, etc)

B. Parent (self): Parents/family general health status? C. Observation General Appearance of Child General Appearance of Parents 2) Nutritional- Metabolic Pattern A. Parents report of: Breast feeding bottle? Estimate of intake? sucking strength Appetite? Feeding discomfort? 24- hour intake of nutrients Supplements Eating Behavior Food preferences? Conflicts over food? Birth weight? Current weight? Skin problem? Rashes, lesions, etc? B. Observation Height Weight Skin Color, hydration, rashes, lesions, etc?

3) Elimination Pattern A. Parents Report of: Bowel Elimination pattern (describe), frequency, character, discomfort? Diaper Change Routine Urinary Elimination pattern (describe), frequency of diaper change. Estimate Amount? stream (strong, dribble) Excess perspiration? odor? 4) Activity- Exercise Pattern A. Parents Report of: Bathing routine? (when, how, where, type of soap) Dressing routine? (Clothing, inside/outside home? Crib or others? Describe? Typical days activity (hours spent in crib, playing, type of toys) Active? Activity Intolerance? Perception of the babys/childs strength (strong/ fragile) Child: Self- care ability (bathing, feeding, toileting, dressing, grooming) Parent (self) child care, home maintenance activity pattern? B. Observation Reflexes (appropriate to age) Breathing pattern, rate, rhythm Heart sounds, rate, rhythm Blood Pressure 5) Sleep Pattern A. Parents report of: Sleep pattern: Estimated hours Restlessness: Nightmare Infants: Sleep Position? Body movements?

B. Parent (Self): Sleep Pattern 6) Cognitive- Perceptual Pattern A. Parents report of: General Responsiveness Response to talking? Noise? Object? Touch? Following Objects with eyes? Response to crib toys Learning (changes noted) what teaches baby? Noises? Vocalization? Speech pattern? Words? sentences Vision, hearing, touch Use of stimulation? talking, games Child: Name, address, tel. num. Pain? Discomfort (describe) 7) Self- Perception- Self Concept Pattern A. Parents Report of: Mood State If Child: Childs sense of worth, identity B. Childs Report of: Mood state Many/ few friends? Liked by others? Self- Perception (good most of the time?, hard to be good Ever Lonely Fears (transient/ frequent) C. Observation: Child: Eye contact, speech Pattern, posturing D. Parent (self) General sense of worth, identity, competency 8) Role- Relationship Pattern A. Parents Report of:

 Family Household structures Family Problems/ stressors Family members/infant (or child interaction) Infant/child response to separation Child: dependency Child: Play pattern Child: Temper Tantrums? Discipline Problems? Child: School Adjustments B. Observation: Smiling response (infant) Social interaction (child)? Aggressive/ withdrawn? Response to vocalization? Requests? C. Parent (self) Role engagements? Satisfaction? Work? Social? Family Relationships? 9) Sexually- reproductive pattern A. Patients report of: Childs feeling of maleness/ femaleness? Questions regarding sexuality? How she responds

B. Parent (Self) If Applicable: Reproductive history? Sexual Satisfaction/ problems C. Observation: Child toys 10) Coping Stress tolerance pattern A. Parents report of: Childs pattern of handling problems, frustrations, anger, etc Stressors, tolerance? B. Parent (self) Strategies for handling problems Use of support system Life stressors? Family stress? 11) Value Belief Pattern A. Parent (self): Things important in life? Desire for the future? If appropriate: Perceived impact of disease or goals?