A comprehensive assessment is done to establish a data base for developmental assessment and for nursing diagnosis and treatment. Information is needed on (1) the development of each functional pattern and anatomical growth, (2) current health patterns, and (3) family health and the home environment in which the infant or child is developing. The questions/items listed below can be used selectively for problem screening. Questions should be directed to the primary care giver.
NURSING HISTORY
1. Health-perception – health management pattern
Parents’ report of:
a. Mother’s pregnancy/labor/delivery history (of this infant, of others)?
b. Infant’s health status since birth?
c. Adherence to routine health checks for the infant/child? Immunizations?
d. Infections/illnesses in the infant/child? Child’s absences from school/day care? e. If applicable: Infant’s/child’s medical problems, treatment, and prognosis?
f. If applicable: Actions taken by parents when signs and/or symptoms were perceived? g. If appropriate: Has it been easy to follow doctors’ or nurses’ suggestions?
h. Preventive health practices (e.g., diaper change, clean clothes, hand washing)?
i. Do parents smoke? Around children?
j. Accidents? Types? Frequency?
k. Infant’s crib toys (safety)? Child's toys? Carrying safety? Car safety?
l. Parents’ safety practices (e.g., household products and medicines)
Parents (self):
a. Parents’/family’s general health status? Illnesses? Injuries?
2. Nutritional-metabolic pattern
Parents’ report of the infant’s/child’s:
a. Breast/bottle feeding? Intake (estimated)? Schedule? Sucking strength?
b. Appetite? Feeding discomfort? Gas? Burping?
c. 24-hour intake of nutrients? Supplements?
d. Eating behavior? Food preferences? Conflicts over food?
e. Birth weight? Current weight?
f. Skin problems: For example, rashes, lesions, others?
Parents (self):
a. Parents’/family’s nutritional status? Height/Weight? Problems?
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3.
Elimination pattern
Parents’ report of the infant’s/child’s:
a. Bowel elimination parents and children? (Describe) Frequency? Character discomfort? b. Diaper changes? Potty training – bowel, bladder? (Describe routine)
c. Urinary elimination pattern? (Describe) Number of wet diapers per day?
(Estimate amount) Stream (strong, dribble)?
d. Excess perspiration? Odor?
Parents (self):
a. Elimination pattern? Problems?
4. Activity-exercise pattern
Parents’ report of:
a. Bathing routine? (When, how, where, and what type of soap?)
b. Dressing routine? (Clothing worn, changes inside/outside home)
c. Typical day’s activity for the infant/child (e.g., hours spent in crib, being carried, playing; type of toys used)?
d. Infant’s/child’s general activity level? Tolerance?
e. Perception of infant’s/child’s strength (“strong” or “fragile”)?
f. Child’s self-care ability (bathing, feeding, toileting, dressing, grooming)?
Parents (self):
a. Activity/exercise/leisure pattern? Child care? Home maintenance?
5. Sleep-rest pattern
Parents’ report of:
a. Sleep pattern of the infant/child: Estimated hours?
b. Infant’s/child’s restlessness? Nightmares? Nocturia?
c. Infant’s sleep position? Body movements? Nighttime routine?
Parents (self):
a. Sleep pattern?
6. Cognitive-perceptual pattern
Parents’ report of:
a. General responsiveness of the infant/child?
b. Infant’s response to talking? Noise? Objects? Touch?
c. Infant’s following of objects with eyes? Response to crib toys?
d. Ability to learn (changes noted)? What is being taught to the infant/child?
e. Noises/vocalizations? Speech pattern? Words? Sentences?
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f. Use of stimulation: For example, talking, games, what else?
g. Vision, hearing, touch, kinesthesia of the infant/child?
h. Child’s ability to tell name, time, address, telephone number?
i. Infant’s/child’s ability to identify needs (hunger, thirst, pain, discomfort)?
Parents (self):
a. Problems with vision, hearing, touch, other senses?
b. Difficulties making decisions? Judgments?
7. Self-perception – self-concept pattern
Parents’ report of:
a. Infant’s/child’s mood, state (irritability)?
b. Child’s sense of worth, identity, competency?
Child’s report of:
a. Mood state?
b. Many/few friends? Liked by others?
c. Self-perception (“good” most of time? Hard to be “good”?)
d. Ever lonely?
e. Fears (transient/frequent)?
Parents (self):
a. General sense of worth, identity, competency?
b. Self-perception as parents?
8. Role-relationship pattern
Parent’s report of:
a. Family/household structure?
b. Family problems/stresses?
c. Interactions among family members and infant (or child)?
d. Infant’s/child’s response to separation?
e. Child: Dependency?
f. Child: Play pattern?
g. Child: Temper tantrums? Discipline problems? School adjustment?
Parents (self):
a. Role engagements? Satisfaction?
b. Work/social/marital relationships?
9. Sexually-reproductive pattern
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Parents’ report of child’s:
a. Feeling of maleness/femaleness?
b. Questions regarding sexuality? How parent responds?
Parents (self):
a. If applicable: Reproductive history?
b. Sexual satisfaction/problems?
10. Coping – stress-tolerance pattern
Parents’ report of:
a. What produces stress in child? Level of stress tolerance
b. Child’s pattern of handling problems, frustrations, anger?
Parents (self):
a. Life stressors? Family stress?
b. Patterns for handling problems? Stress? Anger? Support systems?
11. Value-belief pattern
Parents’ report of:
a. Child’s moral development, choice behavior, commitments?
Parents (self):
a. Things important in life (values, spirituality)? Desires for the future?
b. If appropriate: Perceived impact of disease on goals?
12. Other
a. Any other things that we haven’t talked about that you’d like to mention? Any
questions?