I.

Health perception-health management pattern A. Child or baby 1. Pregnancy/labor/delivery history (baby or child)? 2. Health status since birth? 3. Immunizations? Checkups? 4. Infections? Frequency? Absences from school? 5. Medical problem, treatment and prognosis? 6. Actions taken when signs and symptoms perceived? 7. Been easy to follow things that doctors and nurses suggest? 8. Preventive health practices (diaper change)? 9. Do parents smoke (or people around the child or baby)? 10. Accident s frequency? 11. Crib toys (safety)? Carrying safety? Car safety? 12. Safety practices (household products, med, etc.) 13. Admitted when? 14. IV? Drops per minute? 15. Medications and functions B. Parent/ family s general health status? C. General appearance of parents and child/ infant. Nutritional- Metabolic Pattern A. Child 1. Breastfeeding/ bottle? Estimate intake? 2. Appetite? Feeding discomfort? 3. 24-hour intake of nutrients? 4. Supplements? 5. Eating behavior? 6. Food preferences? Conflict over food? 7. Birth weight? Current weight? 8. Skin problems: rashes, lesions, etc. 9. Height, weight 10. Skin color Elimination 1. Bowel elimination pattern (describe). Frequency? Character, discomfort? 2. Diaper change routine? 3. Urinary elimination pattern (describe). Frequency of diaper change? 4. Estimate amount of urine and stool. 5. Excess perspiration? Odor? Activity- exercise pattern 1. Bathing routine?

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2. 3. 4. 5. 6. 7. 8. 9. 10. V.

Dressing routine? Crib toys? Typical day s activity? Activity intolerance? Parent: child care, home maintenance activity pattern Reflexes? Breathing pattern, rate, rhythm Heart sounds, rate, rhythm Blood pressure

Sleep-rest pattern 1. Sleep pattern: estimated hours? 2. Restlessness? Nightmares? 3. Infants: sleep position? Body movements? Cognitive- perceptual pattern 1. General responsiveness 2. Response to talking? Noise? Object? Touch? 3. Follow objects with eyes? Response to crib toys? 4. Learning (changes noted). What teaches baby? 5. Noises/ vocalization 6. Speech pattern? Words? Sentences? 7. Use of stimulation: talking games, etc? 8. Vision, hearing, touch, kinesthesia? 9. Child: able to tell name, time, address, number? 10. Pain? Discomforts? Self perception pattern A. Child 1. Mood state? 2. Many or few friends? Liked by others? 3. Self perception? Good or bad? 4. Ever lonely? 5. Fears? B. Observation 1. Child: eye contact, speech pattern, posturing? C. Parent (self) 1. General sense of worth, identity, competency? Role-relationship pattern A. 1. Family or household structures? 2. Family problems/ stressors?

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VIII.

3. Family members/ infant interaction? 4. Stranger or separation anxiety 5. Child: dependency, play, pattern, school adjustments B. 1. Smiling response? 2. Social interaction? 3. Response to vocalization C. Parent(self) 1. Role engagements? Satisfaction? 2. Work? Social? Family? Relationships? IX. Sexuality pattern A. 1. Child s feeling of maleness/ femaleness? 2.Questions regarding sexuality? How he responds. B. Parent 1. Sexual satisfaction/ problems? 2. Reproductive history. Coping stress A. 1. Child s pattern of handling problems, frustrations, anger, etc.? 2. stressors, tolerance? B. parent (self) 1. strategies for handling problems? 2. use of support systems? 3. life stressors? Family stress? XI. Value- belief pattern A. Parent (self) 1. Things important in life? Desire for the future 2. Perceived impact of disease on goals?

X.