In: Nursing
Growth and development template for data collection technique (Physical finding to report for and older adult)
Q: growth and development data collection.
Ans: basic template for growth and development data collection
Bio- graphic data
name of client :
age:
sex:
date of admission ;
time of admission ;
I.P No:
Unit:
Address;
provisional diagnosis;
cheif complaints;
present history of illness;
past history of illness;
BIRTH HISTORY
Antenatal history;-
1. Position of the baby;
2. presentation ;
3. Antenatal checkup:
Intranatal history;-
Postnatal history;-
APGAR SCORE TABLE
Criteria | 0 | 1 | 2 |
Respiration | Absent | slow, regular | good, crying |
Heart rate | Absent | slow, below 100bpm | more then 100bpm |
Muscle tone | flaccid | some flexion of extremities | active body movement |
Reflex response | no response | grimace | cry |
Skin colour | blue, pale |
body pink extrimitie blue |
Completely pink |
Total score
no depression : 7- 10
mild depression : 4-6
severe depression : 0-3
Reflexes;-
Physical assessment
1. temp-
2. Pulse-
3. resp-
Anthropometric measurement
1. Height
2. weight
3. Head circumference
4. mid- arm circumference
Head to toe examination
Head:
eyes;
nose;
ears;
mouth;
neck;
chest;
abdomen;
genitalia;
back;
extrimities;
History of family illness;-
family pedigree
;-
Dietary history;-
Rest and sleep;-
economic history ;
Growth and development ;
According to book and Clie
Book picture | client picture |
1. Growth 2. development |