Rengucci L M
Crit Care Nurs Clin North Am. 1992 Sep;4(3):471-80.
This article provides nurses who care for infants with a tool to document both physical examination and nursing assessment. Specific information to gather data and where to organize initial data are described. This tool also accommodates documentation of the first minutes of assessment and treatment provided when delivering care to critically ill infants on admission to the unit. In addition, it provides a means of further documenting nursing assessment information at a later time (e.g., psychosocial needs). The functional health patterns are a framework to organize the nursing assessment of the neonate and his or her family, and this assessment is the data base for both nursing diagnosis and individualized care planning.
本文为护理婴儿的护士提供了一种记录体格检查和护理评估的工具。文中描述了收集数据的具体信息以及整理初始数据的位置。该工具还适用于记录在重症婴儿入院时提供护理的最初几分钟的评估和治疗情况。此外，它还提供了一种在稍后阶段进一步记录护理评估信息的方法（例如，心理社会需求）。功能健康模式是组织对新生儿及其家庭进行护理评估的框架，而这种评估是护理诊断和个性化护理计划的数据库。
