Note: This guideline is currently under review Show
IntroductionAssessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The Nursing and Midwifery Board of Australia (NMBA) in the national competency standard for registered nurses states that nurses, “Conducts a comprehensive and systematic nursing assessment, plans nursing care in consultation with individuals/ groups, significant others & the interdisciplinary health care team and responds effectively to unexpected or rapidly changing situations. AimThe aim of this guideline is to ensure all RCH patients receive consistent and timely nursing assessments.
Definition of TermsAdmission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs. Shift Assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time. Focused assessment: Detailed nursing assessment of
specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system. Approach to physical assessment
Admission AssessmentAn admission assessment should be completed by the nurse with a parent or care giver, ideally upon arrival to the ward or preadmission, but must be completed within 24hours of admission. Admission assessment is in the admissions tab of the ADT navigator with additional
information being entered into the patient’s progress notes. Privacy of the patient needs to be considered all times. Patient historyNursing staff should discuss the history of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status, implants and family and social history. Recent overseas travel should be discussed and documented. General AppearanceAssessment of the patients’ overall physical, emotional and behavioral state. This should occur on admission and then continue to be observed throughout the patients stay in hospital.
Vital signsBaseline observations are recorded as part of an admission assessment and documented on the patient’s observation flowsheet. Ongoing assessment of vital signs are completed as indicated for your patient. It is mandatory to review the ViCTOR graph at least every 2 hours or as patient
condition dictates to observe trending of vital signs and to support your clinical decision making process.
Additional Measurements
Physical assessment:A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation/inspection, palpation, percussion and auscultation are techniques used to gather information. Clinical judgment should be used to decide on the extent of assessment required. Assessment
information includes, but is not limited to: Primary assessment (Airway, Breathing, Circulation and Disability) and Focussed systems assessment. Information regarding each assessment criteria is specified comprehensively in the “Shift assessment” section below. Shift AssessmentAt the commencement of every shift an assessment is completed on every patient and this
information is used to develop a plan of care. Initial shift assessment is documented on the patient care plan and further assessments or changes to be documented in the progress notes. Clinical judgment should be used to decide on the extent of assessment required.
Focused AssessmentA detailed nursing assessment of specific body system(s) relating to the presenting problem or other current concern(s) required. This may involve one or more body system. Nursing staff should utilise their clinical judgement to determine which elements of a focussed assessment are pertinent for their patient. Neurological SystemA comprehensive neurological nursing assessment includes neurological observations, growth and development including fine and gross motor skills, sensory function, seizures and any other concerns. Neurological observations
Seizures
Growth & development
Fine & gross motor skills
Sensory functions
Respiratory System:Respiratory illness in children is common and many other conditions may also cause respiratory distress. Assessment of severity of respiratory conditions Respiratory assessment includes: History
Inspection/Observation
Auscultation
Palpation
CardiovascularAssessment of the cardiovascular system evaluates the adequacy of cardiac output and includes. Inspection
Palpation
Auscultation
GastrointestinalAssessment will include inspection, auscultation and light palpation of the abdomen to identify visible abnormalities; bowel sounds and softness/tenderness. Ensure stomach is not full at time of assessment as this may induce vomiting. History
Inspection
Palpation
Auscultation
RenalAn assessment of the renal system includes all aspects of urinary elimination
MusculoskeletalA musculoskeletal assessment can be commenced while observing the infant/child in bed or as they
move about their room. Be aware that during periods of rapid growth, children complain of normal muscle aches. Throughout this assessment limbs/joints should be compared bilaterally. Inspection
Palpation
Neurovascular observations
SkinSkin assessment can identify cutaneous problems as well as systemic diseases. Inspection/Observation
Palpate:
EyeInspection of the eye should always be performed carefully and only with a compliant child. Inspection/Observation
Ear/Nose/Throat (ENT)Assessment of ear, nose, throat and mouth is essential as upper respiratory infections, allergies; oral or facial trauma, dental caries and pharyngitis are common in children. This includes a thorough examination of the oral cavity.The examination of the throat and mouth is completed last in younger, less cooperative children. Inspection
Palpation
Evaluation of assessmentIn the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. The nurse must draw on critical thinking and problem solving skills to make clinical decisions and plan care for the patient being assessed. If any abnormal findings are identified, the nurse must ensure that appropriate action is taken. This may include communicating the findings to the medical team, relevant allied health team and the ANUM in charge of the shift. Patients should be continuously assessed for changes in condition while under RCH care and assessments are documented regularly. Links
Evidence TableComplete evidence table document here. References:
Please remember to read the disclaimer. The development of this nursing guideline was coordinated by Mercy Thomas, Graduate Nurse Educator, Nursing Education, and approved by the Nursing Clinical Effectiveness Committee. Updated November 2017. Which finding would alert the nurse to the possibility of respiratory distress in a newborn?Signs and Symptoms
Grunting “ugh” sound with each breath. Changes in color of lips, fingers and toes. Widening (flaring) of the nostrils with each breath. Chest retractions - skin over the breastbone and ribs pulls in during breathing.
What are 4 common signs of respiratory distress in a newborn?What are the symptoms?. Fast and shallow breathing.. Grunting.. Flaring of the nostrils with each breath.. Bluish tone to a baby's skin and lips.. Pulling inward of the muscles between the ribs when breathing.. What does respiratory distress look like in babies?Signs and Symptoms
Is your child breathing faster than usual? Retractions - Check to see if the chest pulls in with each breath, especially around the collarbone and around the ribs. Nasal flaring - Check to see if nostrils widen when breathing in. (“Ugh” sound), wheezing or like mucus is in the throat.
Which assessment findings would indicate a possible asthma exacerbation?Severe shortness of breath, chest tightness or pain, and coughing or wheezing. Low peak expiratory flow (PEF) readings, if you use a peak flow meter. Symptoms that fail to respond to use of a quick-acting (rescue) inhaler.
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