IntroductionAssessment is a key component of nursing practice, required for planning and provision of patient and family centered care. The Nursing and Midwifery Board of Australia (NMBA) in the national competency standard four for registered nurses' highlights that nurses conduct a comprehensive and systematic nursing assessment in order to plan holistic and patient family centered nursing care and responds effectively to unexpected or rapidly changing situations. Show
AimThe aim of this guideline is to ensure all RCH (Royal Children Hospital) patients receive consistent and timely nursing assessments. The guideline specifically seeks to provide nurses with:
Definition of Terms
Approach to physical assessment
Admission AssessmentAn admission assessment is required to be completed by the nurse responsible for admission/allocated to the patient within 4hrs of arrival to an inpatient ward or day treatment area. The information can be obtained from the patient, parent, or carer. It may also be collected as part of a preadmission process. Elements of the admission assessment satisfy national standard requirements and 'required nursing admission documentation' in EMR. This is completed/documented in the Nursing Admission Navigator in EMR and information documented can be automatically filed into a nursing admission note when using the navigator. It is important that nursing staff view the demographics check and acknowledge if Aboriginal and Torres Strait Islander status has been completed, inform/refer the family of the Wadja team. For more education regarding culturally safe care staff are encouraged to enroll in the Aboriginal
Cultural Safety course via learning hero. Patient historyNursing staff should discuss:
For neonates and infants consider:
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 Consider signs of deterioration including: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement. Age specific considerations can be found in the table below.
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 clinically indicated for each patient. It is recommended to review the ViCTOR graph under the ‘Obs’ tab on EMR after each set of observations to observe trending of vital signs and to support your clinical decision-making process. For further information please see: Observation and continuous monitoring guideline, Assessment of severity of respiratory conditions CPG, ViCTOR webpage.
Additional Measurements
Primary assessment:Primary assessments should be completed at the start of every shift and then as clinically indicated or if the patient's condition changes. This assessment is documented in flowsheets, further assessments, or changes to be documented in the progress notes. Clinical judgment should be used to decide on the extent of assessment required. Primary assessment information includes, but is not limited to:
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 systems. Nursing staff should utilise their clinical judgement to determine which elements of a focused assessment are pertinent for their patient. Documentation of focused assessments may occur
in flowsheets, progress notes or POCT/Orders. Neurological SystemA comprehensive neurological nursing assessment includes neurological observations (GCS vital signs, pupil examination limb strength), growth and development including fine and gross motor skills, sensory function, cerebellar function, cranial nerve function, reflexes, 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. See: Assessment of severity of respiratory conditions CPG. 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 abnormalities may arise from and be localised to the skin or indicate a systemic condition that led to cutaneous changes. History
Inspection/Observation
PalpationSkin temperature, moisture, skin turgor EyeInspection of the eye should always be performed carefully and only with a compliant child. If child is distressed, consider early ophthalmology referral as clinically indicated. History
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
Mental Health/WellbeingIn the adolescent patient it is important to consider completing psychosocial assessments, as physical, emotional, and social well-being are closely interlinked. The
HEEADSSS assessment is a psychosocial screening tool which can aide in engagement (assist in building a rapport) with the young person while gathering information about their family, peers, school and inner thoughts and feelings. The main goals of the HEEADSSS assessment are to screen for any specific risk-taking behaviors and identify areas for intervention, prevention and health education. For more information see
Engaging with and assessing the adolescent patient. It is important to note that it is best completed with the adolescent alone and establishing (a) rapport with the young person assists in obtaining an accurate assessment. It is not always possible to cover every aspect of the HEEADSSS assessment
in a single encounter, it may require a few shifts to fully complete. More information can also be located on the Mental State Examination CPG. The behavioral support profile is a documentation tool for the non-medical needs of our patients, including their communication preferences/abilities, sensory needs, behaviors of concerns and triggers to name a few. It can be used for any patient with any diagnosis, but is aimed for patients with communication difficulties, behaviors of concern or severe anxiety. For more info click here. Evaluation of assessmentIn the evaluation phase of assessment, ensure the information collected is complete, accurate and documented appropriately. The nurse must utilise critical thinking and 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. Abnormal assessment findings should also be handed over as appropriate. Patients should be continuously assessed for changes in condition while under RCH care and assessments documented regularly. Special Considerations Concise nursing assessment is to be completed at the start of each patient encounter for Wallaby/outpatient teams. Nurses providing outpatient care may include observations/primary assessments in clinical note/plan of care for reference across patient encounters. Links
Evidence TableComplete evidence table document here. Please remember to read the disclaimer. The development of this nursing guideline was coordinated by Danica Van Den Dungan, Clinical Nurse Educator, Nursing Education, and Stacey Richards, Clinical Nurse Consultant, Nursing Research, approved by the Nursing Clinical Effectiveness Committee. Updated November 2022. What are the methods to assess learning needs quizlet?What are the 9 steps of assessing learning needs?. Identify.. Choose right setting.. Collect data about learner.. Collect data from the learner.. Involve members of health care team.. Prioritize needs.. Determine availability of educational resources.. Assess demands of organization.. What are the 3 basic learning principles nursing?Let's start with the first three principles. They are relevance, motivation, and readiness. By relevance, I meant the material being presented to the clients needs to be meaningful to them, easily understood by them, and related to information they already know.
What are the five steps in the teaching learning process nursing?The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective.
What is the nurse's primary role in planning for the patient's educational needs?Nurses must assess their patients to pinpoint the best way to educate them about their health and determine how much they already know about their medical condition. They need to build a rapport with patients by asking questions to zero in on concerns.
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