Introduction
Assessment 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.
Aim
The 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:
- Indications for assessment
- Approach to assessment in children
- Types of assessments
- Structure for assessments
- Link EMR for documentation of assessments
Definition of Terms
- Primary assessment: Concise nursing assessment completed at the commencement of each shift, patient encounter or if patient condition changes at any other time. Completed/Documented in the Primary Assessment flowsheet or progress/patient encounter note in EMR.
- 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 systems. Completed/documented in the Focused Assessment flowsheet in EMR.
Approach to physical assessment
- Consider the age and developmental stage of the child. Modify language and communicate style to be consistent with child’s needs.
- Use play techniques for infants and children.
- Implement behaviours that show respect for child’s age, gender, cultural values and personal preferences. Privacy of the patient always needs to be considered.
- Gather as much information as possible by observation first. Use a systematic approach; but be flexible to accommodate child’s behavior.
- Examine least intrusive areas first (i.e. hands, arms) and painful and sensitive assessment last (i.e. ears, nose, mouth).
- Determine what parts of the exam is to be completed before possible crying which may be seen in some children (i.e. heart, lungs & abdomen).
- Involve the family, parents and carers in the assessment process. Encourage the child and family to ask questions and voice any concerns; listen and follow up any concerns they may have regarding the clinical condition of their child.
- Where possible, assessments should be clustered with other cares at a time when the child is relaxed and compliant. However, the clinical need of the assessment should also be considered against the need for the child to rest. For a stable child it may be appropriate to delay assessments until the child is awake.
- Throughout the assessment process, the nurse should communicate findings and refer concerns to the ANUM, medical team and/or allied health as necessary.
- Serious clinical concern and/or identification of a deteriorating patient requires fast and appropriate escalation of care as per the
Deteriorating Patient: Escalation of Care flow chart and the
Medical Emergency Response Procedure.
- More information regarding child development from 0-6 years can be found via the
RCH Learning Hero package ‘Know Me Early’.
Admission Assessment
An 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 history
Nursing staff should discuss:
- History of current illness/injury (i.e. reason for current admission) and relevant past medical history,
- Allergies and reactions,
- Medications,
- Immunisation status,
- Implants/LDA’s
- Infectious/Isolation Status
- Cultural/Religious preferences including Aboriginal and Torres Strait Islander status
- Family and social history
- Recent overseas travel
For neonates and infants consider:
- Maternal history,
- Antenatal history,
- Delivery type and complications if any,
- Apgar score, resuscitation required at delivery
- Hep B and Vitamin K status
- Newborn Screening Tests (see Child Health Record for documentation).
General Appearance
Assessment 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.
| Neonate and Infant |
Young Child |
Adolescent |
|
Parent infant, infant parent interaction
Body symmetry, spontaneous position, and movement
Symmetry and positioning of facial features
Strong cry |
Parent child, child parent interaction
Mood and affect
Gross and fine motor skills
Developmental milestones
Appropriate speech |
Mood and affect
Personal hygiene
Communication |
Vital signs
Baseline 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
- Weight: on admission and/or weekly/daily as clinically indicated.
- Paediatric nutrition screening tool: completed for all paediatric patients on admission and is a requirement for compliance to accreditation standard 5. See
Nutrition Screening Guideline for more information.
-
Consider need for height, head circumference and blood Glucose level (on admission and as clinically indicated)
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:
| |
Assessment Considerations |
| General Appearance |
See the information above |
| Airway |
Patent, partially obstructed or obstructed
Noises, secretions, cough, artificial airway |
| Breathing |
Respiratory Rate, Regularity (regular, irregular, apnoea)
Breathing effort (spontaneous or supported)
Respiratory distress – work of breathing (nil, mild, moderate or severe)
Breath sounds (clear, absent, decreased, crackles, wheeze, bilateral air entry and movement)
Also see
Oxygen delivery device Nursing Guideline. |
| Circulation |
Skin temperature peripherally and centrally (warm, cool, cold, hot, diaphoretic)
Skin colour (normal, pink, pale, dusky, mottled, cyanotic, or other) *assess skin, lip, oral mucosa and nail bed colour
Central Capillary refill time (
<2 brisk, 2-3 normal, 3-4 slugglish, >4seconds slow)
Skin Turgor (Quick return, slow return, tenting, other)
Oral mucosa (moist, dry, pale or cyanotic)
Pulses palpated, (location left and right, rate, rhythm and strength)
ECG rate and rhythm if monitored |
| Disability |
Level of consciousness (Alert Voice Pain Unconscious score, AVPU score), or
Level of sedation score University Michigan Sedation Score (UMSS)
Gross Motor Function Classification System (GMFCS)
Identify any abnormal movement or gait and any aids required such as mobility aids, transfer requirements, glasses, hearing aids, prosthetics/orthotics required
Seizure activity (yes or no) |
| Observation of vital signs including Pain |
See above
Observation and Continuous Monitoring Nursing Guideline
|
| Skin |
Colour, turgor, lesions, bruising, wounds, pressure injuries. |
| Hydration/Nutrition |
Assess hydration and nutrition status and check feeding type- oral, nasogastric, gastrostomy, jejunal, fasting, and breast fed, type of diet, IV fluids. IV fluids – follow Standardised checking procedure for infusion pump programming at the RCH policy. |
| Renal/GIT Output |
Assess bowel and bladder routine(s), incontinence management including urine output, bowels, drains and other total losses (drains etc).
Review fluid balance activity under the ‘Fluid Balance’ tab on EMR. |
| Risk Assessment |
Pressure injury risk assessment
Falls risk assessment
Patient Identification Procedure |
| Wellbeing |
Assess for Mood, sleeping habits and outcome, coping strategies, reaction to admission, emotional state, comfort objects, support networks, reaction to admission and psychosocial assessments. |
| Social |
This may include discussing a wide range of factors including Parents/carer/ guardian, siblings, living arrangements, visiting plans, transport, specific cultural requirements, schooling, discharge plan etc. Pertinent social assessment information such as court orders can also be documented in the FYI tab to
alert all members of the health care team. |
Focused Assessment
A 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 System
A 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
- Assess Level of Consciousness. RCH uses a modified version of the Glasgow coma scale to assess and interpret the degree of consciousness and is documented on neurological observation chart. Review the Glasgow Coma Scale in CPG: Head injury.
- Assess the child’s eye opens spontaneously, only when touched or spoken to, only to pain or not at all.
- Observe the child’s best age-appropriate verbal response. For infants, an assessment is made of their cry and vocalization. Always ensure the score reflects the assessment of the patient I.e. if a patient is nonverbal the GCS can never be 15.
- Observe the child’s best age-appropriate motor response.
- Arm and leg movements, assess both right and left limb and document any differences.
- Pupil size, shape and reaction to light.
- For neonates and infants check fontanels. Neonates should also be assessed for presence of marks from forceps or vacuum delivery device, or presence of cephalohematoma or caput succedaneum
- Importance of Vital signs. Vital sign changes are late signs of brain deterioration. Respiratory pattern provides a clear indication of brain functioning. Note for Cheyne Stokes, rapid, irregular, clustered, gasping or ataxic breathing. Other vital sign changes to be aware of include temperature alterations, blood pressure increases widening of pulse pressures, alterations to pulse rate including bradycardia for more information see
Trauma Service: Head Injury.
Seizures
- For information regarding Seizures please see the
seizure CPG.
Growth & development
- Observe the head, shape, size and mobility. Head circumference should be measured, over the most prominent bones of the skull (e.g. frontal and occipital bones).
- In neonates and infants palpate fontanels and cranial sutures.
- Inspect the spine looking for midline, lumps, dimples, hair or deformities
- Quality of cry or vocalization
- Review the history on attainment of developmental milestones, including progression or onset of regression. Consider attainment of rolling, sitting, crawling, walking, language development, bladder/bowel control, reading etc.
- Does the infant visually fix and follow.
- For more detailed information please see
Child Growth in the Early Years.
Fine & gross motor skills
- Observe posture and tone
- Spontaneous versus controlled movement
- Bilateral symmetry
- Coordination and strength of movements
- Gait and balance
- Neonatal reflexes: sucking, rooting, Moro, palmar, plantar, Babinski reflex
Sensory functions
- Taste- sweet, sour, salty
- Hearing in each ear
- Response to tactile stimuli (touch)
- Vision including the range of motion of both eyes assessing extraocular movement
- Smell
- Proprioception
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
- Onset and duration of symptoms. E.g. cough / shortness of breath
- Triggers (dust/aerosol/pollen/exercise)
Inspection/Observation
- Airway – patency, description (own, artificial eg. Trache, NPA).
- Observe the overall appearance of the child - alert, orientated, active/hyperactive, drowsy, irritable.
- Colour (centrally and peripherally): pink, flushed, pale, mottled, cyanosed, clubbing).
- Respiratory rate and pattern (regular, irregular, apnoea, shallow, tachypnoea, bradypnoea, Cheyne-Stokes).
- Respiratory effort (Work of Breathing -WOB) - mild, moderate, severe, inspiratory: expiratory ratio, shortness of breath (full sentences, short sentences, single words), spontaneous or supported (via NIV).
- Use of accessory muscles (UOAM) - intercostal, subcostal, suprasternal, supraclavicular, substernal retractions, head bob, nasal flaring, tracheal tug, grunting, abdominal.
- Symmetry and shape of chest.
- Tracheal position.
- Audible sounds (without stethoscope) - vocalisation, wheeze, stridor. (inspiratory/expiratory), stertor, grunt, cough (dry/productive/paroxysmal/moist).
- Monitor for oxygen saturation.
Auscultation
- Audible breath sounds (with a stethoscope)
- Clear
- Listen for and describe location of absence /equality of breath sounds.
- Auscultate lung fields for bilateral adventitious breath sounds - wheeze, crackles, stridor (inspiratory/expiratory).
- Describe location of adventitious breath sounds.
Palpation
- Bilateral symmetry of chest expansion
- Skin condition – temperature, turgor and moisture
- Capillary refill (central/peripheral)
- Fremitus (tactile)
- Subcutaneous emphysema
Cardiovascular
Assessment of the cardiovascular system evaluates the adequacy of cardiac output and includes.
Inspection
- Examine circulatory status (assess pallor, CRT and oedema).
- Assess hydration status (skin turgor, oral mucosa, and anterior fontanels in infants).
- Colour (central and peripheral): example: pink, flushed, pale, mottled, cyanosed, clubbing. Consider eyes, lips and nail beds.
- Capillary Refill Time (CRT) apply pressure for 5 seconds centrally and peripherally brisk (
< 2 sec) or sluggish (> 5 sec). Ensure documentation reflects central/peripheral CRT.
- Presence of oedema (central and/or peripheral): example periorbital, lower extremities and trunk may be a sign of fluid overload.
- Assess blood pressure and ECG heart rhythm (sinus rhythm, arrhythmia etc).
Palpation
- Palpate
- central and peripheral pulses for rate, rhythm and strength (bounding, weak, moderate, strong, absent).
- Skin condition – warmth to touch (peripheral and central), skin turgor and diaphoresis.
Auscultation
- Auscultate the apical pulse and the chest for heart sounds and murmurs.
- Compare peripheral pulse and apical pulse for consistency (the rate and rhythm should be similar).
Gastrointestinal
Assessment 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
- Feeding (type of feed/patterns / difficulties) e.g. TPN, formula feeds, breastfeeding, any allergies / intolerances of feed.
- Elimination (frequency, consistency, colour, any bleeding).
- Pain, cramping, nausea, vomiting (frequency, colour, bleeding, consistency).
- Previous GI interventions /concerns such as stoma, bowel obstruction etc.
- Previous NGT/NJT/PEG/PEJ.
Inspection
- Shape /symmetry of the abdomen (flat, rounded, distended, scaphoid).
- Contour of the abdomen (Smooth, lesions, malformations, any old or new scars).
- Distention (mild/moderate/severe – tight/shiny).
- Umbilicus (bulging, scars, piercings). In neonates observe for redness, inflammation, discharge, presence of cord stump.
- Inguinal area (bulging, herniation).
- Visible peristalsis.
- Presence of NG/NGT/PEG/PEJ (indication).
- Stoma site (dressing regimen/frequency and consistency of output).
Palpation
- Light palpation only to identify.
- Guarding.
- Tenderness.
- Distention (soft, firm).
- Pain (location, characteristics).
Auscultation
- Four quadrants (RUQ, RLQ, LUQ, LLQ) for bowel motility.
- Bowel sounds present (frequency/character).
- Absent bowel sounds (one or all quadrants).
- Abdominal girth measurement as clinically indicated.
Renal
An assessment of the renal system includes all aspects of urinary elimination
- Urinary pattern, incontinence, frequency, urgency, dysuria.
- Assess urine for: colour, odour and appearance (clear, cloudy, red flecks, sediment).
- Hydration status including strict fluid balance, frequent blood pressure and weight (specifically weight gain or loss).
- Growth and feeding, diet or fluid restrictions.
- Skin condition: assess for dehydration status and diaphoresis.
- Urine output (Normal children
<2yrs is between 2-3ml/kg/hr, >2yrs is between 0.5-1ml/kg/hr).
- Urinalysis (pH, protein, glucose, blood, ketones, leukocytes, specific gravity).
- Review blood chemistry results, urea, creatinine, electrolytes, albumin and haemoglobin.
Musculoskeletal
A 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
- Child’s gait and ambulation.
- Posture, movement and body symmetry.
- Limbs for swelling, redness and obvious deformity.
- Joint range of motion – is it passive or independent? Are limbs moving equally, is there pain on movement?
- Joints for redness or swelling.
Palpation
- Limbs for muscle mass, tone, strength.
- Limbs for pain or tenderness.
Neurovascular observations
Skin
Skin abnormalities may arise from and be localised to the skin or indicate a systemic condition that led to cutaneous changes.
History
- Obtain a history of the rash from a parent /carer including travel and immunisation history.
- When did the rash start and has it changed.
- Constitutional symptoms (fever, cough, coryza, headache).
- History of allergic reactions?
Inspection/Observation
- Non-blanching petechial rash, diffuse erythema or a toxic appearing child warrants immediate review.
- Colour of the skin (pale/flushed, cyanotic, normal pigmentation).
- Rash: Examine the morphology of lesions (e.g.: raised or flat, fluid filled), assess colour, size, texture, blanchable and quality (itchy or painful) and distribution (e.g.: widespread, scattered, palmar surface, mucous membranes, or scalp involvement.
- Observe for lice or ticks.
- Bruising/wounds/pressure injuries: Assess any existing wounds and utilise a Wound Care Assessment tab in the EMR flowsheet for ongoing wound assessment and management.
- Examine high risk areas regularly, including bony prominences and equipment sites (masks, plasters, tubes, drains, etc.) for pressure injuries (
Pressure injury prevention and management). Report if evidence of pressure injury.
Palpation
Skin temperature, moisture, skin turgor
Eye
Inspection 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
- Does the child wear glasses?
- Is the eye painful, red or has the child had blurred or loss of vision?
- Medication history (may affect pupil size).
Inspection/Observation
- Dysmorphic features: Symmetry, shape, and position of eyes.
- Eyelid symmetry (signs of ptosis).
- Conjunctiva, and eyelids for inflammation or discharge.
- Color of sclera - yellow (signs of Jaundice), red (inflammation).
- Assess for normal and symmetrical movement of eyes in all directions.
- Pupil symmetry, size and shape of the pupils, reactivity to light and accommodation.
- Check ‘gross’ visual acuity if child of an appropriate age for example asking how many fingers, what animal is on the wall? If there are any concerns, consider formal assessment utlising the Snellen chart/medical review. If the child is too young to check visual acuity, ascertain whether the child can fix
and follow - for toddlers try a toy, for infants try a toy or a light. If a child wears glasses or contacts, use them during examination.
- Presence of tears. (Close eyes in unconscious patient to protect cornea from drying and injury). If unable to close eyes protective eye dressing should be commenced to protect from exposure keritinopathy (
Eye care in PICU guideline).
- Test for red eye reflex. Discuss with senior nursing team/medical team if this test is clinically indicated and consider
referral to an ophthalmologist.
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
- Inspect ears for symmetry, shape, and position (dysmorphic or malposition ears).,
- Test hearing acuity by performing whisper test.
- Observe for any external trauma, obvious cerumen, inflammation, redness or exudate, any obvious discharge, child pulling on ear, or foreign body using otoscope.
- Inspect any hearing aids and surrounding skin for pressure sores, skin break down or abnormalities.
- Inspect nose for symmetry, nasal patency, tenderness, septal deviation, masses, or foreign bodies, note the colour of the mucosal lining, any swelling, discharge, dryness or bleeding.
- Inspect lips for shape, symmetry, colour, dryness, and fissures at the corners of the mouth.
- Inspect teeth for number present, condition, colour, alignment, implants and caries.
- Inspect gingival tissue noting colour and condition.
- Observe for bleeding gums, trauma to tongue or oral cavity, and malocclusion.
- Look for excessive fluid/secretions in the mouth.
- Inspect the hard and soft palate for lesions, uvula, size of tonsils, and buccal mucosa for colour, exudate, and odour.
- Observe for difficulty or inability to swallow.
- Observe for pain and coughing during swallowing.
- Inspect neck for asymmetry, masses, tenderness, tracheal deviations and trauma.
Palpation
- Palpate external structures of the ear (tragus, mastoid) for masses lesions or tenderness
- Palpate frontal and maxillary sinuses for tenderness in the older child.
- Palpation of the lips, gums, mucosa, palate and tongue, may be possible in the compliant or older child, noting lesions, masses or abnormalities.
Mental Health/Wellbeing
In 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 assessment
In 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 Table
Complete evidence table document here.
Please remember to read the
disclaimer.
The development of this nursing guideline was revised 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. Previous authors to this guideline include: Mercy Thomas