In this section
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.
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:
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.
Nursing staff should discuss:
For neonates and infants consider:
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.
Parent infant, infant parent interaction
Body symmetry, spontaneous position, and movement
Symmetry and positioning of facial features
Parent child, child parent interaction
Mood and affect
Gross and fine motor skills
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.
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:
Patent, partially obstructed or obstructed
Noises, secretions, cough, artificial airway
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)
Oxygen delivery device Nursing Guideline.
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
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 and Continuous Monitoring Nursing Guideline
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.
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.
Pressure injury risk assessment
Falls risk assessment
Patient Identification Procedure
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.
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.
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:
Assessment of the cardiovascular system evaluates the adequacy of cardiac output and includes.
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.
An assessment of the renal system includes all aspects of urinary elimination
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.
Skin abnormalities may arise from and be localised to the skin or indicate a systemic condition that led to cutaneous changes.
Skin temperature, moisture, skin turgor
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.
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.
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
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.
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.
Observation and Continuous Monitoring clinical guideline (nursing)
Pain Assessment and Measurement clinical guideline
Neonatal Pain assessment
Pressure injury prevention and management clinical guideline (nursing)
Documentation clinical guideline (nursing)
Neurovascular observations clinical guideline (nursing)
Eye care in PICU
Spinal Cord injury clinical guideline (nursing)
Assessment of severity of respiratory conditions
Complete evidence table document here.
Please remember to read the