In this section
Note: This guideline is currently under review
Assessment 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.
The aim of this guideline is to ensure all RCH patients receive consistent and timely nursing assessments.
The guideline specifically seeks to provide nurses with:
Admission 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.
An 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.
Nursing 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.
For neonates and infants consider maternal history, antenatal history, delivery type and complications if any, Apgar score, resuscitation required at delivery and Newborn Screening Tests (see Child Health Record for documentation).
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.
Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
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 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.
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.
At 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.
Patient assessment commences with assessing the general appearance of the patient. Use observation to identify the general appearance of the patient which includes level of interaction, looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
Assessment information includes, but is not limited to:
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 system. Nursing staff should utilise their clinical judgement to determine which elements of a focussed assessment are pertinent for their patient.
A comprehensive neurological nursing assessment includes neurological observations, growth and development including fine and gross motor skills, sensory function, seizures and any other concerns.
Respiratory illness in children is common and many other conditions may also cause respiratory distress.
Assessment of severity of respiratory conditions 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 assessment can identify cutaneous problems as well as systemic diseases.
Inspection of the eye should always be performed carefully and only with a compliant child.
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 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.
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.
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Jarvis, C., Forbes, H., & Watt, E. (2011). Jarvis's physical examination & health assessment / Carolyn Jarvis ; Australian adapting editors, Helen Forbes, Elizabeth Watt: Chatswood, N.S.W. : Elsevier Australia
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Massey, D. (2006). The value and role of skin and nail assessment in the critically ill. Nursing in Critical Care, 11(2), 80-85.
Massey, D., & Meredith, T. (2010). Respiratory assessment 1: Why do it and how to do it? British Journal of Cardiac Nursing, 5(11), 537-541.
Massey, D., & Meredith, T. (2011). Respiratory assessment 1: Why do it and how to do it? British Journal of Cardiac Nursing, 6(11), 537-541.
Meredith, T., & Massey, D. (2011). Respiratory assessment 2: More key skills to improve care. British Journal of Cardiac Nursing, 6(2), 63-68.
Murphy, J. F. (2013). Revisiting developmental assessment of children. Irish Medical Journal, 106(5), 132.
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Susan, S. (2012). Pediatric Physical Examination & Health Assessment: Jones & Bartlett Learning.
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