What further assessment is necessary for the nurse to conduct before making a nursing diagnosis

Brooker D. Person-centred dementia care.London: Jessica Kingsley; 2007

Centre for Policy on Ageing. The effectiveness of care pathways in health and social care. 2014. https://tinyurl.com/3t835kfd (accessed 1 November 2021)

Department of Health. Refocusing the Care Programme Approach. Policy and positive practice guidance. 2008. https://tinyurl.com/anyrzhy6 (accessed 3 November 2021)

Department of Health. Personalised care planning: improving care for people with Long term conditions. 2011. https://tinyurl.com/uc3u3tkh (accessed 1 November 2021)

Department of Health. Care planning in the treatment of long term conditions: final report of the CAPITOL Project. 2013a. https://tinyurl.com/7399vphc

Foundations of nursing practice: making the difference, 2nd edn. In: Hogston R, Simpson PM (eds). London: Palgrave Macmillan; 2002

Kozier B, Erb G, Berman A, Snyder S, Lake R, Harvey S. Fundamentals of nursing: concepts, process and practice, 8th edn. Harlow: Pearson Education; 2008

Leach M. Clinical decision making in complementary & alternative medicine.Chatswood (NSW, Australia): Elsevier; 2010

Lloyd M. A practical guide to care planning in health and social care.Maidenhead: Open University Press; 2010

Matthews E. Nursing care planning made incredibly easy!.Philadelphia (PA): Lippincott Williams and Wilkins; 2010

Monitor. Delivering better integrated care: A summary of what delivering better integrated care means and how Monitor is supporting the sector. 2015. https://tinyurl.com/825k8kd6 (accessed 1 November 2021)

NHS website. NHS launches accredited suppliers for electronic patient records. 2019. https://tinyurl.com/4fzs4up5 (accessed 1 November 2021)

National Institute for Clinical Excellence. What to expect during assessment and care planning. 2021. https://tinyurl.com/63hm5vvp (accessed 1 November 2021)

NHS England. Personalised care and support planning handbook: the journey to person-centred care: Core information. 2016a. https://tinyurl.com/9fyrtw45 (accessed 1 November 2021)

Nursing and Midwifery Council. Future nurse: standards of proficiency for registered nurses. 2018a. http://tinyurl.com/yddpadva (accessed 1 November 2021)

Nursing and Midwifery Council. The code: professional standards of practice and behaviour for nurses, midwives and nursing associates. 2018b. https://tinyurl.com/gozgmtm (accessed 1 November 2021)

Revello K, Fields W. An educational intervention to increase nurse adherence in eliciting patient daily goals. Rehabil Nurs. 2015; 40:(5)320-326 https://doi.org/10.1002/rnj.201

Note: This guideline is currently under review

• Introduction
• Aim
• Definition of Terms
• Admission Assessment
• Shift Assessment
• Focused Assessment
  • Neurological
  • Respiratory
    
  • Cardiovascular
    
  • Abdomen and Gastrointestinal
  • Renal
    
  • Musculoskeletal
    
  • Skin
    
  • Head and Neck
    
  • Eye
    
  • Ear, Nose and Throat
  • Evaluation
• Links
• Evidence Table
• References
  

Introduction

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.

Aim

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:

• Indications for assessment
• Approach to assessment in children
  
• Types of assessments
  
• Structure for assessments

Definition of Terms

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.

Approach to physical assessment 

• Consider the age and developmental stage of the child.
  
• Implement behaviours that show respect for child’s age, gender, cultural values and personal preferences.
  
• Modify language and communicate style to be consistent with child’s needs.
  
• Introduce yourself to the child and family and establish rapport. Use play techniques for infants and young children.
  
• Gather as much information as possible by observation first
  
• Use systematic approach; but be flexible to accommodate child’s behaviour.
  
• 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)
  
• Encourage the child and family to ask questions and voice any concerns.
  
• 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 refer any serious concerns to the ANUM and to medical team.
  

Admission Assessment

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.

Patient history

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). 

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.
Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.

• Neonate and Infant
  
  • Parent infant, infant parent  interaction
    
  • Body symmetry, spontaneous position and movement
    
  • Symmetry and positioning of facial features
    
  • Strong cry
    
• Young Child
  
  • Parent child, child parent  interaction
    
  • Mood and affect
    
  • Gross and fine motor skills
    
  • Developmental milestones
    
  • Appropriate speech
    
• Adolescent
  
  • 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 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.

• Temperature: tympanic temperatures for children older than 6 months. Less than 6 months use digital thermometer per axilla.
  
• Respiratory Rate: count the child’s breaths for one full minute. Assess any respiratory distress.
  
• Heart Rate: Palpate brachial pulse (preferred in neonates) or femoral pulse in infant and radial pulse in older children. To ensure accuracy, count pulse for a full minute.
  
• Blood Pressure: Baseline measurement should be obtained for every patient. Selection of the cuff size is an important consideration. A rough guide to appropriate cuff size is to ensure it fits a 2/3 width of upper arm. For neonates without previous hospital admissions do a blood pressure on all 4 limbs.
  
• Oxygen Saturation: Monitor as clinically indicated. Note oxygen requirement and delivery mode.
  
• Pain: Use FLACC, Faces, numeric scale, Neonatal Pain Assessment Tool as appropriate to the age group.  Areas such as PICU and NICU use specialised pain scales for intubated and sedated patients. E.g. Modified Pain Assessment Tool (MPAT), Comfort B. Review current pain relief medications/practices.
  

Additional Measurements

• Weight: on admission and/or weekly/daily as clinically indicated.
  
• Height: as clinically indicated.
  
• Head circumference: as clinically indicated.
  
• Blood sugar level (BSL): as clinically indicated.
  

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 Assessment

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:

• Airway: noises, secretions, cough, any artificial airways
  
• Breathing: bilateral air entry and movement, breath sounds, respiratory rate, rhythm, work of breathing: - spontaneous/ laboured/supported/ ventilator dependent, oxygen requirement and delivery mode.
  
• Circulation: pulses (location, rate, rhythm and strength); temperature (peripheral and central), skin colour and moisture, skin turgor, capillary refill time (central and Peripheral); skin, lip, oral mucosa and nail bed colour. ECG rate and rhythm if monitored.
  
• Disability: use assessment tools such as, Alert Voice Pain Unconscious score (AVPU) or 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.
  
• Observation of vital signs including Pain: use FLACC, Wong Baker Faces, numeric scale, Neonatal Pain assessment tool, Comfort B scale as appropriate to the age group. Review current pain relief medications/practices.  For further information please see the Pain Assessment and Measurement clinical 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.
  
  • On admission, the paediatric nutrition screening tool* should be completed for all paediatric patients and is a requirement for compliance to accreditation standard 5. The screening tool comprises of 4 ‘yes/no’ questions used to identify those patients that require nutritional assessment and interventions. Information can be obtained from parents/carers, medical records and by examining the child.  Children that do not require nutrition assessment should be rescreened every 7 days during their hospital stay. Rescreening should include regular weights and monitoring of nutritional intake.
    *Adapted from Dietetics and Food Service, Lady Cilento Children’s hospital’s ‘Paediatric Nutrition Screening Tool Instructions for use’ information sheet.
    
• Output: Assess Bowel and Bladder routine(s), incontinence management urine output, bowels, drains and total losses. Review fluid balance activity 
  Blood sugar levels as clinically indicated.
  
• Focused Assessment: assessment of presenting problem(s) or other identified issues, e.g. cardiovascular, respiratory, gastrointestinal, renal, eye, etc.
  
• Risk Assessment: pressure injury risk assessment (link to pressure guideline), falls risk assessment (link to Falls guideline), ID bands.
  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.
  In the adolescent patient it is important to consider completing psychosocial assessments as physical, emotional and social well-being are closely interlinked. The HEADSS assessment is a psychosocial screening tool which can 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 HEADSS assessment are to screen for any specific risk taking behaviours 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 you may need to establish a rapport with the young person and may require a few shifts to fully complete the HEADSS assessment.
  Social: This may include discussing a wide range of factors including Parents/ carers/ 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.
  
• Review the history of the patient recorded in the medical record. It may be necessary to ask questions to add additional details to the history.

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 system. Nursing staff should utilise their clinical judgement to determine which elements of a focussed assessment are pertinent for their patient.

Neurological System 

A 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

• 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.
    
  • 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. Temperature alterations may indicate dysfunction of the hypothalamus or the brain stem. Blood pressure increases with increased intracranial pressure. Pulse rates initially rise as a compensatory mechanism, and then slow in instances of increased intracranial pressure
  

Seizures

• Onset of seizures
  
• Description of the type of seizure
  
• Duration of seizures
  
• Precipitating factors

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?

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
  
• Smell 
  
• Proprioception
  

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

• Onset + duration of symptoms cough / shortness of Breath 
  
• Triggers ( dust / aerosol / pollen)

Inspection/Observation

• 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, rhythm and depth (shallow, normal or deep)
  
• Respiratory effort (Work of Breathing -WOB): mild, moderate, severe, inspiratory: expiratory ratio, shortness of breath
  
• Use of accessory muscles (UOAM): intercostal/subcostal/suprasternal/supraclavicular/substernal retractions, head bob, nasal flaring, tracheal tug.
  
• Symmetry and shape of chest
  
• Tracheal position
  
• Audible  sounds: vocalisation, wheeze, stridor, grunt, cough - productive/paroxysmal
  
• Monitor for oxygen saturation

Auscultation 

• Listen for absence /equality of breath sounds
  
• Auscultate lung fields for bilateral adventitious noises e.g.: wheeze, crackles, stridor etc.
  

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 and hydration status of upper and lower extremities:
  
• Colour (central and peripheral): pink, flushed, pale, mottled, cyanosed, clubbing
  
• Capillary Refill Time (CRT): brisk ( < 2 sec) or sluggish
  
• Presence of oedema (central and/or peripheral)
  
• Hydration status: Skin turgor, oral mucosa, and anterior fontanels in infants

Palpation

• Palpate central and peripheral pulses for rate, rhythm and volume
  
• Skin condition – temperature(peripheral and central), turgor and diaphoresis

Auscultation

• Auscultate the apical pulse
  
• Compare peripheral pulse and apical pulse for consistency (the rate and rhythm should be similar).
  
• Auscultate the chest for heart sounds and murmurs

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
  
• Hydration status including fluid balance, BPand weight
  
• Growth and feeding, diet or fluid restrictions
  
• Skin condition: temperature, turgor and moisture
  
• Urine output (Normal children <2yrs is between 2-3ml/kg/hr, >2yrs is between 0.5-1ml/kg/hr)
  
• Urinalysis (pH, ketones, protein, blood, 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

• As clinically indicated see Neurovascular Observation Clinical Guideline. 
  

Skin 

Skin assessment can identify cutaneous problems as well as systemic diseases.

Inspection/Observation

• Colour of the skin(pale/flushed, cyanotic, burned tissue)
  
• Rash:  Note the size, colour, texture and shape of the lesions (e.g.: raised or flat, fluid filled) and the number and distribution (e.g.: sparse, numerous, over limbs etc.), itchy, painful. 
  Note which area of the body it covers. Obtain a history of the rash from a parent /carer. 
  Non-blanching petechial rash should be reported immediately.
  
• 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 any irregular bruising. 
  
• Nevi/Moles: Observe for size, any irregular borders, variation in colours.  Larger nevi and changing ones should be reviewed by appropriate medical staff.
  
• Hair: observe the condition of the scalp. Cradle cap is most common in newborns and is identified by thick, crusty scales over the scalp. Observe for lice or ticks

Palpate:

• Skin  temperature, moisture, turgor, oedema, deformities, hematomas and crepitus
• Hair texture for brittleness, moisture

Eye 

Inspection of the eye should always be performed carefully and only with a compliant child.

Inspection/Observation

• Bilateral symmetry, shape, and placement of eye in relation to the ears. 
  
• Bilateral symmetry ,size and shape of the pupils, reactivity to light
  
• Conjunctiva, and eyelids for inflammation, color and discharge
  
• Color of sclera 
  
• Iris for upslanting/downslanting of palpebral fissures
  
• Check visual acuity if child of an appropriate age. 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.  Assess the requirement for glasses or contacts.
  
• Visual field
  
• 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. The red reflex test can reveal problems in the cornea, lens and sometimes the vitreous, and is particularly useful as this test can alert us to large lesions in the retina. This test could be done during routine assessment or when parents are concerned about the child's vision or the appearance of her or his eyes. The red reflex is tested by viewing the pupil through an ophthalmoscope from a distance of approximately eighteen inches. A darkened room would be preferred as it is much easier to see the red reflex. To be considered normal, a red reflex should be identical in both eyes. Dark spots in the red reflex, a markedly diminished reflex, the presence of a white reflex, or asymmetry of the reflexes (Bruckner reflex) are all indications for 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),
  
• Observe for any external trauma, obvious cerumen, inflammation, redness or exudate, any obvious discharge, child pulling on ear.
  
• 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, color, dryness, and fissures at the corners of the mouth 
  
• Inspect teeth for number present, condition, color, alignment, and caries. 
  
• Inspect gingival tissue noting color 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 color, exudate, and odour.

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 

Evaluation of assessment 

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. 

Links

• 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

Evidence Table

Complete evidence table document here.

References: 

• Aylott, M. (2006). Observing the sick child: part 2a: respiratory assessment. Paediatric Nursing, 18(9), 38-44. 
  

• Aylott, M. (2007). Observing the sick child: part 2c: respiratory auscultation. Paediatric Nursing, 19(3), 38-45. 

• Aylott, M. (2007). Observing the sick child: Part 2b Respiratory palpation. Paediatric Nursing, 19(1), 38-45.

• Baid, H. (2006). Patient assessment. The process of conducting a physical assessment: a nursing perspective. British Journal Of Nursing, 15(13), 710-714.

• Bickley, L. S., Szilagyi, P. G., & Bates, B. (2009). Bates' guide to physical examination and history taking (10th ed.): Philadelphia : Wolters Kluwer Health/Lippincott Williams & Wilkins, .

• Brocato, C. (2009). A lot of nerve: how to perform a full neurological assessment for medical & trauma patients. JEMS: Journal of Emergency Medical Services, 34(3), 72-72-75, 77, 79-82 passim. doi: 10.1016/s0197-2510(09)70074-9

• Chiocca, E. M. (2011). Advanced pediatric assessment / Ellen M. Chiocca (1st ed.): Philadelphia, Lippincott William & Wilkins

• Doyle, M., Noonan, B., & O¿connell, E. (2013). Care study: a cardiovascular physical assessment. British Journal of Cardiac Nursing, 8(3), 122. 

• Futagi, Y., Toribe, Y., & Suzuki, Y. (2009). Neurological assessment of early infants. Current Pediatric Reviews, 5(2), 65-70. 

• Higginson, R., & Jones, B. (2009). Respiratory assessment in critically ill patients: airway and breathing. British Journal of Nursing, 18(8), 456. 

• Hockenberry, M. J., & Wilson, D. (2009). Wong’s essentials of pediatric nursing (8th ed.): Elsevier.

• Hornor, G. (2007). Genitourinary assessment: an integral part of a complete physical examination. Journal of Pediatric Healthcare, 21(3), 162-170. 

• Howlin, F., & Benner, M. (2010). Cardiovascular assessment in children: assessing pulse and blood pressure. Paediatric Nursing, 22(1), 25-36. 

• 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

• Kyle, T., & Carman, S. (2008). Essentials of Pediatric Nursing (2nd ed.): Lippincott Williams & Wilkins.

• 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. 

• Selby, M. (2010). Acute illness in children. Practice Nurse, 40(3), 14-17. 

• Susan, S. (2012). Pediatric Physical Examination & Health Assessment: Jones & Bartlett Learning.

• Yock, A., & Corrales, M. S. ( 2010). Assessment of the unwell child Australian family physician, 39(5), 270-275.

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.  

What are the requirements for preparing a nursing diagnosis?

When developing a nursing diagnosis for a client what should the nurse do first?

What are the 3 major steps in nursing assessment?

What are the 4 general components of a nursing assessment?