Observations are recorded as part of an admission assessment and documented on the patient’s observation flowsheet. Symmetry and positioning of facial features Neonate and Infantīody symmetry, spontaneous position, and movement This should occur on admission and then continue to be observed throughout the patients' stay in hospitalĬonsider signs of deterioration including: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.Īge specific considerations can be found in the table below. Newborn Screening Tests (see Child Health Record for documentation).Īssessment of the patients’ overall physical, emotional, and behavioral state.Apgar score, resuscitation required at delivery.Delivery type and complications if any,.Cultural/Religious preferences including Aboriginal and Torres Strait Islander status.reason for current admission) and relevant past medical history, History of current illness/injury (i.e.For more education regarding culturally safe care staff are encouraged to enroll in theĪboriginal Cultural Safety course via learning hero. 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 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. Elements of the admission assessment satisfy national standard requirements and 'required nursing admission documentation' in EMR. It may also be collected as part of a preadmission process. The information can be obtained from the patient, parent, or carer. RCH Learning Hero package ‘Know Me Early’.Īn 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. More information regarding child development from 0-6 years can be found via the.Serious clinical concern and/or identification of a deteriorating patient requires fast and appropriate escalation of care as per theĭeteriorating Patient: Escalation of Care flow chart and the.Throughout the assessment process, the nurse should communicate findings and refer concerns to the ANUM, medical team and/or allied health as necessary.For a stable child it may be appropriate to delay assessments until the child is awake. However, the clinical need of the assessment should also be considered against the need for the child to rest. Where possible, assessments should be clustered with other cares at a time when the child is relaxed and compliant.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. Involve the family, parents and carers in the assessment process.Determine what parts of the exam is to be completed before possible crying which may be seen in some children (i.e.hands, arms) and painful and sensitive assessment last (i.e. Examine least intrusive areas first (i.e.Use a systematic approach but be flexible to accommodate child’s behavior. Gather as much information as possible by observation first.Privacy of the patient always needs to be considered. Implement behaviours that show respect for child’s age, gender, cultural values and personal preferences.Use play techniques for infants and children.Consider the age and developmental stage of the child. Modify language and communicate style to be consistent with child’s needs.Completed/documented in the Focused Assessment flowsheet in EMR. This may involve one or more body systems. Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient.Completed/Documented in the Primary Assessment flowsheet or progress/patient encounter note in EMR. Primary assessment: Concise nursing assessment completed at the commencement of each shift, patient encounter or if patient condition changes at any other time.
Link EMR for documentation of assessments.The guideline specifically seeks to provide nurses with: The aim of this guideline is to ensure all RCH (Royal Children Hospital) patients receive consistent and timely nursing assessments. 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 nursingĪssessment in order to plan holistic and patient family centered nursing care and responds effectively to unexpected or rapidly changing situations. Assessment is a key component of nursing practice, required for planning and provision of patient and family centered care.
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