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Assessment is an important component of nursing practice, necessary for the planning and delivery of patient and family-centred care. A comprehensive nursing assessment includes both subjective (qualitative) and objective (quantitative/measurable) elements, namely, general appearance, patient history, physical examination and measurement of vital signs. Of these four components, the area of subjective assessment and observation of clinical appearance is the focus of the present chapter. Objective physical assessment, including history taking and monitoring will follow in subsequent chapters.
Subjective nursing assessment is an individualized, qualitative approach that does not use objective, measurements, tools or equipment. Rather, it is based on individualized clinical observation relating to the physical, emotional and behavioural characteristics of the child and family. Therefore, by its very nature, such a form of assessment can be open to interpretation and opinion. However, it also serves as an essential starting point to any holistic assessment of a child and family. Inspection and observation of general appearance and behaviour are therefore an integral part of an initial assessment before any objective data can be recorded. The skills of performing sound, clinical observation and judgement develop over time and through experience by nursing students and beyond into qualification. The importance of such skills should not be underestimated. It should also be remembered that parents or primary caregivers are best placed to recognize concerns and will report these based on subjective observations of changes in their child’s physical or emotional state. This information should be considered alongside nursing assessment data.
The initial nursing assessment of a child should be undertaken with a parent or known caregiver upon arrival to a ward, on pre-admission or, in the case of out-of-hospital care, at the first meeting following introduction to a new child and family in line with any referral for ongoing care. Ideally, initial assessment should be completed within 24 hours of admission and any key information should be documented clearly using appropriate records.
Observation can be carried out while taking the history and establishing rapport. This can be done in conjunction with observations by and from the parents, if present, along with sound clinical nursing judgement. For example, you can observe the child’s behaviour, level of understanding and general appearance on admission at first introduction and consider this with the parents’ own reports. General appearance of the child and family includes observation of their physical, behavioural and emotional state. At any age, considerations for the subjective assessment of the child or young person include:
Are they able to respond appropriately to questioning and are they obeying requests? Or are they resistant in their responses and reaction?
Care of the child encompasses a wide range of ages from newborn up to the adolescent period. Although some of the principles of assessing children are similar to assessing adults, children are not just small adults, and the approach to assessment and content can be quite different. Moreover, assessment changes in relation to what to observe as children develop and get older so that eventually, in the young person, it is similar to adults. The Figure aims to highlight the important differences to give some general principles and provide an outline of subjective assessment in different age groups. This emphasizes that the approach to subjective assessment is influenced by a child’s age, stage of development and level of understanding.
In the neonatal and infant period, physical assessment includes, for example, observation of facial features, symmetry, posture, movement and tone of the limbs. Behavioural elements include presence of a strong cry and normal responses to being held/consoled. Emotional elements include observation of interaction between them and their parents. In the young child, gross physical and fine motor skills can be observed according to age expectations, with refinement occurring as the child gets older. Age-appropriate speech and language can also be noted. Behaviour can be observed by a child’s mood and, again, interaction with parents. In an adolescent, similar points can be addressed but in line with behaviours applicable to teenage years, including level and type of communication and emotional reaction.
Subjective assessment can also be carried out according to the biological system, as is commonly used in the systematic approach to holistic physical examination. This will be covered in greater detail in Chapter 3. A full examination of all the systems is the most thorough way to gain a complete physical picture of the child or young person. The subjective components of these systems are displayed in the Figure.
To conclude, sound clinical judgement goes hand in hand with subjective nursing assessment and should be used to make decisions on the need for further, more objective, and possibly more invasive assessment methods.
History taking is a key component of a nursing patient assessment and an important part of prioritizing and planning care. Traditionally, a medical history is undertaken for a diagnosis and to ultimately decide on appropriate treatment. A nursing history should be carried out jointly and is regarded as a key skill that develops through experience. It should include physical, social and psycho-emotional domains. In its simplest form, history taking involves asking appropriate questions to children, young people and/or their families to obtain vital information to assist the subsequent care. An overview of history taking and its components can be seen in the Figure.
Nursing history taking fits well with a person-centred approach to care where nurses are expected to get to know their patients and understand the needs and problems of the children in their care. Integral to this process is the need for effective communication skills, which should aim to achieve holistic, thorough history taking in the context of a therapeutic relationship.
An essential part of person-centred communication during history taking is the establishment of rapport between the nurse and child or young person and family. See the Figure for the Calgary-Cambridge communication framework that can be used to understand the vital elements of this process. This covers elements that are required for any patient but they can easily be applied to a child, young person and their parents.
Other factors need to be considered in relation to communication during history taking. If a child or family does not speak English, it will be necessary to arrange an interpreter to clarify what is said. In addition, for very young children or those who have no or limited speech, the history is taken from the parents. In older children, there must be a balance between giving them independence and getting a full account of the illness or situation.
Communication during history taking may also be compromised by factors such as the child’s distress. Parents may be extremely anxious, particularly in settings such as accident and emergency rooms. Histories may therefore need to be brief and focused. If a comprehensive history is not achievable in the first instance, it may be necessary to continue adding detail later. The nature of nursing means that relationships between nurses and children or young people in their care can be developed over a longer period, with more frequent contact than other members of the multi-disciplinary team. Within this context, history taking can be seen as a process of getting to know the child and family better and to understand their needs and concerns. It can also be viewed as an incremental process where information is accumulated over time. This means history taking need not necessarily take place in a formal consultation and can take place informally, depending on the situation. Whatever mode is employed, there are key components of any history taking, discussed below.
In the hospital setting, history taking can follow a structured approach using, for example, a mnemonic to aid comprehensive information gathering. One example of such a framework is the mnemonic SAMPLE.
Finally, it is essential that a compassionate approach be upheld in history taking which demonstrates attention to privacy and dignity as well as upholding confidentiality. This may not be easy in a busy environment where space is limited. This highlights the potential ethico-legal implications in relation to how information is collected and protected. Additionally, issues of safeguarding are also important to take account of recognizing that not all parents or carers have the child’s best interests at heart and may conceal vital facts, hindering a full and accurate picture. Multi-disciplinary support in such cases may be sought.
Assessment of the child or young person and family is multi-faceted. The important components include subjective observation and history taking, as discussed in Chapters 1 and 2, along with objective measurements and monitoring data, depending on the individual situation. In order to manage the assessment process and ensure vital- elements are not missed, it is useful to employ a systematic approach to assessment that can guide the nurse through the process with a logical structure.
The well-documented and recommended approach to systematic assessment is the ABCDE approach: Airway, Breathing, Circulation, Disability (Neurological), Exposure. Such a mnemonic-based approach has previously been highlighted by the use of SAMPLE for history taking (see Chapter 2) serving to guide assessment in a structured and logical way. The ABCDE mnemonic is endorsed by Resuscitation Councils worldwide. However, this approach does not just apply to resuscitation; it also applies to the context of emergency care or critical illness or injury as highlighted in the Figure.
The ABCDE approach is applicable in all clinical emergencies. It can be used in the street without any equipment or, in a more advanced form, upon the arrival of the emergency medical services, in emergency rooms, in general wards of hospitals, or in intensive care units. Each stage of the ABCDE approach is outlined in detail in the Figure.
The aims of the ABCDE approach are:
The ABCDE approach is applicable to all patients, both adults and children. The clinical signs of critical conditions are similar, regardless of the underlying cause. This makes exact knowledge of the underlying cause unnecessary when performing the initial assessment and treatment. The ABCDE approach should be used whenever critical illness or injury is suspected. It is a valuable tool for identifying or ruling out critical conditions in daily practice. Respiratory or cardiac arrest is often preceded by adverse clinical signs and these can be recognized by applying the ABCDE approach to potentially prevent this situation. ABCDE is also recommended as the first step in post-resuscitation care upon the return of spontaneous breathing and circulation.
It is important that the order from A through to E is maintained. For example, there is no point addressing circulation if the airway is not patent. In addition, regular reassessment is essential after each stage and remains the case in any event where a child deteriorates. The ABCDE approach and the importance of reassessment will be emphasized again in Chapters 56–59.
Systematic assessment can also be considered in relation to three phases: primary, secondary, and tertiary. ABCDE is part of primary assessment along with subjective observation (see Chapter 1). Once this has been undertaken and reassessment has confirmed a desired outcome (i.e. the situation is no longer life-threatening), then one can move to secondary assessment. This is a more thorough examination and focused history of the child or young person. History taking is covered in Chapter 2. Finally, further assessment by investigations and monitoring are part of the tertiary phase.
A structured approach to assessment can use the systems of the body in relation to the physical examination of a child. Such a method is used, for example, to examine newborn babies at discharge from hospital and neonates at their six-week postnatal check. A head-to-toe approach works through each of the systems. Conducting a head-to-toe assessment ensures that a nurse is thorough in the assessment of the child. By starting at the head and working down to the feet, this ensures that nothing is missed in any of the major body systems. This type of assessment means that a nurse is checking all systems for abnormalities and is less likely to miss any problems. The head-to-toe assessment follows a logical sequence starting at the head and neck, moves on to the chest, then to the abdomen and limbs.
In nursing practice, a systematic approach to assessment can be aided by the use of assessment tools. Mnemonics such as SAMPLE and ABCDE are tools in that they serve to guide practice logically in order to ensure a thorough assessment. Examples of other assessment tools are:
Communication is an essential skill in the assessment and care of children, young people and their families. There are four main types of communication, each with sub-areas to aid the sharing and understanding of information.
When communicating verbally, the type of language used should be considered, avoiding the use of jargon. For children and families whose first language is not English, interpreting services should be used, ensuring individual needs are met. The ability to understand, on the part of both child and family, should be considered, taking into account age, developmental level and cognitive ability, adapting the language and approach used as necessary.
Non-verbal communication techniques, such as active listening, body language, facial expressions and therapeutic touch, contribute to a large portion of how information is conveyed and received. Active listening skills require the listener to make a conscious effort to focus on what is being said, improving their ability to understand information. Body language, such as eye contact, sitting directly opposite, nodding and an open posture, also demonstrate that the listener is interested and engaged in the conversation, encouraging the speaker to continue with the sharing of information; essential during the assessment process.
In relation to assessment, documentation is essential, acting as a record of the information obtained from the child and family. It also enables the sharing of information between professionals within the multi-disciplinary team. When documenting information, all records should be factual and accurate, with a date, time and signature on completion.
To accurately assess a child it is necessary to build a therapeutic relationship with the child, gaining their trust and reducing anxiety; all of which increase the accuracy of assessment. A central technique to this is the use of play. Play can be used to do the following:
When considering the use of play, age-appropriate toys should be used, considering the child’s developmental stage. It may also be useful to ask the child’s parents/carers what type of toys/activities the child enjoys, increasing the ability to interact and engage with the child.
All children should be provided with the tools and ability to communicate in the most appropriate way based on their individual ability. It may therefore be necessary to consider the use of alternative methods such as Makaton, sign language and the Picture Exchange Card System (PECS) to ensure that all children and families are provided with the tools to effectively communicate with healthcare professionals.
Although communication is essential to accurate assessment, there are numerous barriers that impact on the effectiveness of communication, negatively impacting the assessment process. Techniques to improve communication should therefore be consider and used, improving the ability to effectively interact with the child and their family, facilitating the building of therapeutic relationship, gaining trust and increasing the ability to accurately assess and care for children/young people and their families.