Use play techniques for infants and young children. Examine least intrusive areas first i. 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.
Less than 6 months use digital thermometer per axilla. Assess any respiratory distress. 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. Baseline measurement should be obtained for every patient. Selection of the cuff size is an important consideration. For neonates without previous hospital admissions do a blood pressure on all 4 limbs. Monitor as clinically indicated. Note oxygen requirement and delivery mode.
Blood sugar level BSL: 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. ECG rate and rhythm if monitored. Observation of vital signs including Pain: For further information please see the Pain Assessment and Measurement clinical guideline Skin: Colour, turgor, lesions, bruising, wounds, pressure injuries. Assess hydration and nutrition status and check feeding type- oral, nasogastric, gastrostomy, jejunal, fasting, and breast fed, type of diet, IV fluids.
Assess Bowel and Bladder routine s , incontinence management urine output, bowels, drains and total losses. 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.
ABCDE Assessment - How To Assess a Critically Ill Patient |Ausmed
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. 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.
The ABCDE Assessment:
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. For infants, an assessment is made of their cry and vocalization. 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.
Head circumference should be measured, over the most prominent bones of the skull e. Does the infant visually fix and follow? Assessment of severity of respiratory conditions Respiratory assessment includes: Colour centrally and peripherally: Examine circulatory status and hydration status of upper and lower extremities: Colour central and peripheral: 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.
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. Note the size, colour, texture and shape of the lesions e.
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Note which area of the body it covers. Non-blanching petechial rash should be reported immediately.
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. Pressure injury prevention and management. Report any irregular bruising. Observe for size, any irregular borders, variation in colours. Larger nevi and changing ones should be reviewed by appropriate medical staff.
Cradle cap is most common in newborns and is identified by thick, crusty scales over the scalp. Observe for lice or ticks Palpate: 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.
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. This content is accessible to all versions of every browser. However, this browser may not support basic web standards , preventing the display of this site's design details. Some popular browsers that support these standards so that content may be accessible to all users are:.
It is important to perform a history and do a focused physical exam to be sure that there aren't any medical risks that would predispose the patient to a medical emergency during the actual procedure. It is also important to talk to the patient to get a feel for the patient's psychological state. Be sure to assess the following:.
Module 01: Advanced Pain Control and Sedation
In order to answer these questions, a risk assessment is performed, which requires taking a medical history and performing a physical examination. Most of the information obtained in the medical history will be the basis for the risk assessment and it is important for the clinician to spend time talking with the patient.
Information gathered in the patient history includes:. During the physical examination a review of systems is conducted, in order to obtain information about specific organ systems. The focused physical exam should include the following components:. A good history is merely confirmed by the physical examination. Begin with the basic vital signs including blood pressure, heart rate, respiratory rate, and record the height and weight of the patient.
How To Assess a Deteriorating / Critically Ill Patient (ABCDE Assessment)
A complete pre-operative physical exam should also include a head and neck exam, cardiovascular exam and pulmonary exam. In addition, it is also important to perform an airway exam, and that involves looking at the tongue, at the neck. During the airway exam, use the following questions to help you determine if the patient is at risk for airway obstruction during sedation:. During the history and physical examination, it is also important to ascertain the patient's anxiety level.
The ASA Classification system is used by anesthesiologists to classify patients according to their medical history. It is a graded scale from one through five, with an E is added to indicate an emergency procedure.