Assessments

One of the major things we learn to do in nursing school is how to write a good assessment, right? This can be a daunting task. One of the best ways to learn to do assessments is to pick a routine that works for you and stick to it. However, when you are dealing with pediatric patients, you have to be a little bit flexible with your order! This is why I teach my students to really think about your patient, think about what is going on with them and make sure you check the most important things first. For instance, if you have a patient with asthma exacerbation, you would want to be sure and do your respiratory assessment first or at a time when the child is calm (like when sleeping for instance). When dealing with pediatric patients, you never know how far you will be able to get into your assessment before there is a melt down and then you can't hear anything. So, think about the most important things to assess on your patient so you can be sure to get those done.

Also, it's perfectly fine to do a lot of your assessment with the caregiver holding the child. If this helps the patient be more calm and feel more secure, then try to do what you can with them in the caregiver's lap. You can't do this for all parts of the assessment or all procedures, but try to work this into your assessment when appropriate. If your patient starts crying in the bed, try giving them to the caregiver to see if that will help you get a little further along.

Don't forget that everything around the patient is a part of your assessment as well! You should always be checking lines, IVs, machine settings and the patient's environment with every assessment. This is especially true with pediatric patients. Be sure that no one has left caps or other small items in the bed that might pose a choking hazard for a small child. Don't forget bed and crib rails too! A safety assessment should be a part of what you do every time you walk into the room. Keep in mind that you may have patients that are developmentally delayed so even if you have a child that really should be past the point of putting everything in their mouth, they may have a developmental delay that causes them to have behaviors common to earlier stages of development.

So, how do you write up your assessment? Try to do your write-up in the same order every time so that you don't miss anything. Be sure to include anything that is unique to the child. Don't just write a "normal" assessment. Document lines, G-tubes, scars, abnormals, etc. that are unique for the patient.

Start EVERY assessment with a brief description of who your patient is. It is difficult to put the information in your assessment into context if you don't tell me a little about the patient on the front end. Don't forget to include your vital signs (including pain [don't forget to list the pain scale!] and weight). For pediatric patients, I always require my students to add a statement about development as well. Just add a blurb at the end about whether or not the patient has met their developmental milestones on time and if so, how that is evidenced. Also, DO NOT write "normal" or "within normal limits" for any of the systems. As an instructor, I need to know that you know what normal is! So, don't write: CV: WNL. You need to write something like: CV - Regular heart rate and rhythm, no murmurs noted, s1/s2 present, no s3/s4 noted. PMI is palpable at 5th ics. No heaves. - or something to that effect. Now I know that you know what you are looking for when assessing the CV system.

Watch for tomorrow's post where I will post an example of a good, complete pediatric assessment.