EDUCATION

Office of Kids Families December 2015

PAEDIATRIC RISK ASSESSMENT & NURSING

CARE ASSESSMENT CHARTS

Background

ACT/NSW Paediatric & Children’s Healthcare Network Clinical Nurse

Consultants group identified the need for standard Paediatric Risk /

Nursing Assessment charts

Aim to reduced unwarranted clinical variation in the care for children

across NSW no matter where they present

NSW Kids and Families facilitated a State working party to develop

the charts, with representation from tertiary and non-tertiary facilities

including rural and remote sites across NSW

This group developed charts aimed for state-wide consistency for

children and adolescents admitted to acute paediatric in-patient

areas. Paediatric sub-specialty areas may add/utilise their own forms

Consultation

Office of Kids and Families (Paediatrics, Maternity, Child Protection, Youth Health)

Children’s Healthcare Network

Sydney Children’s Hospitals Network

Clinical Excellence Commission

State Forms Management Committee

E-Health (to harmonise with development of EMR2)

Nursing & Midwifery Office

Statewide consultation to clinicians and managers via LHD CEs and DoNMs

Trial sites: Bega, Goulburn, RNSH, Manning, Broken Hill, SCHN & JHCH

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Why do we need standard forms?

The Children’s Healthcare Network State Paediatric Clinical Nurse

Consultants group identified a need for standardised paediatric risk

assessment charts for acute paediatric in-patient units:

To meet the National Safety and Quality Health Service

(NSQHS) Standards

To meet the clinical needs common to acute paediatric wards

To avoid duplication and reduce number of assessment charts

To include mandated tools (e.g. falls, pressure injury, nutrition)

The charts

1. Paediatric Risk Assessment Form (incorporating either the modified Glamorgan or Braden Q pressure injury scale)

2. Paediatric Nursing Assessment & Care Plan (Paediatric Nursing Care Plan - extended stay form available for longer admissions)

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Completing the charts

To be completed by the admitting nurse on patients admitted

to an acute paediatric in-patient area.

All sections of the charts are mandatory.

Nursing staff need to use clinical judgement to assess if the

situation is appropriate to complete the assessment forms

immediately upon admission.

If charts cannot be completed during the admission process then

omissions and reasons why need to be recorded in the healthcare

record.

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Why two charts?

The charts were not developed as a single booklet as some

information can be at the bedside and some cannot.

Bedside: Paediatric Nursing Assessment & Care Plan can be

used as a working document in the bedside notes during

admission and filed in healthcare record following discharge

(refer to current ward practice)

Healthcare Record: The Paediatric Risk Assessment form is

to be kept in the patient’s’ healthcare record and NOT at the

bedside as it contains child protection screening information.

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EMR and the charts

The information in the paper copies and the information

required in EMR2 are the same.

The formats for each vary but not the information

You need to complete EMR or paper copies – as per local

facilities procedure

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PAEDIATRIC RISK

ASSESSMENT CHART

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Paediatric Risk

Assessment

Chart (Page 1)

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Page 1 - Paediatric Risk Assessment

Incorporating several mandatory risk assessment tools:

– modified Glamorgan or Braden Q pressure injury

– Humpty Dumpty falls

– Nutritional

– Child safety and welfare

Additional risk assessment information relates to:

– Social history

– Risk assessment

– Behaviour, emotion, mental health

– Infection control

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Page 2 -

Incorporating

Falls

Assessment

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Page 2 - Paediatric Falls Assessment

Initial assessment - Falls risk - adapted from the Miami

Humpty Dumpty falls risk assessment

To be used in conjunction with the CEC Paediatric Falls risk

program and education. Program information available at: http://www.cec.health.nsw.gov.au/programs/falls-prevention/paed-falls

Initial and subsequent scores and level of risk to be recorded in

the Care Plan

‘Action column’ to guide staff how to action an identified falls

risk. Document any actions taken in the health care record

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Page 3 –

Glamorgan

Pressure

Injury Tool

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Page 3 –

Braden Q

Pressure

Injury Tool

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Page 3 - Paediatric Pressure Injury

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Initial Assessment - Pressure Injury Risk Assessment

using either the modified Glamorgan or Braden Q scale

Visualise skin and document integrity on care plan

Initial and subsequent scores and level of risk to be

recorded in the Care Plan. Document any changes in

health care record

‘Action required’ column to guide staff in management

Page 4 – Child

Protection

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Page 4 - Child Protection

Child Safety, Welfare and Wellbeing Risk Assessment - taken from

the Mandatory Reporter Guide

For staff use only - Health care professional observation and

assessment form

Parents/carers are NOT to be asked these questions

This is an initial assessment on admission. Staff need to re-assess if

any concerns arise during the admission

‘Action required’ column to guide staff - area for staff to write

concerns

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PAEDIATRIC NURSING

ASSESSMENT & CARE PLAN

CHART

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Page 1 –

Paediatric

Nursing

Assessment

Can be kept at the bedside or as per

usual practice for unit

To be completed on admission to

the ward

- Admission details

- Orientation to the ward

- Nursing Assessment

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Brochures

Your Health Rights and Responsibilities –

A Guide for Patients, Carers & Families

http://www.health.nsw.gov.au/patientconcerns/Publications/health-rights-responsibilities-public.pdf

What you need to know about Information Privacy

http://www.health.nsw.gov.au/patients/privacy/Pages/privacy-poster.aspx

Youth Friendly Confidentiality Resources

We keep it zipped – we provide a confidential service for young people

http://www.kidsfamilies.health.nsw.gov.au/publications/youth-friendly-confidentiality-resources/

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Pages 2 & 3 -

Paediatric

Nursing Care

plan

To be completed initially and updated

when care changes (not necessary

to change each shift unless required)

For Falls Risk and Pressure Area

Care sections of the care plan

document score and risk actions

required

Extended stay care plans available

as a single additional page

Nursing Care Plan

Care Plans are to be revised and signed for when care

changes

Not routinely signed at the end of each shift

May require more than one revision in a shift (e.g. pre and post

operatively)

Or may require no revision of care during a shift

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Page 4 –

Discharge

Planning

Discharge planning

Parent carer authority

discharge signature

Parents to sign when

patient being discharged

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Any questions….

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