Discussion: Developmental markers

Discussion: Developmental markers

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Assignment: Developmental markers a nurse should assess on the patient

Consider the following patient scenario:

A mother comes in with 9-month-old girl. The infant is 68.5cm in length (25th percentile per CDC growth chart), weighs 6.75kg (5th percentile per CDC growth chart), and has a head circumference of 43cm (25th percentile per CDC growth chart).

Describe the developmental markers a nurse should assess for a 9-month-old female infant. Discuss the recommendations you would give the mother. Explain why these recommendations are based on evidence-based practice.

Introduction

Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. The Nursing and Midwifery Board of Australia (NMBA) in the national competency standard for registered nurses states that nurses, “Conducts a comprehensive and systematic nursing assessment, plans nursing care in consultation with individuals/ groups, significant others & the interdisciplinary health care team and responds effectively to unexpected or rapidly changing situations.

Aim

The aim of this guideline is to ensure all RCH patients receive consistent and timely nursing assessments.
The guideline specifically seeks to provide nurses with:

• Indications for assessment
• Approach to assessment in children
• Types of assessments
• Structure for assessments

Definition of Terms

Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs.

Shift Assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time.

Focused assessment: Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body system.

Approach to physical assessment

• Consider the age and developmental stage of the child.
• Implement behaviours that show respect for child’s age, gender, cultural values and personal preferences.
• Modify language and communicate style to be consistent with child’s needs.
• Introduce yourself to the child and family and establish rapport. Use play techniques for infants and young children.
• Gather as much information as possible by observation first
• Use systematic approach; but be flexible to accommodate child’s behaviour.
• Examine least intrusive areas first (i.e. hands, arms) and painful and sensitive assessment last (i.e. ears, nose, mouth)
• Determine what parts of the exam is to be completed before possible crying which may be seen in some children (i.e. heart, lungs & abdomen)
• Encourage the child and family to ask questions and voice any concerns.
• Where possible assessments    should be clustered with other cares at a time when the child is relaxed and compliant. 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. Admission assessment is in the admissions tab of the ADT navigator with additional information being entered into the patient’s progress notes. Privacy of the patient needs to be considered all times.

Patient history

Nursing staff should discuss the history of current illness/injury (i.e. reason for current admission), relevant past history, allergies and reactions, medications, immunisation status, implants and family and social history. Recent overseas travel should be discussed and documented.
For neonates and infants consider maternal history, antenatal history, delivery type and complications if any, Apgar score, resuscitation required at delivery and Newborn Screening Tests (see Child Health Record for documentation).

General Appearance

Assessment of the patients’ overall physical, emotional and behavioral state. This should occur on admission and then continue to be observed throughout the patients stay in hospital.
Considerations for all patients include: looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.

• Neonate and Infant
  • Parent infant, infant parent  interaction
  • Body symmetry, spontaneous position and movement
  • Symmetry and positioning of facial features
  • Strong cry
• Young Child
  • Parent child, child parent  interaction
  • Mood and affect
  • Gross and fine motor skills
  • Developmental milestones
  • Appropriate speech
• Adolescent
  • Mood and affect
  • Personal hygiene
  • Communication