PAEDIATRIC RISK ASSESSMENT & NURSING CARE ... two charts? The charts were not developed as a single...
Transcript of PAEDIATRIC RISK ASSESSMENT & NURSING CARE ... two charts? The charts were not developed as a single...
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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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 - 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 - 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
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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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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