In this assignment I will reflect upon a neurological assessment I carried out of a child admitted to paediatric Accident and Emergency department following a head trauma.
Assessment -Theory-3000 word essay
The theoretical assessment is in two parts; Students are expected to carry out an assessment of a child in an ambulatory setting of their choice, giving a clear rationale, supported by evidence and using appropriate assessment tools.
Reflection on the assessment and communication skills required assessing the child and families health care needs using a cyclical approach.
Student information:
Name: Kim Chappelle-Hedges
Student Number: 10277631
Intake: October 2001
Module: 6
Diploma of Higher Education Nursing (Child branch)
APPENDIX 1
In this assignment I will reflect upon a neurological assessment I carried out of a child admitted to paediatric Accident and Emergency department following a head trauma. I have chosen to reflect upon this particular assessment due to the immense learning achieved and my excitement at the future learning it will bring. Only a brief profile of the child in question will be presented reflecting the amount of information known to me at the time of her arrival. For the purpose of patient confidentiality and respect any information that could lead to the identification of this patient and her family have been either changed or omitted. The patient therefore has been named Anna. Following a profile of Anna to set the scene my reflection will begin based upon Johns (1995) model of structured reflection.
Anna, a 2 1/2 year old female, was playing at home one morning when a 28 inch television fell on top of her, falling from the top of a chest of drawers and hitting the right side of her head, screamed out alerting her mother in the next room who called for an ambulance. I was asked to carry out Anna's neurological assessment following the primary survey.
Upon arrival at the paediatric Accident and Emergency Department, c - spine immobilisation was in place and Anna was highly distressed so I encouraged Anna's mother to continually talk to her and try to remain in sight, explaining that this may help to reassure her. I also fetched some suitable toys for her from the play specialist.
While assessment of Anna's airway, breathing and circulation was completed, I explained the procedures as clearly as possible and answered any questions.
The handover from ambulance staff helped me to establish the history of the injury, and Anna's course since the injury occurred. I documented this information in Anna's notes and informed the relevant staff.
I carried out a rapid assessment of Anna's conscious level using the AVPU categories (see Appendix 2) and placed Anna in the alert category as my observations concluded she was aware of, and responding to the people, movement and noises around her appropriately.
Her vital signs including heart rate, blood pressure, respirations, pulse oximetry and temperature were stable and age appropriate.
Before examining pupil size and reactivity I enlisted the support of Anna's mother (who had seemed to have moved further away from Anna) to help facilitate her involvement. I explained what I was going to do and she seemed happy to assist me. I performed the assessment on her first so that Anna could see, and hoped this would prepare her and gain her cooperation. Her pupil size was 4 and responded quickly and positively.
I began frequent 1/2 hourly assessments of neurological function and level of consciousness using an adapted paediatric version of the Glasgow Coma Scale (see Appendix 3), the first of which I carried out alongside another nurse, as I wanted to be sure I was using the assessment tool properly. Anna consistently scored 14/14, her vital signs remained stable, and she had experienced no nausea or vomiting.
Following a full head to toe examination no other injuries were located and it was decided Anna had experienced only an isolated, minor head injury with no cervical spine abnormality. Therefore, the protective measures were removed and after brief observation Anna was discharged home with verbal and written advice on what Anna's mother should observe for and what action to take if she had any concerns.
I was asked if I wanted to take on the responsibility of caring for and assessing Anna about two minutes before her arrival. All I new at that point was that she was a two - year - old head trauma victim with a possible cervical spine injury. In that brief time before her arrival I experienced feelings of excitement, enthusiasm, motivation to learn as much as possible from this new opportunity, and proud that the nursing staff had faith in my capabilities. Amidst the mass of nursing, ambulance and medical staff that gathered upon Anna's arrival, the noise and seeming panic and confusion which ensued my initial feelings where taken over by my own panic and anxiety. This caused me to question my capabilities, prompting frustration in my lack of confidence, and my feelings that to ask for support and encouragement from staff would some how lessen my achievements and affect how dependable I was viewed by staff.
I then recognised that if the atmosphere and unfamiliarity of A & E had evoked such fear in me, then the psychological impact it would have on Anna would be massive. Considering it was her first experience of the hospital environment in addition to the impact of her accident, Anna was probably deeply frightened and traumatised by the whole experience and I did not wish to exacerbate her fear and distress. I would have to swallow my pride and ask for help in order to act in Anna's best interests and cause her no further psychological harm. In ...
This is a preview of the whole essay
I then recognised that if the atmosphere and unfamiliarity of A & E had evoked such fear in me, then the psychological impact it would have on Anna would be massive. Considering it was her first experience of the hospital environment in addition to the impact of her accident, Anna was probably deeply frightened and traumatised by the whole experience and I did not wish to exacerbate her fear and distress. I would have to swallow my pride and ask for help in order to act in Anna's best interests and cause her no further psychological harm. In addition, a very agitated and distressed child could have made my assessment increasingly difficult. I felt it important for Anna's mother to assist me in the care and assessment of Anna and to remain close to her (as long as she was willing). These actions would provide Anna with a familiar face and voice to focus on and help alleviate her fear and aid cooperation with my assessment procedures( Williams, 1995;Simons, 1999).
As I had never worked in A & E before I was not used to the lack of preparation and information available to me, so I asked if I could receive handover in an attempt to find out as much as possible about Anna. I remember ferociously writing as much information down as I could, concerned that my inexperience in paediatric trauma care would lead to my missing out something of vital importance. The amount of notes I had to sift through in order to produce a clear and concise information base to record in Anna's notes probably looked extreme to any on-looking nursing staff, however the final result was praised by my mentor for it's thoroughness and relevance. I was pleased that I had the sense to realise the extent to which my knowledge and experiential deficiencies in this area could harm my patient and affect the care she received, and proud that despite any embarrassment my actions may have caused me I still acted on her behalf. As the circumstances of Anna's admission affected the data collected I made use of the time I had with Anna and her mother to further interview them and dispense information. I believe that this provided an opportunity for me to establish a good working relationship with them both.
Due to the recognised importance of Anna's neurological assessment and my concerns regarding my lack of training in the use of the departments chosen assessment tool the following questions arose - How do I assess this? Why am I assessing this? What am I looking for? Will I use to correct techniques? Will I interpret the information correctly, and can I do this? To address and remedy these concerns I asked if my mentor would talk through each section of the assessment tool briefly and then carry out a simultaneous assessment to check my interpretation. The results of our assessments were the same and she questioned me as to why I gave those particular scores. Anna scored a 4 for eye opening since her eyes were opened spontaneously, she did not answer my questions but she did respond to her mother using appropriate words, and 2-3 word sentences scoring a 5 for verbal response. Since Anna pushed a nurses hand away whist she was trying to administer pain relief and since she reached out to take a toy from her mother a 5 for motor response was given. My confidence had grown and I was happy to continue my assessments alone and refer to her when necessary.
The AVPU (Alert, Verbal, Painful, Unresponsive) system I used in my rapid assessment can provide a rough guide to whether patients need airway protection, but full assessment will still be required (Mackway-Jones and Maurice, 1999; Gentleman,1999).
Then I assessed Anna further using the following assessment tools: the Glasgow Coma Scale and the Glasgow Coma Score. The Glasgow Coma Scale provides a standardised framework for assessing cerebral function and describing the level of consciousness of a patient in terms of three aspects of responsiveness: eye opening, verbal response, and best motor response.
The Glasgow Coma score is an artificial index; obtained by adding scores for the three responses. This score can provide a useful single figure summary and a basis for systems of classification, but contains less information than a description separately of the three responses.
The three responses of the original) scale, not the total score, should therefore, be of use in describing, monitoring and exchanging information.
Examination of the cranial nerves, in particular pupil reactivity, and neurological examination of the limbs, in particular the pattern and power of movement, provide supplementary information about the site and severity of local brain damage.
Measuring Anna's vital signs were also of great importance as the centres for their vital signs are located within the brain stem and normal brain stem function is affected by pressure upon the brain stem from cerebral lesions, edema, or herniation, and direct invasion of the brain stem by tumours and trauma. This can often cause changes in vital signs.
These assessment tools are used widely to assessing patients both before and after arrival at hospital( Gentleman and Teasdale,1981;Ingersoll and Leydon,1987; Winkler et al,1984). Extensive studies have supported their repeatability (Teasdale et al 1978;Rowley and Fielding, 1990,1991), their validity (Pal et al 1989;Marshall et al, 1991;Signorini et al, 1999), and other properties (Prasad,1996).
Despite the apparent simplicity and clarity of the Glasgow Coma Scale the above studies seem to imply, my initial concerns regarding lack of experience in the use of these assessment tools may have been founded since others argue that it is open to misinterpretation and misapplication leading to confusion (Morris, 1993), especially when only the total score is reported (Bassi,2000). High levels of consistency can be achieved, if training in the use of the scale is provided and reinforced (Rowley and Fielding,1991).
The GCS is less accurate at predicting the outcome of head injury in children than in adults ( Hazinski, 1992). In paediatric practice the original GCS has been modified in a variety of ways to make assessment more relevant to child development (Huband and Trigg ,2000) and an implication of this is that anyone who uses this tool must have knowledge of developmentally appropriate responses for children of particular age groups. Ferguson-Clark and Williams (1998) argue that this knowledge falls into two areas: physiological development - such as differences brain weight, body proportions, rapid periods of growth, ability to control fine movements, and psychological development - which vary hugely between individual children. I enlisted the help of Anna's mother in many parts of the assessment process to help me to elicit and interpret Anna's responsiveness to stimuli as often she would refuse to cooperate with me or at first she was frightened of me, due to an appropriate fear of strangers and her situation (May,1999). Social factors such as her brother's name, her nick name and the name of her rabbit were all obtained through discussion with Anna's mother and incorporated into my interactions with Anna so as to build up a trusting relationship with her and to assess her orientation to time, place and person( Campbell and Glasper, 2001). In this instance I found Anna's family to be an extremely useful resource contributing to the wealth of information about Anna's behavioural and functional level, and this assisted me in individualising my assessment to Anna's needs.
Initially Anna was observed from a distance and I observed her eye opening, appropriateness of vocalisation, motor activity, interaction with her mother and any seizure activity. Following this I approached Anna's mother to discuss my observations to establish whether she considered these observations to be normal for her child. Heimann (2000) argues that nurses control assessment and inhibit families from expressing themselves through the uncritical use of frameworks and tools, the use of questioning as the most predominant means of collecting information and failing to check the validity of assessment. I believe that whilst I question the rationale and effectiveness of certain practices and I did check the validity of my observations, I do rely on questioning a great deal in my interactions with parents and carers
Careful, repeated observation forms a major part of the assessment and subsequent care of patients. How often observations should be made does not appear to have been rigorously studied, but should relate to the estimated risk. The risk of rapid deterioration is higher during the first six hours and diminishes as the time since injury increases (Hickey, 1992), and the factors to be considered include: the history of post traumatic amnesia, the pattern of GCS findings, findings on skull x - ray or CT scan, and the time lapse since injury. Until Anna's results had come back from the radiology department and found no abnormalities I was carrying out neurological observations at half hourly intervals. I was then going to reduce the frequency of my observations to hourly, given that Anna was stable and her condition classed only as a minor head injury, even though I was somewhat reluctant to do so since changes in neurological signs may be rapid and dramatic or very subtle, developing over a period of time, however by this time doctors had arrived to perform their final assessment of Anna before she was discharged.
My aim throughout my assessment was to prevent any further damage, detect promptly any neurological deterioration that may need referral to a microsurgical unit, or to confirm satisfactory recovery and to enable discharge. These processes require good verbal and written communication and record - keeping. Therefore the skills I utilised to communicate the details of mechanism and type of injury and chart Anna's neurological progress since arrival in A & E could be used to recognise any discrepancies between assessments, suggesting deterioration, or other concerns about Anna's condition and allow for discussion with the relevant medical staff.
In terms of the standardised sheet used to document neurological function it may often be necessary to add a narrative description of neurological function in the nurses notes to expand upon the recorded assessment data, or to add pertinent information.
This experience has given me new knowledge of great relevance to my nursing practice. I now appreciate even more so than before the importance of effective neurological assessment in paediatrics, in particular the under five age group. I have experienced the process of conducting a neurological assessment and understand the specific factors that relate to neurological assessment in children. I utilised a wide range of communication skills in order to care for and assess Anna, also I used my skills to gain the cooperation and trust of both Anna and her mother. Under pinning this is the realisation that knowledge of child development, and the ability to assess the child as an individual is a complex skill that is of underlying importance in all interactions with children, and was in this case vital to the validity of Anna's assessment. The effectiveness of forming partnerships with parents was highlighted, as well as the benefits it brings to the quality of care and assessment the child and family receive, I also got the opportunity to learn be developed throughout my nursing practise.
This experience allowed me to gain further knowledge and experience of how nurses collaborate with members of the multi-disciplinary team and the importance of good record - keeping and documentation. I feel that this experience has left me highly motivated and excited, I have gained experience in a previously unknown area of care and believe that my from them about their child and new ways of interacting with them that could increased confidence, and the skills and understanding I would bring if a similar situation should arise, would mean vast improvements from the care I was able to deliver in this particular situation. However due to the tremendous scope of paediatric trauma, the age range involved and the different skills required for injuries causing different and more severe neurological problems, this experience has only fuelled my curiosity.
From this experience my views regarding parental participation have been altered, and in my future practice I would like to work on my confidence and assertiveness so as not to be embarrassed by their presence when I am caring for patients so that I can both assist them in providing nursing care for their children, and listen and learn from them about child and family needs. This personal development in myself will also assist with my interactions with fellow nursing staff and members of the multi- disciplinary team.
With regards to my interest in developing my knowledge of paediatric
neurosurgeon and observed a paediatric craniosynostosis following his care from preparation to surgery to his admission onto a general paediatric ward from a high dependency unit. I intend to arrange visits with a paediatric trauma care team in the near future also.
From my reflection and discussion upon this experience I can conclude that neurological assessment in children requires a complex mix of skills, nurses must have a detailed knowledge of child development from a physiological and psychological perspective, in addition to the ability to assess each child individually. The skills to communicate will both the child and family, and to collaborate and coordinate care as part of multi-disciplinary team. Experience and knowledge is essential to gain an accurate assessment of any potential or existing neurological problems, and regardless of the tool used, the nurse should be familiar with the tool and it's short comings in order take steps to counteract these.
References:
HICKEY,J.V. (1992) The Clinical Practice of Neurological and Neurosurgical Nursing. (3rd Edition) Philadelphia: J.B. Lippincott Company
JOHNS, C. (1995) Framing Learning Through Reflection with Carper's Fundamental ways of Knowing in Nursing. Journal of Advanced Nursing, 22, pp226-34
HEINMAN, K. (2000) Family Nursing: Family Needs. Paediatric Nursing. 12 (7), Sept. pp31-35
TEASDALE, G. and JENNETT, B. (1974) Assessment of Coma and Impaired Consciousness. A Practical Scale. Lancet. 2, pp81-4
CAMPBELL, S. and GLASPER, E.A. (2001) Whaley and Wong's Children's Nursing. London: Mosby
MAY, L. (1999) 'I've Got a Tummy Ache in my Head' Communicating With Sick Children. Paediatric Nursing. 11(4), March. pp21-23
FERGUSON - CLARKE and WILLIAMS (1998)
BASSI, S. et al. (2000) GCS: a Help or a Hindrance. Proceedings of the Society of British Neurological Surgeons. British Journal of Neurology, Neurosurgery and Psychiatry.
MORRIS, K. (1993) Assessment of Communication and Conscious Level: an Audit of Neurosurgical Referals. Injury. 6. pp369-372
GENTLEMAN, D. and TEASDALE, G. (1981) Adoption of the GCS in the British Isles. British Medical Journal. 283, pp408
INGERSOLL, G.L. and LEYDON, D.B. (1987) The GCS for Patients with Head Injuries. Critical Care Nurse. 7, pp26-32
WINKLER, J.V. et al (1984) Pre -hospital use of the GCS in severe Head Injury, Journal of Emergency Medicine. 2. pp1-6
TEASDALE, G. et al. (1978) observer Variability in Assessing Impaired Consciousness and Coma. Journal of Neurological Neurosurgical Psychiatry. 41, pp603-610
ROWLEY,G. and FIELDING, K. (1990) Reliability of assessment by Skilled Observers using the GCS. Journal of Advanced Nursing. 7, pp13-17
PAL, Y. et al. (1989) The value of the GCS and Injury Severity Score. Journal of Trauma. 29, pp746-748
MARSHALL, L.F. et al. (1991) The outcome of severe closed Head Injury. Journal of Neurosurgery. 75. pp28-36
SIGNORINI, D.F. et al, (1999) Predicting survival using simpl clinical variables. Journal of Neurology,Neurosurgery and Psychiatry. 66, pp20-25
(PRASAD, K. (1996) The GCS : a critical appraisal of it's clinimetric capabilities. Journal of Clinical Epidemiology. 49, pp755-63
MACKWAY-JONES and MAURICE, S. (1999) 'The Unconscious Patient' In Greaves, I and Porter, K.M. (eds) Pre Hospital Medicine: the Principles and Practice of Immediate Care. London: Arnold. P146
GENTLEMAN, D. (1999) 'Head and Neck Injuries' IN Greaves, I. and Porter, K.M. (eds) Pre Hospital Medicine: the Principles and Practice of Immediate Care. London: Arnold
WILLIAMS, C. (1995) Children's Understanding of Treatment in A &E. British Journal of Nursing. 4(7) pp385-387
SIMONS, J.M. (1999) Young Children in A & E: a Local Review. Paediatric Nursing. 11(10), pp24-27.
