Nursing assessment, history taking and collaborative working

Learning objectives

After studying this chapter, the reader will have an understanding of:

  • the importance of a structured approach during a nursing assessment for the child with respiratory disease
  • the significance of a paediatric early warning scoring system for respiratory assessments
  • the significance of history taking and building relationships with parents
  • the impact of presenting symptoms associated with respiratory disease on the activities of daily living
  • the impact of collaboration on health.


Comprehensive history taking, good consultation skills and a thorough assessment are the starting point of all patient care. This model of practice provides a framework for guidance, based on the activities of daily living for nurses, referred to by Roper, Logan and Tierney (2000) as the nursing process. This process emphasises nursing care based on the concept of assessment, planning, implementation and evaluation (Holland et al. 2008).

There is also a need within modern healthcare to use the concepts of critical analysis, including best practice (Basford and Slevin 2003) and available evidence such as the British guidelines on the management of asthma (BTS 2011). This will be covered in more detail in Chapter 10. This chapter will provide an overview of assessment, history taking and consultation skills for nurses. Consideration will also be given to the importance and benefits of assessment, when planning care for children with respiratory disease.


When planning care following the Roper 1996 nursing model, a thorough assessment needs to be carried out in a systematic manner (Basford and Slevin 2003). This enables the identification of a problem with the ultimate aim of assisting a diagnosis. This approach can also be applied to many specialist areas such as children’s respiratory nursing.

Table 3.1 Normal pulse and respiration

Adapted from Huband and Trigg (2000).

Age Respiratory rate; breaths per minute Pulse; beats per minute
Infants 30–60 100–220
3 months–2 years 25–35 80–150
3–7 20–30 70–100
8–18 20–25 55–90

Using a framework such as the nursing process not only assists with assessment of the patient but also enables nurses to consider particular elements of the assessment, such as breathing. Naturally, respiration is relevant to respiratory disorders and is also essential for life. Any alteration in breathing affects other activities of daily living such as eating and drinking (Holland et al. 2008). Therefore a holistic approach to assessment is recommended, including prioritising nursing activity when planning care.

Recording the respiratory rate is the most significant observation in the respiratory system (Smyth 2001). A child in respiratory distress can present with grunting, head bobbing and recession (the use of accessory muscles). This clinical presentation is also highlighted within NICE guidelines (2007), which provides a comprehensive framework when assessing patients for respiratory distress.

It is important that nurses have a clear understanding of the normal values when monitoring vital signs such as pulse and respiratory rate (Table 3.1). This allows interpretation of observations which a child may present with when unwell. Also, the respiratory rate should not be taken when a child is crying as this ultimately affects the respiratory rate.

Assessment and recording of observations, with the use of a paediatric early warning scoring system (PEWS), are now an established part of clinical practice, following the introduction of NICE guidelines to assist the early detection of sick patients who have the potential to become critically ill (NICE 2007). The NHS Institute for Innovation and Improvement (2011) has also produced a ‘paediatric trigger tool’ in conjunction with healthcare professionals caring for children. The ethos of this was to assist practitioners to maintain patient safety with care delivery by using a scoring system.

Oliver et al. (2010) report that when caring for children, observations are not always recorded on a regular basis. This also included variation in which specific observations were actually recorded; for example, the pulse rate may be recorded but not the respiratory rate. Oliver et al. suggest that early warning scoring systems can help to address this problem, in areas that have yet to introduce this in practice.

The introduction of this concept is based on the traffic light system of red, amber and green when assessing clinical risk (NICE 2007). Thompson et al. (2009) found that a system of monitoring vital signs can be of value for both serious and less serious infection in children.

Therefore, the importance of recording height and weight should not be underestimated in ­children. Not only are they important for drug therapy and developmental milestones but they are important parameters for assessing states of dehydration and fluid requirement, needed to correct dehydration. This can be significant with infants who have bronchiolitis and present with symptoms such as tachypnoea, poor feeding and low oxygen levels.

At postregistration level, nurses have the extended knowledge that enables them to interpret what the observations are indicating. Oliver et al. (2010) observed in practice that respiration was the one observation that was often omitted, despite the use of a scoring system. This indicates that nurses caring for children with respiratory conditions can benefit from support and education from experienced individuals, such as the respiratory nurse specialist. Oliver et al. reinforce this point by ­suggesting that the success of a paediatric early warning scoring system is reliant on nurses not only recording the observations but understanding and acting on such recordings for the sick child.

Box 3.1 Signs of cyanosis


Central cyanosis

Discoloration of lips, tongue and mucous membranes
Discoloration of fingers/toes

Peripheral cyanosis

Discoloration of affected area
Cold extremities
Discoloured nail bed
Mottled extremities

Essentially, nursing observations not only assist with diagnosis but can help prevent long-term complications. For example, post pneumonia, a child who continues to cough should undergo ­further investigations because this can be an indication of persisting atelectasis. If this is not treated then bronchiectasis can develop (Smyth 2001).

During observations, it is also useful to assess skin colour for signs of cyanosis. Cyanosis is caused by a high level of deoxygenated haemoglobin in the tissue (Ward et al. 2006). The skin has an abnormal discoloration and can have a greyish blue tinge. There are many causes of cyanosis, including impaired blood flow or circulatory shock. The presenting signs and symptoms are dependent on the underlying cause, which will determine whether it is central or peripheral cyanosis (Box 3.1). Central cyanosis occurs with heart and lung disease or haemoglobin that is abnormal. Peripheral cyanosis occurs as a result of blood flow that is impaired, causing reduced circulation and the removal of oxygen in the peripheral tissues (Ward et al. 2006).

Although cyanosis is more obvious in the lips or tongue, it can be difficult to assess, particularly in children. It is important that nurses understand how this can be much more difficult to assess in children with darker skin colour.

Although it is important to make an assessment of the respiratory system, it is also paramount to consider the psychological impact of ill health on the child’s and family’s quality of life and wellbeing.

History taking

Taking a history is not just a process of information gathering. History taking also requires interaction with all concerned and an acknowledgement of the problem (Smyth 2001). It is also important to use a systematic and structured approach, including various factors (listed in Box 3.2) that may affect patient care. This allows the opportunity for parents to provide information that may be vital. Equally as important is a discussion with the family about home life and other physiological issues such as lack of sleep. Therefore, when taking a history from parents, effective communication is key.

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Oct 19, 2016 | Posted by in NURSING | Comments Off on Nursing assessment, history taking and collaborative working
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