Assessment of the child or young person and family is multi-faceted. The important components include subjective observation and history taking, as discussed in Chapters 1 and 2, along with objective measurements and monitoring data, depending on the individual situation. In order to manage the assessment process and ensure vital- elements are not missed, it is useful to employ a systematic approach to assessment that can guide the nurse through the process with a logical structure.

The well-documented and recommended approach to systematic assessment is the ABCDE approach: Airway, Breathing, Circulation, Disability (Neurological), Exposure. Such a mnemonic-based approach has previously been highlighted by the use of SAMPLE for history taking (see Chapter 2) serving to guide assessment in a structured and logical way. The ABCDE mnemonic is endorsed by Resuscitation Councils worldwide. However, this approach does not just apply to resuscitation; it also applies to the context of emergency care or critical illness or injury as highlighted in the Figure.

The ABCDE approach is applicable in all clinical emergencies. It can be used in the street without any equipment or, in a more advanced form, upon the arrival of the emergency medical services, in emergency rooms, in general wards of hospitals, or in intensive care units. Each stage of the ABCDE approach is outlined in detail in the Figure.

The aims of the ABCDE approach are:

• to provide life-saving treatment;
  
• to break down complex clinical situations into more manageable parts;
  
• to serve as an assessment and treatment algorithm;
  
• to establish common situational awareness among all health professionals.

The ABCDE approach is applicable to all patients, both adults and children. The clinical signs of critical conditions are similar, regardless of the underlying cause. This makes exact knowledge of the underlying cause unnecessary when performing the initial assessment and treatment. The ABCDE approach should be used whenever critical illness or injury is suspected. It is a valuable tool for identifying or ruling out critical conditions in daily practice. Respiratory or cardiac arrest is often preceded by adverse clinical signs and these can be recognized by applying the ABCDE approach to potentially prevent this situation. ABCDE is also recommended as the first step in post-resuscitation care upon the return of spontaneous breathing and circulation.

It is important that the order from A through to E is maintained. For example, there is no point addressing circulation if the airway is not patent. In addition, regular reassessment is essential after each stage and remains the case in any event where a child deteriorates. The ABCDE approach and the importance of reassessment will be emphasized again in Chapters 56–59.

Systematic assessment can also be considered in relation to three phases: primary, secondary, and tertiary. ABCDE is part of primary assessment along with subjective observation (see Chapter 1). Once this has been undertaken and reassessment has confirmed a desired outcome (i.e. the situation is no longer life-threatening), then one can move to secondary assessment. This is a more thorough examination and focused history of the child or young person. History taking is covered in Chapter 2. Finally, further assessment by investigations and monitoring are part of the tertiary phase.

A structured approach to assessment can use the systems of the body in relation to the physical examination of a child. Such a method is used, for example, to examine newborn babies at discharge from hospital and neonates at their six-week postnatal check. A head-to-toe approach works through each of the systems. Conducting a head-to-toe assessment ensures that a nurse is thorough in the assessment of the child. By starting at the head and working down to the feet, this ensures that nothing is missed in any of the major body systems. This type of assessment means that a nurse is checking all systems for abnormalities and is less likely to miss any problems. The head-to-toe assessment follows a logical sequence starting at the head and neck, moves on to the chest, then to the abdomen and limbs.

In nursing practice, a systematic approach to assessment can be aided by the use of assessment tools. Mnemonics such as SAMPLE and ABCDE are tools in that they serve to guide practice logically in order to ensure a thorough assessment. Examples of other assessment tools are:

• AVPU (Alert – Voice – Pain – Unresponsive): Measure the level of neurological response as part of the D (Disability / neurological) component of ABCDE: see later chapters.
  
• Pain assessment tools: the presence of pain is assessed on a number of criteria comprising physiological, behavioural and biochemical signs. The score indicates the level of pain and guides appropriate analgesia. On a more simplistic level, pain can be assessed by asking a child to grade their pain from a selection of graded scores.
  
• PEWS (Paediatric Early Warning Score): see later chapters.
  
• GCS (Glasgow Coma Scale); see later chapters.
  
• Skin assessment tools (e.g. Braden Q and Glamorgan tools: see Chapter 19). Skin is assessed on a range of criteria, each one scored on a scale of 1–4 with the total score indicative of the risk of skin breakdown.