Platform 3 : Acute care (children’s high dependency unit)

Platform 3: Assessing needs and planning care

Proficiencies

3.2 demonstrate and apply knowledge of body systems and homeostasis, human anatomy and physiology, biology, genomics, pharmacology and social and behavioural sciences when undertaking full and accurate person-centred nursing assessments and developing appropriate care plans

3.4 understand and apply a person-centred approach to nursing care, demonstrating shared assessment, planning, decision making and goal setting when working with people, their families, communities and populations of all ages

3.5 demonstrate the ability to accurately process all information gathered during the assessment process to identify needs for individualised nursing care and develop person-centred evidence-based plans for nursing interventions with agreed goals

3.6 effectively assess a person’s capacity to make decisions about their own care and to give or withhold consent

3.15 demonstrate the ability to work in partnership with people, families and carers to continuously monitor, evaluate and reassess the effectiveness of all agreed nursing care plans and care, sharing decision making and readjusting agreed goals, documenting progress and decisions made

3.16 demonstrate knowledge of when and how to refer people safely to other professionals or services for clinical intervention or support

What Alexis did

Throughout the shift, Alexis undertook regular and systematic assessments of Freddie’s condition under the supervision of her practice supervisor.

Alexis completed hourly neurological observations, including use of the Glasgow Coma Scale (GCS), to monitor for any signs of deterioration following the suspected head injury. These observations were carried out consistently with the same registered nurse to support continuity and accuracy of assessment.

In addition to neurological observations, Alexis recorded vital signs and contributed to a structured A-E (Airway, Breathing, Circulation, Disability, Exposure) assessment. This enabled a holistic understanding of Freddie’s physical and neurological status and supported early identification of any changes.

During the initial assessment, Alexis and her practice supervisor spoke with Freddie to gather information about the incident. Although Freddie showed no immediate signs of deterioration, he was unable to recall events following the collision, indicating a potential head injury and the need for ongoing monitoring and further investigation, including an Magnetic Resonance Imaging (MRI) scan.

Alexis contributed to risk assessment and care planning, recognising the need for appropriate moving and handling and positioning due to the suspected head injury. She observed how adjustments were made to reduce the risk of further harm during movement and investigations.

Alexis also participated in the ongoing assessment and management of Freddie’s pain. Freddie was using a morphine Patient Controlled Analgesia (PCA) device, and Alexis monitored his pain using a 0–10 pain scale. She observed how this information informed clinical decisions, including the reduction of morphine dosage as his pain improved.

All assessments and observations were documented using the Paediatric Early Warning Score (PEWS) chart and the trust’s documentation systems to support ongoing monitoring and escalation where required.

Alexis observed how care was planned and coordinated with the multidisciplinary team (MDT), including referrals for imaging and consideration of follow-up care with community services such as the GP and school nurse.

What this demonstrates

• Alexis demonstrated application of knowledge of anatomy, physiology and neurological assessment when undertaking and interpreting observations, including GCS and A–E assessment (3.2)
• She contributed to holistic, person-centred assessment by considering both physical injuries and Freddie’s neurological status following the incident (3.2, 3.4)
• Alexis used information gathered from assessments to support identification of care needs, including the requirement for ongoing monitoring, imaging and pain management (3.5)
• She demonstrated a person-centred approach by involving Freddie in discussions about his condition, including pain assessment, and supporting him to express how he was feeling (3.4, 3.6)
• Alexis recognised the importance of continuous monitoring and reassessment, including tracking changes in neurological observations and pain levels to inform care (3.15)
• She demonstrated understanding of how clinical findings inform decision-making and escalation, including referral for MRI and MDT involvement (3.16)
• Alexis contributed to accurate and timely documentation of assessments using PEWS and nursing records, supporting safe and effective care planning (3.5, 3.15)

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