Assessment, Clinical Judgement and Care Planning
Structured assessment
Assessment is systematic and prioritised. Use an ABCDE approach for the acutely unwell patient, treating catastrophic findings before moving on, then a focused secondary assessment. Record and act on complete observations (respiratory rate, oxygen saturation, heart rate, blood pressure, temperature, level of consciousness, pain) and use an early warning score to trigger escalation rather than relying on your own threshold. Include falls, pressure ulcer and nutritional risk screening, delirium screening, and sepsis screening where indicated.
Clinical judgement
The nursing process - assess, diagnose (nursing problems, not medical diagnoses), plan, implement, evaluate - is the backbone. Clinical judgement means recognising cues, forming hypotheses, acting, and re-evaluating. Goals should be person-centred, measurable and time-bound, with clear evaluation criteria.
Traps
- Acting on a single abnormal observation while ignoring the trend.
- Being reassured by one normal value in a patient who otherwise looks unwell.
- Writing a medical diagnosis where a nursing problem is required.
- Setting a goal that cannot be measured, such as "patient will feel better".
- Planning care without involving the patient or considering discharge.
Rule of thumb
If a patient has a deteriorating early warning score, a new confusion or a new oxygen requirement, escalate first and investigate second. Never wait for the next round of observations to reassess someone who looks unwell.
Worked example
A 78-year-old has RR 26, SpO₂ 92% on air, HR 112, BP 105/58, temperature 38.6 °C and new confusion. Several parameters are abnormal, plus a new change from baseline. This is a deteriorating patient: escalate using a structured handover (ISBAR), stay with the patient, commence continuous monitoring and repeat observations, and document.