HCSW Development Link Nurse Tracy Culkin

2011

Rational for Observational Updates

To conform with the trusts observational policy

Patient safety

To have a better understanding of observational charts

To have a better understanding Early Warning Scoring (EWS)

To understand your role when charting and recording patient observations

The Trusts observational policy

Sets out the standard expected of all Healthcare Professionals who undertake observations of any type when delivering patient care to adults

Observations are defined as the following actions

Taking a blood pressure

Taking a pulse

Taking respirations

Taking a temperature

Taking oxygen saturation levels

Taking an apex beat rate

Assessing neurological status

Assessing urine output (where applicable)

Duties and Responsibilities

Gain understanding ,Knowledge and skills to undertake clinical observations

Document and report findings appropriately

Record and Monitor finding

Recording on obs Charts

The front of the Pt’s Obs chart must be completed !!!!

Attach pt label

Fill in pt’s age, weight, allergies

Ward area, consultant, Date of admission

All early warning instructions

Obs Charts Cont... inside

Patient name Start date & time Temp + alert if one Pulse & Bp + alert if one Respirations Saturations + alert Urine output if needed EWS, Pain & Sedation, weight & signature

Please remember to report findings

EWS SystemScore 3 2 1 0 1 2 3

Heart rate <40 <40-50 51-100 101-110 111-130 >130

Respiratory

Rate

<=9 10-14 15-20 21-30 >30

Blood

Pressure

<=70 71-80 81-100 101-199 >=200

Temperatur

e

<35 35-38 >38

Central

Nervous

system

Sudden

confusio

n

Alert Voice Pain Unrespo

nsive

Urine

Output

NiL <30 30-39 40-99 100-150 151-199 >=200

EWS Triggers1-3 inform nurse in charge

Patient triggers 3 in one category increase obs ½ hourly contact SHO/REG

Total score is 4or 5 contact SHO/REG record obs ½ hourly

Total score is 6 or above Contact SHO/REG IMMEDIATELY to review pt complete EWS on meditech

Practical Session

How well can you complete an Obs Chart?

How well can you document EWS and report findings?

Lets Find out!!!!

Feedback

Did you find the session helpful? Did you receive a EWS card? Do you feel more confident about

documenting EWS? Do you feel more confident on completing

observation charts If future sessions are held on the above topic

what would you like to see added to the session?

The End

Any Questions ?