1. HCSW Development Link Nurse Tracy Culkin
2011

2. 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

3. 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

4. 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)

5. Duties and Responsibilities
 Gain understanding ,Knowledge and skills
to undertake clinical observations
 Document and report findings
appropriately
 Record and Monitor finding

6. 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

7. 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

8. EWS System
Score 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

9. EWS Triggers
 1-3 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

10. Practical Session
How well can you complete an
Obs Chart?
How well can you document
EWS and report findings?
Lets Find out!!!!

11. 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?

12. The End
Any Questions ?