Download Physiological Observations of Adult Patients in the Community Setting

PHYSIOLOGICAL OBSERVATIONS
OF ADULT PATIENTS IN THE COMMUNITY SETTING
POLICY
To be read in conjunction with Physiological Observations Policy for Inpatients
and Minor Injury Units (including Wessex House)
Version:
3
Ratified by:
Senior Managers Operational Group
Date ratified:
December 2015
Title of originator/author:
Community Night Nurse
Senior Nurse for Clinical Practice
Title of responsible committee/group:
Clinical Governance Group
Date issued:
December 2015
Review date:
November 2018
Relevant Staff Groups:
All clinical staff in a Community
Health setting
This document is available in other formats, including easy read summary versions and other
languages upon request. Should you require this please contact the Equality and Diversity
Lead on 01278 432000
Physiological Observations of Adult Patients in the Community Setting within their own homes
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DOCUMENT CONTROL
Reference
LB/Jan16/POAPC
Version
3
Status
FINAL
Author
Senior Nurse Clinical Practice
Community Night Nurse
Revised Policy format post acquisition
Amendments
Updated to include the NEWs observation chart and
parameters
Document objectives: To set out a minimum standard of type and frequency of
observations to be taken in the community setting and to ensure that abnormal
results are acted on appropriately and in a timely manner.
Intended recipients: All clinical staff in Community Health setting
Committee/Group Consulted: District Nursing Best Practice Group
Monitoring arrangements and indicators: See relevant section of policy
Training/resource implications: Training provided by Clinical Skills Facilitators
Approving body and date
Clinical Governance
Group
Date: December 2015
Formal Impact Assessment
Impact Part 1
Date: May 2015
Clinical Audit Standards
NO
Date: N/A
Ratification Body and date
Senior Managers
Operational Group
Date: December 2015
Date of issue
December 2015
Review date
November 2018
Contact for review
Senior Nurse for Clinical Practice
Lead Director
Director of Nursing & Patient Safety
CONTRIBUTION LIST Key individuals involved in developing the document
Name
Designation or Group
Mary Martin
Professional Lead for District Nursing
Members
DN Best Practice Group
Members
Clinical Policy Review Group
Members
Clinical Governance Group
Lisa Stone
Interim Lead for Clinical Practice
Suzi Davies
Clinical Skills Facilitator (East)
Liz Berry
Senior Nurse Clinical Practice
Robin Payne
Clinical Skills Facilitator (West)
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CONTENTS
Section
Summary of Section
Doc
Document Control
2
Cont
Contents
3
1
Introduction
4
2
Purpose & Scope
4
3
Duties and Responsibilities
4
4
Explanations of Terms used
5
5
Documentation
5
6
Physiological Observations that should be
undertaken on adult, non-labouring patients
6
7
Fluid Charts
10
8
Assessing the Patient
10
9
Seeking Help
11
10
Immediate Measures
11
11
Training Requirements
12
Equality Impact Assessment
12
12
13
Monitoring Compliance and Effectiveness
12
14
Counter Fraud
13
15
Relevant Care Quality Commission (CQC)
Registration Standards
13
16
References, Acknowledgements and Associated
documents
13
17
Appendices
15
Appendix A
National Early Warning Score (NEWS) - A Guide to
Scoring
16
Appendix B
Sepsis Proforma for Community Settings
17
Appendix C
Adult Observation Chart
18
Appendix D
Competency Assessment for Physiological
Observations
20
Page
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1.
INTRODUCTION
1.1
To set a minimum standard of type and frequency of observations to be taken
on adult patients in the community setting within their own homes by:

Staff identifying deteriorating patients early by observation

Understanding the use of NEWS scoring to highlight changes in patients’
condition

Staff following the Sepsis Proforma to ensure all steps have been taken

Advising staff when and who to inform of deterioration
2.
PURPOSE & SCOPE
2.1
Support the use of the National Early Warning Score (NEWS) to guide clinical
decision making (Appendix A)
2.2
Highlight the abnormal ranges of observations that should cause concern
2.3
Provide resources to support community staff and training
2.4
Reinforce the Communication Standard of when to call for help. Situation,
Background, Assessment & Recommendation (SBAR)
3.
DUTIES AND RESPONSIBLITIES
3.1
The Trust Board has a duty to care for patients receiving care and treatment
from the Trust.
3.2
The Director of Nursing and Patient Safety is responsible for this policy, but
will delegate authority for the overall implementation and ongoing management
of this policy to the Leads of Services this policy applies to.
3.3
The Senior Nurse for Clinical Practice is the author of this policy and also the
Lead for Deteriorating Patients. This role includes the monitoring of all
unplanned transfers and investigation of incidents where appropriate action,
such as observations or calling for help, has not been taken. Any learning
needs are fed back to the team leader/ward manager. This is reported quarterly
to the Clinical Governance Group in the Deteriorating Patients Improvement
Action Plan.
3.4
The Clinical Governance Group will discuss the quarterly report and may
decide on actions to be taken by the relevant Best Practice Groups.
3.5
The appropriate Best Practice Groups will review the physiological
observation audit and will oversee and report on the action plan.
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3.6
All Team Leaders have a duty to ensure that the staff working in their team are
trained, competent and confident to undertake physiological observations. It is
the responsibility of the person delegating the task to ensure the member of
staff undertaking the delegated duty is competent. The person delegating the
task remains accountable for that delegation. The team leader is also
responsible for ensuring staff complete a DATIX for all unplanned transfers,
and for assisting in the investigation process of any incidents, as well as
feeding back any learning to their team.
3.7
The Clinical Practice Team will provide a rolling programme of training in
Physiological Observations and Recognition and Rescue of Deteriorating
Patients, accessible via the learning and development intranet page. They are
also responsible for assisting in the investigation of any unplanned transfers.
3.8
All Staff working and undertaking physical observations within patient’s own
homes are responsible for complying with this policy.
4.
EXPLANATIONS OF TERMS AND SYMBOLS USED













NEWS – National Early Warning Score
AIM - Acute Illness Management - Early Intervention and Treatment. A
training course for qualified nursing staff
BLS - Basic Life Support. Mandatory resuscitation for all community staff
AVPU - Alert, responds to Voice, responds to Pain, Unresponsive. An
assessment tool for conscious level
RR - Respiratory Rate
HR - Heart Rate
SBP - Systolic Blood Pressure
SpO2 - Saturation (peripheral) of oxygen
GCS - Glasgow Coma Score
CRT - Capillary Refill Time
SBAR - Situation, Background, Assessment, Recommendations. A
method of handing information over in a concise and logical manner
< means ‘smaller than’
> means ‘greater than’
5.
DOCUMENTATION
5.1
All patients should have temperature, pulse, respiration rate, blood pressure,
oxygen saturation, AVPU and urinalysis recorded during first visit to provide
baseline measurements.
5.2
Numerals should not be written on the observation graph, except when
extreme values are recorded outside the graph limits.
5.3
All patients should have a NEWS score attributed to every set of observations.
5.4
If possible the patient’s normal observations should be noted for comparison,
especially if they suffer from chronic illnesses.
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5.5
All patients should have their weight recorded on admission to the case load.
This may be obtained using the Malnutrition Universal Screening Tool (MUST).
Refer to Food and Nutrition Policy.
5.6
All patient observations should be recorded on the organisation’s generic
physiological observation chart.
5.7
Patients must retain the same observation chart, especially when moving
between wards, departments and home so that physiological trends can be
seen.
5.8
All patients should have a set of observations recorded during first visit. The
frequency of observation can be agreed after the patient has been assessed
and a rationale documented in the patients’ records.
5.9
Physiological observations charts should be electronically scanned and then
uploaded into a patients electronic RiO records when the patient is discharged
from the caseload, or is transferred to another healthcare provider
6.
PHYSIOLOGICAL OBSERVATIONS THAT SHOULD BE UNDERTAKEN ON
ADULT PATIENTS
6.1
There are five main physiological observations that are regularly measured as
“vital signs”. These are all included in the NEWS system.

Temperature

Pulse

Respiration rate

Blood pressure (systolic)

Oxygen saturation

Conscious level
Plus additional observations that can provide important physiological
information in the deteriorating patients
 Urine output * includes completion of a fluid balance chart
 Capillary Blood Glucose
 Pain score – recorded on separate chart
6.2
Abnormal observations should initiate an “alert”. Abnormal ranges are provided
by the NEWS scoring (Appendix A). The NEWS score consists of five
measured variables; respiratory rate (RR), heart rate (HR), systolic blood
pressure (SBP), conscious level and urine output. Temperature and oxygen
saturation do not score a NEWS score, but can suggest patient deterioration.
6.3
The range for each observation scored is between 0 and 3; with a score of 0
being in the range, and 3 is the most deranged. A total NEWS score is derived
by adding the six scores to get a total between 0 and 18, with 18 being the
most deranged. A guide to abnormal ranges in other parameters is discussed
in section 8.5
6.4
An alert should cause the practitioner to stop and think about the implications
for the patient. An alert should prompt one or more of the following depending
on the severity of the patient’s condition:

extra vigilance (additional observation parameters being measured)
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



further assessment and intervention by a competent practitioner
book a return visit to reassess all physiological observations in line with
NEWS guidelines and clinical judgement of registered nurse
discussion with General Practitioner (GP) or Out of Hours GP service
999 call
6.5
Frequency of Observations are related to the NEWS score (Appendix B)
6.6
The additional importance of “nurse concern” as a factor in predicting
deterioration should not be underestimated and any member of staff who is
concerned about a patient should not hesitate to call for help.
6.7
Temperature
6.7.1
Although temperature does not form part of the NEWS score it is one of the
“vital signs” and should be regularly measured. It is especially important if your
patient has any type of likely or confirmed infection and especially in
neutropenia patients, and for detecting sepsis.
6.7.2
Low temperature is as significant as high temperature. The Surviving Sepsis
campaign defines one of the parameters for sepsis, as having a core
temperature of >38˚ C or <36˚c (Appendix B).
6.7.3
Hypothermia is defined as a core temperature <35˚C which can become fatal
at <32˚C. Hypothermic patients should be warmed slowly using blankets.
6.8
Pulse
6.8.1
The pulse is a reflection of the heart rate and is frequently measured via the
saturation probe on the automated blood pressure machine; it will therefore be
measuring the pulse in the finger. This poses three issues:



the pulse might not reflect the true heart rate
pulse properties cannot be determined, i.e. volume and regularity
practitioners may not develop expertise in assessing pulse properties
6.8.2
A manual pulse should be taken on first visit to assess the pulse properties
(Rate/rhythm/strength).
6.8.3
A pulse rate of >90 b/min or < 50 b/min should initiate an alert and a manual
pulse should be checked if the heart rate has been read from an automated
machine. The rate and regularity should be checked and recorded.
6.8.4
Sepsis should be considered when the heart rate is >90 b/min.
6.8.5
Any patient who is identified as having a new irregular pulse noted, or any
other concerns with their pulse should be discussed with the GP and
consideration given to a 12 lead ECG being required.
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6.8.6
Patients receiving beta blocker medication will not be able to increase their
heart rate to compensate for hypo perfusion conditions, and therefore other
abnormal signs (high respiratory rate and low urinary output) will have extra
significance.
6.9
Respiration Rate
6.9.1
Respiratory rate is the most sensitive indicator of deteriorating physiology and
must be recorded in all patients.
6.9.2
A respiratory rate of < 12 or > 20 should initiate an alert.
6.9.3
Depth, symmetry and pattern of respiration should also be noted and recorded
if abnormal.
6.10
Blood Pressure
6.10.1 Systolic blood pressure (SBP) less than 110 mmHg should initiate an alert.
6.10.2 A SBP < 90mmHg may be a sign of severe sepsis, fluid loss or cardiac shock
and requires further assessment of the patient.
6.10.3 The SBP should be greater than the heart rate. If the heart rate increases
above the SBP it should initiate an alert.
6.10.4 Falling blood pressure should be regarded as late sign of deterioration.
6.10.5 In cases of very low blood pressure, the electronic BP measuring devices may
not be accurate and a manual sphygmomanometer should be used. Manual
sphygmomanometers must be available to all areas and staff should be trained
and competent to use them.
6.11
Oxygen Saturation
6.11.1 Oxygen saturation (SpO2) should be recorded on all patients.
6.11.2 Unless normal for patient, saturation < 90% with or without supplemental
oxygen needs to be addressed. Escalation and actions will be based on
specific patient presentation.
6.11.3 The concentration of supplemental oxygen should also be recorded and the
oxygen delivery device noted.
6.11.4 If the patient is receiving supplemental oxygen therapy and has an oxygen
saturation reading < 90% (unless normal for patient), the device, flow and
equipment should all be checked to ensure optimum oxygenation. Check
oxygen cylinder capacity, if in use, and ensure there is an adequate supply.
6.11.5 Oxygen saturations will not be accurate in patients with hypo perfusion
conditions. A capillary refill time (CRT) test and mottled knee sign can give
further information on the patient’s perfusion and may initiate an alert. This will
need to be discussed with the GP and / or Nurse Practitioner.
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6.12
Conscious Level
6.12.1 Conscious level should be initially assessed on all patients using the AVPU
scale.
AVPU Scale
A
Alert
Awake
V
Responds to Voice
Lethargy
P
Responds to Pain
Stupor
U
Unresponsive
Coma
6.12.2 If a patient has a primary neurological problem the Glasgow Coma Score
(GCS) should be used by a competent practitioner. For example, a head injury
post fall.
6.12.3 Deterioration in conscious level can be caused by many factors, and a more
comprehensive physical assessment should be undertaken by a competent
practitioner.
6.12.4 New confusion or a change in conscious level is a significant indicator of
deteriorating physiology and should be recorded as 3 on the NEWS score.
6.12.5 A response only to pain or unresponsive, correlates to a GCS of < 8 and
should be treated as a medical emergency.
6.12.6 Any deterioration in conscious level should be followed by a more in depth
assessment of GCS by a competent practitioner.
6.12.7 Patients having seizures are at significant risk and should have a senior
medical review.
6.13
Urine Output
6.13.1 The optimum urine output is 0.5ml – 1ml / kg / hr. In a 70kg adult this is equal
to 35 to 70mls / hr. The minimum desired urine output is 0.5mls / kg / hr, which
is equal to 35mls/hr. Urine output is generally assessed using a fluid balance
chart.
6.13.2 In the majority of patients urine output does not need to be routinely measured,
but should be considered in the following instances;

Patients whose NEWS score is rising. For instance, consider
measuring urine output for 24 hours if a patient has a NEWS score
greater than 4. To be discussed with GP / Nurse Practitioner

Patients with other abnormal signs such as high fever

Patients with other abnormal fluid losses such as vomiting, wound drains,
stomas or diarrhoea

Consider urinary catheterisation or weighing of incontinence pads if
clinically indicated
6.13.3 If a patient has decreased urine output, the frequency of Community Nursing
visits will be increased in order to ensure accurate assessment. The actual
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timing is a clinical decision based on the patient’s overall physical condition and
presentation.
6.13.4 Patients with primary urological or retention problems may have urine output
observations done according to specialist advice.
7.
FLUID CHARTS
7.1
When a fluid chart is in use, it should be fully filled in with both input and output
fluid and quantity.
7.2
Completion of accurate fluid balance in the community can be challenging. It is
most often done in partnership with the patient or their relative/carer. The
patient, relative or carer may complete their own chart or similar record
following guidance from the nurse or a known quantity of fluids may be left for
the patient to drink in order to approximate input between visits. Visual clues
such as used cups and glasses in the home may also be useful indicators of
fluid intake. Suitable receptacles should also be provided in the toilet to inform
output volumes.
7.3
Patients receiving subcutaneous fluid must have a fluid chart in progress.
7.4
Daily and cumulative balances should be entered onto the front of the generic
fluid balance chart.
7.5
Fluid losses from respiration and perspiration (insensible loss) are not normally
recorded, but should be accounted for in patients with fluid balance problems.
Normal insensible loss is approximately 500-1000mls
8.
ASSESSING THE PATIENT
8.1
Staff should ensure the patient is able to understand the information given to
them and are able to give their informed consent. This may necessitate the use
of a professional interpreter and the translation of written information. A
capacity assessment should be considered for those patients who are unable
to consent to the procedure and reference should be made to the relevant
Trust policy (refer to Consent and Capacity to Consent to Treatment Policy).
8.2
Vital signs and NEWS scoring will give an indication of the patient’s condition.
If the patient is deteriorating, a more comprehensive assessment is warranted.
8.3
The ABCDE model of assessment is recommended as it gives a rapid, initial
assessment of the patient’s condition:





8.4
A = Airway
B = Breathing
C = Circulation
D = Disability
E = Environment
Basic guidance on ABCDE is part of BLS training.
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8.5
Help must be sought as soon as possible if any practitioner feels unable to
adequately deal with the situation, or feels that the patient could deteriorate
further.
9.
SEEKING HELP
9.1
Any concerns about the patient must be relayed to the Nurse Practitioner
and/or GP responsible for the care of the patient, and recorded in the patients’
records.
9.2
The following procedure is a guide to calling for help:
9.3
Before calling a GP or Nurse Practitioner, make sure you have all the
information you need to hand.
9.4
Use the SBAR system to communicate.
9.4.1
Situation
State your name, position and where you are located
State the patients name, age and diagnosis
State why you are calling – the current problem, giving the patient’s
physiological observation and your assessment findings
9.4.2
Background
State any relevant events leading up to this event, providing further details of
the patient (diagnosis, resuscitation category, team responsible for care and
reasons for concern.
9.4.3
Assessment
State what you have assessed the situation to be, for example, “I believe the
patient has developed pneumonia”.
9.4.4
Recommendation
Be clear about what you are expecting the GP or Nurse Practitioner to do – for
example, attend immediately, attend within one hour.
9.5
Do not hesitate to call 999 if the patient is rapidly deteriorating or you have any
major concerns.
10.
IMMEDIATE MEASURES
10.1
Simple early measures can often prevent further deterioration of the patient
and avoid the need to admit to secondary care.
10.2
Interventions will depend on the patients’ vital signs and initial assessment but
include some of the following:





Appropriate positioning of the patient
Checking that the optimum amount of oxygen is being delivered if
appropriate
Checking that vital medications have been given
Giving appropriate medications
Checking that infusions are running up to date
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

Simple physiotherapy if trained
Follow Community Sepsis Proforma (if appropriate) (Appendix B)
If you are in any doubt about what to do, or your competency to do it ......call for
help.
11.
TRAINING REQUIREMENTS
11.1
The Trust will work towards all staff being appropriately trained in line with the
organisation’s Staff Mandatory Training Matrix (training needs analysis) where
mandatory training is indicated. All training documents referred to in this policy
are accessible to staff within the Learning and Development Section of the
Trust Intranet.
11.2
All staff working under this policy must be competent to measure Physiological
Observations and be aware of the NEWS Score Guidance (Appendix A). All
new staff must be made aware of this in their induction.
11.3
All clinical staff working under this policy must undertake resuscitation training
as outlined in the Resuscitation Policy.
11.4
All non-registered health care professionals and registered professionals
whose basic training does not include measurement of physiological
observations and who take observations as part of their role, must be trained
and assessed as competent in taking observations. Please see the
Competency Assessment for Physiological Observations (Appendix D)
11.5
It is recommended that all registered nurses in community settings attend the
Recognition and Rescue of the Deteriorating Patient training.
12.
EQUALITY IMPACT ASSESSMENT
All relevant persons are required to comply with this document and must
demonstrate sensitivity and competence in relation to the nine protected
characteristics as defined by the Equality Act 2010. In addition, the Trust has
identified Learning Disabilities as an additional tenth protected characteristic. If
you, or any other groups, believe you are disadvantaged by anything contained
in this document please contact the Equality and Diversity Lead who will then
actively respond to the enquiry.
13.
MONITORING COMPLIANCE AND EFFECTIVENESS
13.1
To monitor compliance, an annual audit will be conducted on the observation
charts. This is part of the Trust Audit Plan. Results and the action plan will be
discussed at the appropriate Best Practice Groups and progress reported to
the Clinical Governance Group on a 6 monthly basis. Any non-compliance and
learning needs identified will be addressed and monitored by the Local team
leaders for that area.
13.2
All feedback, complaints, DATIX reports and serious incidents requiring
investigation and action plans related to this policy will be monitored by the
District Nursing Best Practice Group. Any non-compliance and learning needs
Physiological Observations of Adult Patients in the Community Setting within their own homes
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identified will be addressed and monitored by the Local team leaders for that
area.
14.
COUNTER FRAUD
14.1
The Trust is committed to the NHS Protect Counter Fraud Policy – to reduce
fraud in the NHS to a minimum, keep it at that level and put funds stolen by
fraud back into patient care. Therefore, consideration has been given to the
inclusion of guidance with regard to the potential for fraud and corruption to
occur and what action should be taken in such circumstances during the
development of this procedural document.
15.
RELEVANT CARE QUALITY COMMISSION (CQC) REGISTRATION
STANDARDS
15.1
Under the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014 (Part 3), the fundamental standards which inform this
procedural document, are set out in the following regulations:
Regulation 9:
Regulation 10:
Regulation 11:
Regulation 12:
Regulation 13:
Regulation 14:
Regulation 15:
Regulation 16:
Regulation 17:
Regulation 18:
Regulation 19:
Regulation 20:
Regulation 20A:
15.2
Under the CQC (Registration) Regulations 2009 (Part 4) the requirements
which inform this procedural document are set out in the following regulations:
Regulation 18:
15.3
Person-centred care
Dignity and respect
Need for consent
Safe care and treatment
Safeguarding service users from abuse and improper treatment
Meeting nutritional and hydration needs
Premises and equipment
Receiving and acting on complaints
Good governance
Staffing
Fit and proper persons employed
Duty of candour
Requirement as to display of performance assessments.
Notification of other incidents
Detailed guidance on meeting the requirements can be found at
http://www.cqc.org.uk/sites/default/files/20150311%20Guidance%20for%20providers%20on%2
0meeting%20the%20regulations%20FINAL%20FOR%20PUBLISHING.pdf
Relevant National Requirements
Patient Safety First ‘The how to guide’ for reducing harm from deterioration (2008)
16.
REFERENCES, ACKNOWLEDGEMENTS AND ASSOCIATED DOCUMENTS
16.1
References
British Hypertension Society. Found at www.bhsoc.org
Jevon, P. (2007) Blood Pressure Measurement – Part 2: using automated
devices. Nursing Times Vol: 103, Issue: 19, page 26
Jevon, P; Holmes, J (2007) Blood pressure management _ part 3: lying and
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standing blood pressure. Nursing Times, Vol 103, issue 20, page 24
GE HealthCare (2010) Temporal Scanner. Temporal Artery Scanner. Found at
www.gehealhtcare,com
Higgins, D. (2005) Pulse Oximetry. Nursing Times, Vol: 101, Issue 06, Page 34
Intercollegiate information paper between CSP, RCSLT, BDA and RCN.
Supervision, accountability and delegation of activities to Support Workers: A
guide for registered practitioners and support workers (January 2006)
Luton and Dunstable Hospital NHS Foundation Trust. Cited in Patient Safety
First (2008). “The ‘How to Guide’ for Reducing Harm from Deterioration Version
1:1
Mooney, G. (2007) Temperature. Nursing Times, 13 August 2007
Mooney, G. (2007) Respiratory Assessment. Nursing Times, 13 August 2007
Mooney GP and Comerford DM (2003) Neurological observations. Nursing
Times. 99.17, 24-25
Mooney, G. (2003) Taking the Pulse. Nursing Times, 8 April 2003
Morgan, R.J.M.F, Willams et al (1997) “An early warning system for detecting
developing critical illness” Clinical Intensive Care. 8(2):1
National Institute Clinical Excellence (NICE) (2007): Acutely ill Patients in
hospital
NMC (2015) The Code: Professional standards of practice and behaviour for
nurses and midwives. (Published 29 January 2015)
RCN. Nursing Standard essential guide: Health care assistants and assistant
practitioners Delegation and accountability (February 2007)
Rigby, D, Gray, K (2005) Understanding Urine Testing. Nursing times Vol: 101,
issue 12, Page 60
Royal College of Physicians (2012) National Early Warning Score (NEWS).
Standardising the assessment of acute illness severity in the NHS.
London:RCP
The UK Sepsis Trust Available at http://sepsistrust.org/ [Accessed on 11
November 2015]13.2
16.2
Cross reference to other procedural documents
Admission, Transfer and Discharge Policy (CH)
Blood and Blood Components Transfusion Policy
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Cleaning and the Decontamination of Equipment Policy
Consent and Capacity to Consent to Treatment Policies
Do Not Attempt Resuscitation Policy
Hand Hygiene Policy
Health & Safety Policy
Hypoglycaemia Management Policy for Adult Patients
Insulin Management
Infection Prevention and Control Policy
Learning Development and Mandatory Training Policy
Mandatory Training Matrix (Training Needs Analysis)
Medical Device Policy
Medicines Policy
Physical Assessment & Examination of Service Users Guidelines
Rapid Tranquillisation Policy
Recovery Care Programme Approach (RCPA) Policy
Record Keeping and Records Management Policy
Resuscitation Policy
Safer Moving and Handling Policy
Serious Incident Requiring Investigation (SIRI) Policy
Treatment for Anaphylaxis Guidelines
Untoward Event Reporting Policy
Verification of Death Policy
All current policies and procedures are accessible in the policy section of the
public website (on the home page, click on ‘Policies and Procedures’). Trust
Guidance is accessible to staff on the Trust Intranet.
17.
APPENDICES
17.1
For the avoidance of any doubt the appendices in this policy are to constitute
part of the body of this policy and shall be treated as such. This should include
any relevant Clinical Audit Standards.
Appendix A
NEWS – A Guide to Scoring Frequency of Observations
based on NEWS
Appendix B
Sepsis Proforma for Community Health
Appendix C
Adult Observation Chart
Appendix D
Competency Assessment
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APPENDIX A
National Early Warning Score (NEWS) – A Guide to Scoring
Prevention of critical events and early detection of organ failure
leads to improved outcome and shorter hospital stays for patients.
This table provides an aid to assist in the early identification of
patients at risk of deterioration.
Is your patient’s clinical condition causing concern? If “yes”, score your patient from
the table below
Physiological
Parameters
Respiratory
Rate
Oxygen
Saturations
Any
Supplemental
oxygen
Temperature
≤35.0
Systolic BP
≤90
Heart Rate
≤40
Level of
consciousness
3
2
<8
≤91%
92-93%
1
0
9-11
12-20
94-95%
≥96%
YES
91-100
1
2
3
21-24
>25
NO
35.1-36.0
36.1-38.0
101-110
111-219
41-50
51-90
A
38.1-39.0
≥39.1
≥220
91-110
111-130
≥131
V, P or U
The score is obtained by adding the scores obtained for each abnormal physiological
observation – the total will assist in making a decision about the appropriate
response.
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APPENDIX B
Patient Name
Address
NHS number/DOB
Surviving Sepsis Proforma:
Patient’s at Home & Mental Health Inpatient Areas
Is this likely to be more than a self-limiting
condition?
-
NO
Symptoms of infection (e.g. recent
fever)
Acute deterioration
Unexplained illness (especially in
immunosuppressed/elderly)
-
Sepsis Unlikely
Date
Continue normal care
Time
sign
Sepsis Likely
YES
Any 2 of the following?
-
Please
Tick
Temperature >38 or <36
Resp rate
>20 per minute
Heart rate
>90 per minute
Acute confusion/reduced
conscious level
Glucose
>7.7mmol/l (unless
DM)
NO
-
Systolic BP <90 mmHg
Lactate
>2 mmol/l
Heart rate >130 per minute
Resp rate >25 per minute
*Oxygen sats <91%
Responds only to voice/pain
Unresponsive
Purpuric rash/mottled skin
Action
Urgent GP referral Hospital admission
likely if patient already
receiving antibiotics or
no clear source of
infection
Full bloods - FBC, U&E,
CRP, lactate
Time Sign
PURPLE, YELLOW, BLUE,
GREY(for lactate)
NO
YES
Any 1 of the following?
Date
Please
Tick
YES
*definitive diagnosis of COPD may negate this
trigger, please ensure these patients have ‘target
parameters’ agreed
All red flag sepsis is a time critical condition and
immediate action is required
Repeat visit within 12
hours if admission not
indicated
Reassess for sepsis
within 12 hours if
admission not indicated
Ensure patient/carer
understand specific
‘safety net’ advice if no
admission
Red Flag Sepsis
Date
Action
Time Sign
Dial 999
Arrange blue light
transfer
Write a brief handover
including observations
and any known
antibiotic allergies
15l high-flowAPPENDIX
oxygen
C
via non-rebreathe
mask if available
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APPENDIX C
NEW Physiological Observations Chart for Adults (front)
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NEW Physiological Observations Chart for Adults (back)
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Appendix D
COMPETENCY ASSESSMENT FOR PHYSIOLOGICAL OBSERVATIONS
The competencies are to be used in conjunction with: Somerset Partnership NHS Foundation Trust

Physiological Observations of Inpatients and MIU Policy

Cleaning and Decontamination of Equipment Policy

Hand Hygiene Policy.

Assessing Competency in Clinical Practice Policy

Record Keeping and Records Management Policy

Consent and Capacity to Consent Policy
Other related documents:

NMC (2007), Standards to support learning and assessment in
practice. NMC standards for mentors, practice teachers and teachers.

Intercollegiate information paper between CSP, RCSLT, BDA and
RCN. Supervision, accountability and delegation of activities to
Support Workers: A guide for registered practitioners and support
workers (January 2006).

Royal College of Nursing (RCN) (2008), Nursing Standard Essential
Guide: Health Care Assistants and Assistant Practitioners Delegation
and Responsibility.
The purpose of these competencies is to clarify the knowledge and skills
expected of practitioners, both nursing and allied health professionals, to
ensure safe practice in measuring physiological observations.
Once the practitioner has reached a satisfactory level of competence following
a period of supervised practice, please ensure formal competency is assessed
within three months of completing the initial theoretical/practical training.
The self–rating scale is to be used by the individual practitioner for selfassessment of present performance during supervised practice, and to help
identify learning needs. Their line manager, or other experienced practitioner,
must then assess these skills and sign to confirm competency.
Only qualified practitioners with an NMC/Allied Health Professional Registering
Body recognised teaching and assessing in practice qualification and/or HCAs
with an NVQ A1/D32/33 assessor’s award and who have completed
recognised training and assessment in obtaining physiological observations
can be identified as assessors.
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Key for Self-Assessment
1 = No knowledge / experience
2 = Some knowledge / experience
3 = Competent
4 = Competent with some experience
5 = Competent, experienced and able to teach others
Authors: Sharon Kirwan (Staff Nurse) Wincanton Community Hospital
Jaime Denham Clinical Skills Facilitator (East)
Date
: December 2015
Review : November 2018
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ASSESSMENT OF COMPETENCE FOR PHYSIOLOGICAL OBSERVATIONS
I confirm that I have self-assessed as competent to practice physiological
observations as below:
Practitioner Name:………………………………………………
Practitioner Qualification:
………………………………………………
Practitioner Signature:............................................
Date: ………………..
I confirm that I have assessed the named practitioner above as competent
to perform the above skill.
Name & Title:
………………………………………………
Signature:………………........................…
Date: ……………….
A record of your competency will be kept on your electronic staff record
Upon successful completion of your assessment of competency please give a
copy to your line manager.
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Knowledge and Skills for
Physiological observations
1
Understand the importance
of informed consent and
demonstrate obtaining
consent prior to examination.
2
Demonstrate appropriate
infection control measures
and hand washing
throughout the procedures
with each patient.
3
Obtain an accurate
respiratory rate. Describe
the normal range for
respirations and when/how
to report concerns.
4
Obtain an accurate manual
radial pulse rate and one
from an electronic
monitoring system (if being
used).
Describe normal range for
pulse rate, regularity and
volume and when/how to
report concerns, including
regular and irregular pulse
rates.
Self-Assessment
Score
Tick
Date & Comments
Formal Assessment
Signature
Date & Comments
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
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Knowledge and Skills for
Physiological Observations
5
6
7
Accurately obtain a
manual blood pressure
using the correct cuff size
selection and appropriate
use of
sphygmomanometer and
stethoscope.
Describe the normal range
for blood pressure and
when/how to report
concerns.
Be able to recognise a
systolic and diastolic blood
pressure.
Understand how to use a
vital signs monitor, select
appropriate sized cuff.
Understand which part of
the screen relates to which
reading.
Self-Assessment
Score
Tick
Formal Assessment
Date & Comments
Signature
Date & Comments
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
8
9
Understand the reason for
NEWS scoring.
Demonstrate how to work
out and record NEWS
scores, knowing when and
how to seek advice.
Understand how to take
1
2
3
4
5
1
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and record a lying and
standing (postural) blood
pressure.
10
11
Demonstrate how to
record readings
accurately, using approved
symbols as directed on the
observation chart and the
frequency of measurement
required.
Describe how to maintain
and clean equipment
between patients and
when not in use.
2
3
4
5
1
2
3
4
5
1
2
3
4
5
12
Have general
understanding of level of
consciousness and be
able to perform the “Alert,
Voice, Pain,
Unresponsive” (AVPU)
assessment correctly.
1
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Knowledge and Skills for
Physiological Observations
Self-Assessment
Score
13
Be able to enter fluid in-put
and out-put correctly on
fluid balance chart and
know when to report
concerns.
1
2
3
4
5
14
Correctly obtain oxygen
saturation levels using
pulse oximetry. Describe
normal and abnormal
oxygen saturation level;
recognise levels on air or
with supplementary
oxygen and when/how to
report concerns.
Obtain accurate
temperature using a
temporal/tympanic
thermometer (delete as
appropriate). Describe
normal and abnormal
temperature levels and
when/how to report
concerns.
1
15
Tick
Formal Assessment
Date & Comments
Signature
Date & Comments
2
3
4
5
1
2
3
4
5
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