early warning scoring system and observation teaching session
TRANSCRIPT
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 ?