Clinical Skills: Observations

Adult Nurse, Claire Carmichael, gives an expansive overview of all things related to observations, and explains the equipment you will be using, recording your findings, and what they could indicate.

Hi, everyone. Welcome back to another clinical skills video. In today's video we're going to be going through vital signs or also known as observations.

What Are Observations Or Vital Signs?

Firstly, what are observations or vital signs? Observations are basically a set of things that you assess on a patient and it all starts from the minute you look at your patient.

As you walk up to your patient, you will notice if they're looking a little bit off, if the colour is draining from the face, if they've got blue tinges to the lips, if they're struggling to breathe.

You will be able to recognize if something's really wrong with your patient just by looking at them. And in other cases, patients will be absolutely normal, up, energetic, feeling absolutely fine, but underneath there is something going on and those sort of things can be picked up through your vital signs and observation monitoring.

What Do I Mean By Observation Monitoring?

Things like blood pressure, so checking your patient's blood pressure. Pulse rate, you will check your patient's pulse rate. Breathing rate, how many times are they breathing per minute?

Oxygen levels in the body. Temperature, usually in the ears now. I don't think they do rectum or under the tongue as far as I'm aware. Some places might still have that.

But usually it's within the ear now or they've got the forehead scanners. How accurate the forehead scanners are, I'm not sure. And their conscious levels and all of these are going to paint a picture of your patient for you.

And research shows that actually observation monitoring, so doing that complete set of observations or vital signs on your patient, can literally be lifesaving.

Because usually the first thing to go is something is going AWOL in the body, which is going to trigger the observation charts.

The National Early Warning Score Chart (NEWS)

And this is why we have something called the NEWS chart or the National Early Warning Score chart 2, which is a very specific chart which I'm going to show you here. You may have seen this out in practice already and you may have already used it.

And this chart will be reviewed over the 24-hour period. So it really depends on your patient, what's going on, what score they've got, how frequently you are doing those observations and documenting.

Because what you're wanting to do is do your observation, say, oh, okay, patient's got a high temperature, for example. We're going to give paracetamol to try and reduce the temperature.

We're going to maybe have a look at if there's an infection going on or something like that, do your extra tests. Then you're going to reassess the temperature and everything, see if that temperature's coming down or if it's increasing.

If it's coming down and something's working, then that's a good sign. So you're constantly monitoring, reviewing, monitoring, reviewing until that patient is okay, and the observations are stable again, in the normal range for them.

What Equipment Is Used For Observations?

So what equipment will you use to do this? I have my trusty box here, which is my favorite box. It is my favorite box. And I highly, highly recommend, especially with, I don't mean to be so negative, but with the state of the NHS and the staff shortages and the wait times, I highly recommend everybody get a box like this.

And within this box is going to be your observations monitoring equipment. So the first two that I'm going to go through is blood pressure. So I have a manual blood pressure machine because I find it easy to use.

It's what I've always used, it's what I trained on and I just love a manual blood pressure. I trust my own ears rather than a machine that could potentially go faulty. Batteries might die.

It's really, really good to get used to having a manual set, especially if you're out in clinic and your machine dies on you. You're going to want to know how to use this. But this is your blood pressure machine.

This is the manual one. So you'll have your sphygmomanometer. I never know how to say that word but that is it. It's your gauge, it's your gauge, it's your pump. It's the blood pressure cuff that goes around the arm for that.

I actually have two stethoscopes. This is the one that came with the pack and I also have a very nice Littmann stethoscope, which is hiding under my spare bed somewhere.

Next up we have a oxygen saturations monitor, O2 monitor, Sats probe. You'll hear all sorts of names for this. But this basically goes on the finger. Don't do that with your machine please with the cover but it goes on your finger. It measures the oxygen within the body. It also comes up with a heart rate.

However, I don't find these a hundred percent reliable for heart rate. And not only that, we should be doing a physical check of the heart rate over 60 seconds because what this doesn't account for is anyone with an abnormal rhythm.

And then breathing rate.

So again, there's no machine for this. There might be in places like ITU, HDU, the high dependency... they might have some fancy equipment that does it. I don't know, I've never worked there, but there may be something out there that I don't know about.

But you should be looking straight at your patient's lungs, which can look a little bit awkward if you are there staring at somebody's chest, might be a little bit awkward. So try and do it in a nice, polite manner.

Something that I have done that helps me do this is I'll do it when I'm doing the pulse rate because I'll just say, "I'm just going to do your pulse rate for two minutes."

I will only check the pulse for one minute and then the second minute I'll be doing the respiratory rate and I'll just be looking at the corner of my eye at the chest area just to see what's going on.

So you're measuring the rise and fall of the chest. Probably better if I do it this way. So you're going to be measuring the rise and fall of the chest. That's one. Two. So one, two.

That over 60 seconds and whatever your total is is what the number is for your respiratory per minute or resps per minute on your chart.

Checking Temperature

Next up we have the thermometer.

This one is a forehead one but it also opens up for the ear. And just as a bonus onto temperature, often we think of infections as being everyone's going to get a high temperature. That's what we always look for. We think high temperature, there must be something going on. Is there an infection?

But what about abnormally low temperature? That is the worrying one, because if you've got a patient that's a really severely low temperature and there's no other cause for it, because sometimes you don't put the thermometer into the ear properly, it's going to be colder than normal, that sort of thing.

There's 101 reasons why they might have a cold temperature. But if something like sepsis is happening and they've got an abnormally low temperature, you want to be reporting this to the doctor as soon as you physically can because this could be a sign that the organs are starting to go AWOL, fail, but get damaged.

It's the core temperature that's been affected, which could be signs of liver and things like that, kidneys, all sorts of things could be going on. So please, please, please always think in the back of your mind, abnormally low temperature is also important as the high temperature.

Conscious Levels

And last but not least, like I said, conscious levels. This list is not in any particular order of importance. You can do your observations in any way you feel you want to.

It doesn't matter which one you do first, as long as they're done and they are accurate. So on the chart you might get an acronym, AVPU or AVCPU, something like that. I'm going to have to check the chart again.

But the first one is alert. So is this person alert? So this is me right now. I'm alert, I'm speaking to you, I'm happy, I'm okay. You put A, alert. Are they ... They're not up and they're not alert, their eyes might be closed, but when you speak to them, they respond.

So they might be a little bit... maybe a bit drowsy from medication, something like that. I don't know. Or are we going to move on to the P, which is pain, do they respond to pain? So that person, like I said, with the voice, they won't respond to voice so they can't hear you.

They've got their eyes closed, they're not responding to anything. The minute you press the finger bed, I've seen people do the ears, I've seen people shake the shoulders. I'm not a hundred percent sure which one is the right way round to do it anymore.

But if your patient is responding to that sort of touch that you're doing, then that would go down as a P. Because they're not responding to your voice, they're not sat up and they're alert, but they are responding to some sort of touch and they're telling you to go away, leave them alone or something.

Next one is confused. Are they confused or are they more confused than normal is a very good point to make. Because sometimes you have patients, people who may have came in confused.

Some patients may be mental health patients, they could have learning disabilities, they could have dementia for example. They could have some sort of neurological thing going on where they're just confused.

So their normal for them is a bit confused.

Are they more confused and agitated than normal? More normal for them? And this is where the family and the friends and things like that come into play because they will know what's normal for that person and they can say, "Actually, this is a lot worse than normal."

So then you'd be thinking, okay, what's going on? Or is the person U, unresponsive? They're not responding, they're not replying, you are going to be thinking, oh my god, A to E assessment, CPR right now type of patient. But they might just be breathing, they just can't respond.

They're not responding to anything. They're not talking to you, they're not opening their eyes. They're just as if they're almost asleep but they're not responsive.

Something again is possibly going on... I have seen this before actually when I had a patient who had a hypoglycemic attack, where the sugar levels in the body are abnormally low and they were unresponsive because of that.

And the minute we started giving them some sugar, they came round and they were perfect. So I know I went straight into CPR panic mode, which I probably shouldn't have done, but there are other things. There are many, many things why a patient is unresponsive to you.

So this is your NEWS chart, like I said. I'm going to talk you through how to complete your news chart using this chart. However, I have to say, in many hospital trusts now it's all done online. A lot of people have some form of digital device that they input the observations on and it comes up with the score automatically.

You don't have to do anything. However, what happens if that fails and you need to do a paper chart? You need to know how to complete it, how to do it accurately and how to tally up your scores as well. And this is good for people that are still on paper charts.

Completing A Paper Chart

So here we go. So obviously you're going to have the patient name at the top, date of birth, admission, any details at the top that you want to put. So in this top section here, you're going to put the dates. So today's date. Then the time that you're doing the observations.

And at the top of this chart we have got respirations. So how many breaths per minute? Like I said, rise and fall of the chest over 60 seconds from start to finish.

Get your watch, get your fob watch, look at the clock, get the patient's watch. If you haven't got a watch, get your mentor's. You need to time that 60 seconds. And it's the same with the pulse.

Don't skip corners guys. And as you can see, within the chart you've got these different colours. So red is three. That is warning. Three for warning. If it's red, it's not good.

Two is amber, orange-y colour. Two is still a warning. It's still not good but it's not as bad as a three. White is normal range. This is normal. We're happy in the white zone, everything's okay hopefully. And then this yellow one.

The yellow one's like, hmm, something's going on. I'm not sure what. We're going to give it a one. And don't get me wrong, I don't fully agree with the scores of this.

Because I've seen someone very drastically drop from a respiratory rate of 18 to a 12 to nine. And if I was just to go by just her respiratory rate, she would only be scoring a one.

So I would've had to have gone, leave her, come back. But the fact that hers had dropped so drastically within an hour, that's when you know something is going on.

This patient is in respiratory depression, we need to get something right now this second, not doing our observations and waiting to see if it drops even further. So this is the example of these observation charts is they only go so far. You need to use your clinical judgment, looking at the patient, physically examining your patient, looking for signs of distress and that sort of thing.

Because this isn't accurate. Another example with this, I had a patient who was projectile vomiting and when I say ... I'm talking, I've never seen anyone vomit like this person vomited.

He was in agony and he kept clutching his stomach. He was in agony, he was vomiting. I was like, okay, there's a break where he stopped vomiting for a minute and had some water and I was like, let's get some observations quick before he starts vomiting again.

Did all the observations, he was scoring a zero. There was nothing on the observation charts. But he clearly was really unwell. He looked unwell. So I had to take that further.

Using Your Clinical Judgment

So always use your clinical judgment. This chart only goes so far. As you can see, respiratory rate anywhere between 12 and 20 is a good range. It's normal. Then we've got oxygen.

So this is where they brought in a new scale for patients, such patients like people with COPD. Because people with COPD have abnormal oxygen levels, their respiratory rate may be different.

So this is why they've put in an extra section in this NEWS2 chart to account for is this patient COPD? Are they on oxygen? Because there may be patients on oxygen that things may be affected.

So this is why they've added the oxygen element and for patients that might have COPD might use this as well. But as you can see, 96 and above is great. We want that.

However, if it's 96 and above but they're having to have oxygen to maintain it, so the minute you take that oxygen off, it drops and they need the oxygen to keep it at that level. That's why it's scoring a three because that person isn't breathing as normally on their own.

They need a device to breathe. And that's why it scored so high in this second column here. Or are they between 88 and 93? So as you can see, that white column here, 88 to 93, that's quite low oxygen levels.

However, that's normal if someone has got something like COPD. So this is why this second box is important because if that was someone up here on the top one in the normal scale, someone that doesn't have a condition, they aren't on oxygen.

If they were sitting at 88, look, they would be scoring a three. But they've got COPD, they know that there's things going on, so that's why it's normal in this box. I hope that makes sense. And then again, this one, air or oxygen. Like I was saying, are they on oxygen?

They're going to score more for oxygen because it's more risky. Or are they on air? They're on air, they can breathe normally, their oxygen levels are good. We haven't got a problem with the lungs and circulation in that sort of sense. And then we've got blood pressure.

Blood Pressure

So what is their blood pressure? So as you can see, again, I don't fully agree with this because it goes up to 219. If someone's got a blood pressure of 219 and they came to my clinic, I would be panicking.

That's quite high. But it accounts for things like if someone's just been through some sort of major surgery or something like that, their blood pressure may be potentially quite high because of that.

So I think it factors for that. However, like I was saying previously, if you've got a patient, you know their blood pressure is here, 120, 115, 120, and then suddenly you've measured it, let's just say two hours later, and it's up at 219. You're thinking, oh, why has their blood pressure suddenly jumped from that to that in such a short space of time.

That's when you would be reporting it and saying, "Something's not right here, something's going on," and investigate more. And the same if it's low. If it's low, that is not good. It's just as bad to have a low blood pressure than it is a high pressure.

Because if something's dropped, they've got no circulatory volume, you're going to be starting to think, okay, what could this be? Are they going into hypervolemic shock? Have they got blood loss somewhere and that's why the blood pressure's low?

There's going to be so many things that you are going to be thinking about blood pressure and that's why it scores high. But it also scores high if it's really high because that pressure of the blood going through the arteries and the veins and the body, if that's high, you're at risk of heart attack, strokes, all that sort of thing. So either end, not good, stick to the white section, but use your clinical responsibilities and observations.

Then we've got pulse. Again, same. It's in the circulation, it is in the pulse rate, blood pressure type of section. So again, anywhere between 51 and 90 is normal. Again, use your clinical judgment.

If they've got a really high pulse rate, it's going like this, really, really fast and you are thinking, "Oh my god, why is it going so fast? Why is your heart beating that fast?" Report it. You need to be looking into that and what's happening. And the same if it's really low.

We don't want it to be dropping, we don't want that heart to be stopping. We need to do something about that. So equally dangerous. Next, consciousness, like I was saying, ac-vuh-poo, ACVPU.

So again, if they're alert, normal. If it's confused more than normal, voice, pain, unresponsive, straight three. They're not messing about with this conscious level. Straight three.

Temperature

So like I was saying about temperature, again, it's really bad to be low, really bad to be high. Stick in the middle, stick in the safe zone. Anywhere 36.1 all the way up to 38 max. I would say 38 is high but on this chart it says it's normal. But to me 38 is a temperature.

I had a temperature when I had COVID and my temperature was 38.4 I think at one point. So 38.4 is just a one on here. That made me feel physically sick. I was in bed, I couldn't move.

It was horrific having a temperature that high. So I personally, I don't think 38 ... I think the numbers should be ... But anyway, there's a lot of research, a lot of evidence, a lot of statistics that's gone into this chart to make it the way it is and that's why there's all these ranges.

But think with your head and clinical judgment, like I said. So once you've plotted all of your findings on this chart, you're going to total it up. So you're going to be totaling, let's just say you've got respiratory is normal, yep. Air, normal. Oxygen, normal. All that's normal.

But your blood pressure's 220. So you've got a score of three so far. Then your pulse rate is 131, you've got another three, that's six. Then you've got conscious, oh my god, they are unconscious.

That's another three. They're scoring nine now and then they've got a temperature. Their temperature is 35. Oh my gosh, that is a 12. What am I going to do with this patient?

Calculating The Total NEWS Score And Next Steps

So the NEWS total at the bottom here is a 12. So you put 12 in, and then once you've put your score, your 12 in the bottom, you're going to look, usually there's another side to your observations.

If you're on the digital, it might flag up what to do next but you will be ... At a score of 12, I mean, I would be thinking critical care team. Consultants, doctors, your nurse in charge, anyone you can needs to come and see this patient because they are in a critical... to me, they are critical.

And like I was saying about the chart, it's going to tell you what to do next. This is your chart here, right here. So zero to four, low. There's no risk. You're okay. Three, between three and four, urgent ward based response.

So that means it can be managed within the ward. Then we've got score of between five and six, which is a medium. So it's the key threshold for an urgent response pending what's happening with the patient is what type of response you will have.

And seven or more, like I said, that patient was just a 12 that I just scored. We'd calling the critical care team, get someone in here right now, this patient needs you. And the more you do observations, the more you are assessing patients, the more you're documenting, the easier it becomes to recognize things and pick up on things and think, oh, actually I know what's happening here.

But the best thing you can do is always get help. If you are struggling to understand something, if you think something's not quite right or don't know what it is, trust that gut because we have real gut instincts out there.

We know when something's wrong sometimes. So please report it, get that patient help and get the support you need.

So I hope that's helped in some way. I hope I haven't blown your mind too much. I've tried to put it as simple as possible to help everybody understand but I hope that's helped in some way and helped you think about your observations and the way you document it and things like that.

Thank you everyone. And don't forget to look at the nurses.co.uk website for further videos. Have a great day.