Debs Thomas Faculty Educator, deborah.thomas@heartofengland.nhs.uk
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Please note ......
This workshop is not an observations’ training
session.
Please speak to your manager if you feel you
require more training.
Use the ‘further learning opportunities’
suggestions to develop your learning.
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Intended Learning Outcomes
Explain why observations are taken.
Discuss the role of the Healthcare Assistant (HCA)
when taking observations.
Identify how to take a manual blood pressure.
Demonstrate how to perform a manual blood
pressure.
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Observations
Temperature
Pulse
Respirations
Oxygen saturations
Blood pressure
Neurological
Peak flow
Urine output / testing
Blood glucose testing
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Why take observations?
Form a baseline
Monitor improvement or deterioration
Assist diagnosis
Provide information about health
Monitor treatment
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Responsibilities of HCAs
Possess the right skills and knowledge.
Undertake the appropriate training.
Communicate effectively.
Maintain accurate records.
Follow local policies and guidelines.
Maintain and develop skills and knowledge.
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Current observations issues
Move away from automated blood pressure
devices.
Concerns that some healthcare staff are unable
to identify deteriorating observations.
Early Warning Scores (like MEWS) to be
standardised and launched nationally.
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Blood pressure
“Blood pressure can be defined as the force or
pressure that the blood exerts on the walls
of the blood vessels.”
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Blood pressure
Systolic pressure:
The maximum pressure of blood against the wall
of the artery, i.e. when the heart contracts.
Diastolic pressure:
The minimum pressure of blood against the
vessel walls, i.e. when the heart relaxes.
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Blood pressure range
‘Normal’ Adult Bp
100/60 – 140/90mmHg
MEWS Systolic Parameter
101 – 199mmHg
Low Bp
(Hypotension)
Systolic ( < less than)
<100mmHg
High Bp
(Hypertension)
Diastolic ( > more than)
>90mmHg
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Manual blood pressure
Only undertake this task if you have had the
appropriate training.
Make sure the equipment you use has been
serviced by the organisation.
Follow local policies and guidelines.
blood-pressure-print.pdf
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Summary
Make sure you only undertake the observations
you have been trained to do.
Your actions must be underpinned by the
appropriate skills and knowledge.
Report any changes immediately.
Document your findings clearly.
Follow local policies and guidelines.
Keep on learning!
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Further learning opportunities
Heart of England NHS Foundation Trust (HEFT)
intranet site:
Critical Care Outreach page (MEWS information).
Diabetes page (glucose monitoring competency).
Faculty of Education page (go to Nursing & Midwifery,
then resources, then onto ‘i-skills’, (password iskills).
HCDU on the Faculty of Education page (HCA training).
Library resources (textbooks, journals, databases).
Safety and Governance page (Adult Safety Manual).
SBAR page (SBAR quiz and certificate if successful).
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Further learning opportunities
External on-line sites:
HEFT- (password is iskills) www.iskills4heft.co.uk
Medicines and Healthcare products Regulatory Agency
(MHRA) (on-line obs quiz) – www.mhra.gov.uk
NHS Choices – www.nhs.uk/
Nursing and Midwifery Council – www.nmc-uk.org
Nursing Times – www.nursingtimes.net/
Resuscitation Council UK – www.resus.org.uk
Royal College of Nursing – www.rcn.org.uk
Skills for Health – www.skillsforhealth.org.uk
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Adult
Modified Early Warning Score
Score /
Categories
Respirations
O2 Saturations
3
2
1
0
1
2
3
-
Less than 8
(a minute)
-
9 - 16
17 - 20
21 - 29
30 or more
(a minute)
-
-
-
94% or more
90 - 93%
85 - 89%
Less than
85%
Less than 40
(a minute)
41 - 50
51 - 100
101 - 110
111 - 129
130 or more
(a minute)
Less than 70
(mmHg)
71 - 80
81 - 100
101 - 199
-
-
-
-
Less than 35
(°C)
35.1 - 36
36.1 - 37.6
37.7 - 38.2
38.2 or more
-
-
-
New
Confusion /
Agitation
Alert
Voice
Pain
Unresponsive
-
-
-
No concerns
21 – 35 ml
(an hour)
1 – 20 ml
(an hour)
Nil
Heart Rate
Systolic Blood
Pressure
(SBP)
Temperature
N-AVPU
Urine
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SBAR
SBAR Stages
S
B
A
R
Actions
Situation
• Your name
• Your ward/department
• Why you are calling
Background
• Patient diagnosis
• Patient history
• Patient treatment
Assessment
• Your assessment of the patient’s condition in
relation to your concerns
Recommendation
• What actions you want from the call/conversation
• The timescale for action
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References and further reading
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•
•
•
•
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Dougherty, L . Lister, S. (2008) The Royal Marsden Hospital Manual of Clinical Nursing
Procedures. 7th Edition. Oxford; Wiley-Blackwell.
Higgins, Y. et al. (2008) Promoting patient safety using an early warning scoring system.
Nursing Standard: 22: 44, pp 46-48.
Jevon, P. (2007) Blood Pressure Measurement: Part One Taking and Manual Reading.
Nursing Times: 103: 18, pp 26-27.
Mackenzie, M. Spedding, R. Creedon, K. (2010) Pulse Measurement in Adults. Heart of
England NHS Foundation Trust, www.iskills4heft.co.uk.
Lewis, S. (2011) Hospital staff miss danger signs in deteriorating patients. Nursing
Times. (Retrieved 14.04.12) www.nursingtimes.net/nursing-practice/clinicalspecialisms/cardiology/hospital.
Mackenzie, M. Spedding, K. (2010) Respirations Recording. Heart of England NHS
Foundation Trust, www.iskills4heft.co.uk.
Mahoney, P. (2008) Manual Blood Pressure Measurement. (Retrieved 10.03.1 1).
www.cetl.org.uk
Mains, J. et al. (2008) Measuring Temperature. Nursing Standard: 22: 39, pp 44-47.
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References and further reading
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•
•
•
•
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Peters, C. Bateman, J. (2009) How to be a better HCA: Measuring Blood Pressure. British
Journal of Healthcare Assistants (Volume and Issue numbers missing).
Rawlings-Anderson, K. Hunter, J. (2008a) Monitoring pulse rate. Nursing Standard: 22:
31, pp 41-43.
Rawlings-Anderson, K. Hunter, J. (2008b) Respiratory Assessment. Nursing Standard:
22: 41, pp 41-43.
Shuttleworth, A. (Ed) (2004) Monitoring and Assessment. London; Nursing Times and
Emap Publications.
Spedding, R. Creedon, K. Mackenzie, M. (2010) Blood Pressure recording using noninvasive automated sphygmomanometer. Heart of England NHS Foundation Trust ,
www.iskills4heft.co.uk.
Spedding, R. Creedon, K. Mackenzie, M. (2010) Pulse Oximetry Reading (O2
Saturations). Heart of England NHS Foundation Trust, www.iskills4heft.co.uk.
Spedding, R. Creedon, K. Mackenzie, M. (2010) Temperature Recording. Heart of
England NHS Foundation Trust, www.iskills4heft.co.uk.
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