Observations/SBAR Flashcards
What components make up the basic observations/NEWS 2?
respiratory rate O2 saturations (room air or oxygen) pulse blood pressure (systolic) temperature consciousness
frequency of monitoring with NEWS 2 score of 0
minimum 12 hourly
frequency of monitoring with NEWS 2 score of 1-4
minimum 4-6 hourly
frequency of monitoring with NEWS 2 score of 3 in a single parameter
minimum 1 hourly
frequency of monitoring with NEWS 2 score of total 5 or more
minimum 1 hourly
frequency of monitoring with NEWS 2 score of 7 or more
continuous monitoring of vital signs
clinical response for NEWS 2 score of 0
continue NEWS monitoring
clinical response for NEWS 2 score of 1-4
inform RN (must assess patient within 1 hr) RN decides whether increased freq. of monitoring and/or escalation required
clinical response for NEWS 2 score of 3 in a single parameter
RN to inform medical team caring for patient who will review/escalate as necessary
consider sepsis, complete sepsis bundle if appropriate
clinical response for NEWS 2 score of total 5 or more
RN to inform appropriate physician
clinical review within 1 hr or escalate
consider sepsis, complete bundle if appropriate
consider ceiling of care and resuscitation in liaison w/ senior physician
inform critical care outreach team/HOOP
consider transfer to level 1 or 2 care if appropriate
clinical response for NEWS 2 score of total 7 or more
RN to inform medical middle grade Dr or above
immediate review
document escalation plan and ceiling of care
emergency assessment by critical care outreach/HOOP team
escalate to intensive care unit middle grade DR for emergency review
consider transfer to level 2 or 3 care if appropriate
Should NEWS 2 score replace clinical judgement?
no
give two examples in which a patient has no elevated NEWS but would require escalation
cold/clammy
reduced urine output
NEWS stands for?
National Early Warning Score
protocol for handover is called?
SBAR
