S R A B S B Fluid BalancecContinuation Sheet Fluid …

1 TimeIntakeOutput08:0009:0010:0011:0012:0 013:0014:0015:0016:0017:0018:0019:0020:0 021:0022:0023:0024:0001:0002:0003:0004:0 005:0006:0007:00 TotalsIf urine output falls below the expected hourly amount for 2 consecutive hours,call SHO and Outreach (Bleep 665) Hr Total Intake =mls24 Hr Fluid Balance =mlsTotal Output = .RunningTotalUrineVomit/AspirateRunningT otalCritical Care OutreachPhysiologicalParameters3210123 Respiration Rate<89-1112-2021-24>25 Oxygen Saturations<9192-9394-95>96 Any supplementaloxygenYesNoTemperature< > BP<9091-100 101-110 111-219>220 Pulse<4041-5051-9091-110111-130>131 ConsciousnessAVPU = Alert, Voice, Pain, UnresponsiveAV, P or UDate:..Name:..Hospital No:..Expected Hourly Urine Output = Fluid Balance Continuation SheetFluid Balance Continuation ml/hr ( )TimeIntakeOutput08:0009:0010:0011:0012: 0013:0014:0015:0016:0017:0018:0019:0020: 0021:0022:0023:0024:0001:0002:0003:0004: 0005:0006:0007:00 TotalsIf urine output falls below the expected hourly amount for 2 consecutive hours,call SHO and Outreach (Bleep 665) Hr Total Intake =mls24 Hr Fluid Balance =mlsTotal Output =.

2 RunningTotalUrineVomit/AspirateRunningTo talDate:..Name:..Hospital No:..Expected Hourly Urine Output =.. ml/hr ( )AdultObservationChartNEWS Key0123 TimeIntakeOutput08:0009:0010:0011:0012:0 013:0014:0015:0016:0017:0018:0019:0020:0 021:0022:0023:0024:0001:0002:0003:0004:0 005:0006:0007:00 TotalsIf urine output falls below the expected hourly amount for 2 consecutive hours,call SHO and Outreach (Bleep 665) Hr Total Intake =mls24 Hr Fluid Balance =mlsTotal Output = .RunningTotalUrineVomit/AspirateRunningT otalCritical Care OutreachPhysiologicalParameters3210123 Respiration Rate<89-1112-2021-24>25 Oxygen Saturations<9192-9394-95>96 Any supplementaloxygenYesNoTemperature< > BP<9091-100 101-110 111-219>220 Pulse<4041-5051-9091-110111-130>131 ConsciousnessAVPU = Alert, Voice, Pain, UnresponsiveAV, P or UDate.

3 Name:..Hospital No:..Expected Hourly Urine Output = Fluid Balance Continuation SheetFluid Balance Continuation ml/hr ( )TimeIntakeOutput08:0009:0010:0011:0012: 0013:0014:0015:0016:0017:0018:0019:0020: 0021:0022:0023:0024:0001:0002:0003:0004: 0005:0006:0007:00 TotalsIf urine output falls below the expected hourly amount for 2 consecutive hours,call SHO and Outreach (Bleep 665) Hr Total Intake =mls24 Hr Fluid Balance =mlsTotal Output = .RunningTotalUrineVomit/AspirateRunningT otalDate:..Name:..Hospital No:..Expected Hourly Urine Output =.. ml/hr ( )AdultObservationChartNEWS Key0123 Fluid Balance Continuation SheetFluid Balance SheetClinical Response to National Early Warning Score (NEWS) TriggersNEWS ScoreFrequency of MonitoringClinical Response0 Minimum 6 12 hourly, follow the standards for undertaking clinical observation policy Continue routine National Early Warning Score (NEWS) monitoring with every set of observationsLOWT otal: 1 4 Minimum 4 6 hourly follow the standards for undertaking clinical observation policy Inform registered nurse who must assess the patient Registered nurse to decide if increased frequency of monitoring and/or escalation to doctors, or outreach nurse is appropriate.

4 Re-check and document observations within 5 15 minutesMEDIUMT otal: 5 6 or3-in-one ParameterIncreased frequency tominimum 1 hourly Registered nurse to re-check and document observations within 5 15 minutes, consider starting a Fluid balance chart Registered nurse to immediately inform the surgical team caring for the patient using the SBAR tool, the nurse in charge and the outreach nurse on bleep 665 Urgent assessment by the patients team within 30 minutes Consider clinical care in an environment with monitoring facilities Alan Bray UnitHIGHT otal: 7 or moreContinuous monitoringof vital signs Registered nurse to urgently inform the surgical team looking after the patient, this should be at least a registrar Do a 12 lead ECG and start a strict Fluid balance chart Emergency assessment by the outreach nurse bleep 665 Consider transfer to Alan bray unit for HDU/ITU care Consultant to be informed within 1 hour of NEWS scoring 7 or more, surgical team to inform If in any doubt, or delay in medical response, place a Medical Emergency Call via 2222 ITU registrar Bleep 662 Outreach nurse Bleep 665 Patient labelName.

5 Date of Birth: ..Hospital no: ..NHS no: ..Consultant: ..Ward: .. Weight: ..NEWSB owels OpenMonitoring frequency>25 TimeDateRespAdmissionRate/minDocumentRat e21-2412-209-11<8>96O2 SatsAdmissionDocument %Inspired O2 Mode of delivery94-9592-93<91litresper minuteNC/FMTemp oCDocumenttemp>25 TimeDateRespRate/minDocumentRate21-2412- 209-11<8>96O2 SatsDocument %Inspired O2 Mode of delivery94-9592-93<91litresper minuteNC/FMTemp oCDocumenttemp>39383736<35 BloodPr essur emmHgBloodPr essur emmHg23023022022021021020020019019018018017017016016015015014014013013012012011011010010090908080707060605050>39383736<35 NEWS usessystolic BPAdmissionNEWS usessystolic BPPulse rate/minAdmissionPulse rate/minConsciousConsciousAlertAlertV/P/ UV/P/URestRestMovem tMovem tY/N N/AY/NY/N N/AY/N N/AY/N N/AlevellevelPain ScalePain

6 Scale0 - 100 - 10 Escalation planEscalation planAction recordedAction recordedBlood Glucose levelWeight kgPrint initialsNC= nasal cannula FM = face maskPrint initials13013014014012012011011010010090 90808070706060505040403030 SBAR Hand over Communication ToolThis format should be used to handover a deteriorating SituationS- BackgroundB- AssessmentA- RecommendationsRVerify any critical information received, review the history, seekclarification, ask questions and read back critical test resultsIdentify yourself and position, patients nameand the current situation. Describe what isgoing on with the the relevant history and physicalassessment relevant to the problem,tr eatment/clinical course summary and anypertinent fer your conclusion about the what you think needs to be done,what the patient needs and Key0123 SBAR Handover Communication ToolThis format should be used to handover a deteriorating SituationIdentify yourself and your position, patient s name and the current situation.

7 Describe what is going on with the BackgroundState the relevant history and physical assessment relevant to the problem, treatment/clinical course summary and any pertinent AssessmentOffer your conclusion about the present RecommendationsExplain what you think needs to be done, what the patient needs and any critical information received, review the history, seek clarification, ask questions and read back critical test resultsSpinal Cord injured patients with an injury at level T6 and above are at risk of Autonomic Dysreflexia. Any rise in blood pressure that is 15-20mmhg above the baseline with associated headache, rash or other symptoms may be a sign of Autonomic Dysreflexia. THIS IS A MEDICAL EMERGENCY THEY MAY NOT SCORE ON NEWS.

8 Find the cause of the autonomic dysreflexia bladder, bowel, pain if not found within 10 mins call for urgent >25>25 RespRate/min21-2421-24 Rate/minAdmission ___12-2012-20 Document9-119-11 DocumentRate<8<8 RateO2 SatsAdmission ___Document %>96>96O2 SatsDocument %94-9594-9592-9392-93<91<91 Inspired O2litresper minutelitresper minuteInspired O2 Mode of deliveryNC/FMNC/FMMode of deliveryTemp CAdmission ___Document temp>39383736<35>39383736<35 Temp CDocument tempNEWS usessystolic BPBlood PressuremmHgAdmission ___2302202102001901801701601501401301201 1010090807060502302202102001901801701601 501401301201101009080706050 NEWS usessystolic BPBlood PressuremmHgPulse rate/minAdmission ___1401301201101009080706050403014013012 011010090807060504030 Pulse

9 Rate/minConsciouslevelAlertAlertConsciou slevelV/P/UV/P/UNEWSPain Scale0 - 10 RestRestPain ScaleMovem tMovem t0 - 10 Bowels OpenY/NBowels Open Y/NEscalation planY/NY/NEscalation planAction recordedY/N N/AY/N N/AAction recordedBlood glucose if V/P/UBlood glucose if V/P/UPrint initialsPrint initialsNC= nasal cannula FM = face maskDateTimeScoreActionSignedNEWSB owels OpenMonitoring frequency>25 TimeDateRespAdmissionRate/minDocumentRat e21-2412-209-11<8>96O2 SatsAdmissionDocument %Inspired O2 Mode of delivery94-9592-93<91litresper minuteNC/FMTemp oCDocumenttemp>25 TimeDateRespRate/minDocumentRate21-2412- 209-11<8>96O2 SatsDocument %Inspired O2 Mode of delivery94-9592-93<91litresper minuteNC/FMTemp oCDocumenttemp>39383736<35 BloodPr essur emmHgBloodPr essur emmHg23023022022021021020020019019018018017017016016015015014014013013012012011011010010090908080707060605050>39383736<35 NEWS usessystolic BPAdmissionNEWS usessystolic BPPulse rate/minAdmissionPulse rate/minConsciousConsciousAlertAlertV/P/ UV/P/URestRestMovem tMovem tY/N N/AY/NY/N N/AY/N N/AY/N N/AlevellevelPain ScalePain Scale0 - 100 - 10 Escalation planEscalation planAction recordedAction recordedBlood Glucose levelWeight kgPrint initialsNC= nasal cannula FM = face maskPrint initials13013014014012012011011010010090 90808070706060505040403030 SBAR Hand over Communication ToolThis format should be used to handover a deteriorating SituationS- BackgroundB.

10 AssessmentA- RecommendationsRVerify any critical information received, review the history, seekclarification, ask questions and read back critical test resultsIdentify yourself and position, patients nameand the current situation. Describe what isgoing on with the the relevant history and physicalassessment relevant to the problem,tr eatment/clinical course summary and anypertinent fer your conclusion about the what you think needs to be done,what the patient needs and Key0123