01Principles and purposeThe professional or clinical skill and the decisions it supports.
Clinical observations are procedures, not numbers copied into a chart. Prepare a calibrated thermometer, appropriately sized blood-pressure cuff, pulse oximeter and watch; identify the patient, explain, allow rest where the situation permits and record position, oxygen device and relevant context. Repeat an implausible reading manually or with alternative equipment while treating obvious deterioration immediately.
Measure respiratory rate over a full minute when irregular, noting depth, effort, accessory muscles, audible sounds and ability to speak. Count pulse for rate, rhythm and volume. Measure blood pressure with the arm supported at heart level and a cuff whose bladder fits the arm; a small cuff overestimates. Temperature site and device matter. Assess alertness and new confusion directly.
Pulse oximetry can be wrong with motion, poor perfusion, nail products, sensor misplacement or dyshemoglobinaemia. Check waveform or signal, pulse agreement and the patient. Do not allow a plausible saturation to overrule cyanosis or exhaustion. Record whether on air or oxygen. Escalate both an extreme single parameter and a concerning trend.
NEWS2 standardises acute-illness communication using contemporaneous measurements. NEWS2 Scale 2 requires hypercapnic respiratory failure confirmed by blood gases on the current or a previous admission, plus a competent clinician’s documented decision. COPD alone or an interim 88–92% oxygen target pending gases is insufficient; use Scale 1 otherwise. Follow the local escalation pathway and call earlier for concern; a low aggregate can conceal one dangerous parameter. Reassess after intervention.
Peak-flow equipment comprises a clean compatible meter and mouthpiece, chart or record, and PPE dictated by respiratory-infection risk. Check the device range and marker travel. Explain that this is a maximal blast, not a long slow exhalation. Seat or stand the person safely, loosen restrictive clothing and stop if presyncope, severe cough or marked distress occurs.
For peak flow, set the marker to the lowest value, hold the meter horizontal without blocking the slot, inhale fully, seal lips around the mouthpiece and blow once as hard and fast as possible. Note the value, reset and repeat until three attempts are obtained, allowing rest. Record the highest satisfactory value, not the average. Document poor technique.
Interpret peak flow against the person’s best and action plan where available; population predicted values are less useful for an individual. Variability and response can support asthma assessment but do not diagnose alone. An unexpectedly low value may reflect obstruction, weak effort, leak or the wrong meter. In acute severe symptoms, treatment and escalation take priority over repeated blows.
ECG equipment includes a serviced recorder, ten electrodes, leads, skin-preparation materials, privacy covering and cleaning supplies. Confirm indication, symptoms, time, identity and consent. Position supine or as tolerated, expose only what is necessary and offer a chaperone. Remove electrical interference; clean and dry skin, clip hair if necessary and avoid shaving injuries.
Place limb electrodes symmetrically on limbs, not the torso unless clinically necessary and documented. V1 is fourth intercostal space right sternal edge; V2 fourth left; V4 fifth intercostal space mid-clavicular; V3 midway between V2 and V4; V5 level with V4 at anterior axillary; V6 same horizontal level at mid-axillary. Identify spaces from the sternal angle rather than estimating from breast tissue.
Ask the person to relax and not talk; acquire at standard 25 mm/s and 10 mm/mV unless deliberately changed and labelled. Review trace before disconnecting: identifiers, date/time, calibration mark, twelve leads, baseline stability and unexpected morphology. Limb-lead reversal or high V1/V2 can mimic pathology. Repeat with corrected placement but retain clinically relevant original traces according to policy.
Interpret systematically after checking quality: clinical context, rate, rhythm, P waves, PR, QRS width and axis, R-wave progression, QT and ST–T segments. Compare previous ECGs. Acute ischaemic patterns, broad-complex tachycardia, complete heart block or a symptomatic dangerous rhythm requires immediate senior/emergency response; automated interpretation is an aid, not sign-off.
Safe movement starts with the patient’s current ability, cognition, weight-bearing status, pain, falls risk, lines and orthostatic symptoms. Survey route, brakes, footwear, floor, destination and equipment rating. Explain the plan and roles. Use the correct hoist, slide sheet, transfer aid or extra staff according to local training; never improvise a manual lift beyond competence.
For a bed-to-chair transfer, optimise analgesia, lower and brake the bed, place the chair close with brakes applied, organise lines and allow the person to sit at the edge before standing. Use their strength and prescribed aid. One leader coordinates. Stop for dizziness, knee buckling, distress, equipment shift or loss of line control and return to a safe surface.
After any skill, restore comfort and privacy, clean equipment, perform hand hygiene and document values, position, device, technique limitations, ECG placement variation or assistance used. Escalate abnormalities and name the repeat interval. A completed chart without communicated deterioration is an incomplete procedure.
Key points
- Confirm identity, indication, baseline, equipment function and infection precautions before every measurement.
- Count respiratory rate without prompting when possible; effort, speech and pattern can be more urgent than the number alone.
- NEWS2 uses respiratory rate, oxygen saturation, systolic pressure, pulse, consciousness/new confusion and temperature, with extra points for supplemental oxygen; it supports escalation but does not replace judgement.
- Peak expiratory flow is effort dependent: set the marker to zero, seal lips, blow hard and fast three times and record the highest technically satisfactory result.
- A standard 12-lead ECG requires precise limb and V1–V6 placement, relaxed stillness, correct patient identifiers and stated non-standard placement.
- Verify ECG calibration, artefact and lead reversal before interpreting rate, rhythm, axis, intervals and acute ST–T change.
- Patient movement needs a task-specific assessment of ability, pain, lines, environment, equipment and staff; use local manual-handling training and aids.
- Stop any procedure for collapse, severe breathlessness, chest pain, new neurological deficit, line traction, unsafe load or equipment failure and call for help.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Airway threat, severe work of breathing, shock, reduced consciousness or extreme observation requires ABCDE treatment and early help.
Poor signal, motion, cold peripheries or pulse mismatch makes the displayed saturation unreliable.
Leak, cough, slow exhalation, blocked marker or poor effort invalidates comparison.
Unexpected axis, absent progression or discordant limb leads should prompt electrode and identity recheck before diagnosis.
Acute ST elevation, broad tachycardia, high-grade block or rhythm linked to instability needs immediate escalation.
Dizziness, inability to bear weight, uncontrolled lines or unsuitable equipment requires stopping and revising the plan.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Complete observation set with trend - Why
- Quantify physiology and detect acute change.
- Interpretation and limitations
- Use context, device, oxygen status and prior values; escalate clinical concern despite a low score.
- 02
NEWS2 calculation - Why
- Standardise detection and escalation of acute illness.
- Interpretation and limitations
- Use Scale 2 only after a documented competent-clinician decision for blood-gas-confirmed hypercapnic respiratory failure, current or previously established; otherwise use Scale 1. Single-parameter extremes still require action.
- 03
Best of three peak-flow attempts - Why
- Estimate maximal expiratory flow reproducibly.
- Interpretation and limitations
- Record highest valid effort and compare with personal best; poor technique can falsely lower it.
- 04
Technical ECG quality check - Why
- Prevent artefact and placement error from becoming a false diagnosis.
- Interpretation and limitations
- Confirm calibration, identifiers, all leads and anatomical placement before systematic interpretation.
- 05
Movement risk assessment - Why
- Choose staff, route and aid for a safe transfer.
- Interpretation and limitations
- Current ability and environment determine method; a previous transfer plan may no longer be safe.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked case: breathless before transferDeterioration overrides the planned taskA patient scheduled to walk to a chair is newly breathless, with respiratory rate 30 and oxygen saturation 88% on air.+
- 1Stop the transfer, call for help and assess ABCDE while confirming the oximeter signal, pulse agreement, oxygen prescription and complete observations.
- 2Reason that marked hypoxaemia and tachypnoea require immediate treatment and escalation, not a NEWS2 calculation or peak-flow attempt before action.
- 3Apply authorised emergency measures, obtain senior review and move only if clinically necessary with monitoring, adequate staff and equipment.
- 4Verify response by repeating observations after intervention, documenting oxygen/device and communicating trend and destination handover.
02Peak-flow acquisitionObtain a valid maximal effortPeak flow is requested in a stable person able to cooperate.+
- 1Check meter, infection risk, posture and understanding; demonstrate a hard fast blow.
- 2Obtain three technically valid attempts with rest and record the highest.
- 3Compare with personal best and symptoms, escalate an unexpectedly low or deteriorating result and document technique.
03Standard ECGAcquire before interpretingA diagnostic 12-lead ECG is indicated.+
- 1Confirm identity, symptoms and privacy; prepare skin and anatomical landmarks.
- 2Place ten electrodes accurately, acquire standard calibration and inspect artefact and reversal.
- 3Escalate a dangerous trace, label deviations and document symptom time and clinical action.
04Patient transferPlan, lead and stop safelyA patient needs repositioning or transfer.+
- 1Assess person, load, environment, staff and equipment under the local handling plan.
- 2Brief roles, secure brakes and lines and use the trained aid with one leader.
- 3Stop on instability, restore safety, reassess and document assistance and outcome.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- Repeat observations at the urgency determined by physiology and local escalation policy.
- Recheck after oxygen, analgesia, fluids, bronchodilator or movement.
- Trend peak flow with the same scale and valid technique.
- Ensure urgent ECG findings reach a decision maker immediately.
- Check for pain, dizziness, skin injury or displaced devices after transfer.
- Audit equipment cleaning, calibration and documentation omissions.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Technique creates data
A wrong cuff, electrode or respiratory count can generate confident but unsafe decisions.
Scores support judgement
NEWS2 makes escalation consistent but cannot neutralise obvious clinical concern or a critical parameter.
Peak flow is ballistic
The required manoeuvre is a hard fast blast; a prolonged spirometry-style exhalation answers a different question.
Landmarks beat habit
V1 and V2 placed too high can create misleading anterior and conduction appearances.
Moving is clinical
Transfer changes orthostatic load, pain and line tension and therefore needs reassessment and monitoring.
07Common pitfallsFrequent interpretation and management errors.
- 01
Do not estimate respiratory rate or copy the previous value.
- 02
Do not substitute an 88–92% oxygen prescription or COPD label for the blood-gas confirmation and documented clinical decision required for NEWS2 Scale 2.
- 03
Do not average peak-flow blows or record an invalid highest value.
- 04
Do not place chest electrodes by visual guess over breast tissue.
- 05
Do not accept automated ECG interpretation without trace review.
- 06
Do not remove a clinically important original trace after correcting placement.
- 07
Do not manually lift beyond local training or equipment limits.
- 08
Do not finish without escalation and repeat timing.