UK Nursing Observations: NEWS2, Neurological and Neurovascular Checks

On placement, “Can you do the obs?” can mean several different things. It may mean a routine set of physiological observations for NEWS2, neurological observations after a head injury, or neurovascular observations on an injured or operated limb.

They overlap, but they are not interchangeable. The important first step is knowing what you are assessing, why you are assessing it and what change would need escalation.

1. Routine physiological observations and NEWS2

In UK adult acute care, the National Early Warning Score 2 (NEWS2) is widely used to standardise assessment of acute illness severity and support recognition of deterioration. It does not replace clinical judgement.

A NEWS2 assessment uses six physiological parameters:

• respiratory rate
• oxygen saturation
• systolic blood pressure
• pulse rate
• level of consciousness or new confusion
• temperature.

You also record whether the patient is receiving supplemental oxygen.

Each physiological parameter is allocated a score according to the NEWS2 chart. The scores are added together, but a single markedly abnormal parameter can also be clinically important even when the total score is not high.

Consciousness: ACVPU

NEWS2 uses ACVPU:

• A — Alert
• C — New confusion
• V — Responds to voice
• P — Responds to pain
• U — Unresponsive.

New confusion is significant. Do not dismiss an acutely confused patient simply because the other observations look acceptable.

Oxygen saturation targets

For most acutely ill adults, the usual target oxygen saturation is 94–98%. A target of 88–92% is commonly used for patients at risk of hypercapnic respiratory failure, when clinically appropriate. This is not simply a target for every patient with COPD. Follow the prescribed target range and local oxygen policy.

What should you actually notice?

NEWS2 is more useful when you think in trends rather than isolated numbers. For example, a respiratory rate that has risen from 16 to 24 breaths per minute, a new oxygen requirement, falling blood pressure, new confusion or a progressive increase in NEWS2 may indicate deterioration.

Escalate according to the NEWS2 response thresholds and your local policy, but also escalate clinical concern even when the numerical score seems reassuring. The Royal College of Physicians specifically recognises that clinical concern should prompt escalation.

2. Neurological observations

Neurological observations are used when there is concern about neurological function, for example following head injury, neurosurgery or a change in consciousness. The exact observations and frequency depend on the clinical situation and local policy.

For head injury, NICE recommends recording a minimum neurological observation set that includes:

• Glasgow Coma Scale (GCS)
• pupil size and reactivity
• limb movements
• respiratory rate
• heart rate
• blood pressure
• temperature
• oxygen saturation.

Glasgow Coma Scale: what the numbers mean

The GCS is made up of three separate components. Record the components as well as the total because the same total score can arise from different clinical findings.

• Eyes (E), maximum 4: spontaneous, to sound, to pressure, none.
• Verbal (V), maximum 5: oriented, confused, words, sounds, none.
• Motor (M), maximum 6: obeys commands, localises, normal flexion, abnormal flexion, extension, none.

A fully alert patient may therefore be documented as E4 V5 M6 = GCS 15. The important question is not only “What is the GCS?” but also “Has it changed from the previous assessment?”

Pupils

Assess and document pupil size and reaction to light in accordance with local practice. Look for a new difference between the pupils or a change in reactivity. A new neurological change should be interpreted alongside the rest of the assessment and escalated appropriately.

Limb movement

Compare both sides. A new reduction in movement, weakness or asymmetry can be clinically significant. The assessment required will depend on the patient's condition, so use the prescribed neurological observation chart and seek supervision if you are unfamiliar with the examination.

When should neurological deterioration be escalated?

For patients being observed after head injury, NICE identifies deterioration requiring urgent reassessment, including agitation or abnormal behaviour, a sustained one-point fall in GCS, a greater fall in the eye or motor components, severe or increasing headache, persistent vomiting, or new or evolving neurological signs such as pupil inequality or limb/facial asymmetry.

This is more precise than relying on a rule that the GCS must fall by two points before acting. A smaller change can still matter.

Raised intracranial pressure

Hypertension with widening pulse pressure, bradycardia and abnormal respirations are classically described as Cushing's response and may occur with significantly raised intracranial pressure. This is a late and concerning pattern. Do not wait for the complete triad before escalating a deteriorating neurological patient.

3. Neurovascular observations

Neurovascular observations assess circulation and nerve function distal to an injury, cast, splint or surgical site. They are common in orthopaedic and trauma care.

The assessment usually considers:

• pain — including increasing pain or pain that appears disproportionate to the injury
• colour — compare with the unaffected limb
• temperature — is the distal limb unusually cool?
• capillary refill — assess distal perfusion in context
• pulses — assess the appropriate distal pulse where indicated
• sensation — ask about altered sensation, numbness or tingling
• movement — compare active movement with the unaffected side where appropriate.

The most useful comparison is often the patient's previous assessment and the opposite limb. Document what you actually find rather than simply writing “neurovascularly intact” without performing the assessment.

Compartment syndrome: the red flag

Acute compartment syndrome is a surgical emergency. Severe and escalating pain, particularly pain that appears disproportionate to the injury and pain on passive stretch, are important early warning features. Paraesthesia or sensory change may develop. Pallor, paralysis and absent pulses are concerning but can be late findings, so do not wait for a pulse to disappear before escalating suspected compartment syndrome.

4. Fluid balance and urine output

Fluid balance is another important part of clinical observation. Record intake and output accurately when a fluid balance chart is indicated.

Intake may include oral fluids, enteral feed and intravenous fluids. Output may include urine, vomit, liquid stool and measurable drain or other losses, according to local documentation.

Urine output should be interpreted in relation to body weight, time and clinical context. NICE identifies oliguria as urine output below 0.5 mL/kg/hour and includes sustained oliguria within the criteria used to detect acute kidney injury. A fixed “30 mL per hour” rule is therefore not appropriate for every adult.

If urine output is falling or unexpectedly low, check that the measurement is accurate and escalate according to the patient's condition and local policy. Do not simply wait for the next fluid-balance total if the patient appears unwell.

5. A placement example

You take routine observations from an adult patient. Their NEWS2 is not dramatically different from the previous set, but they are newly confused and their respiratory rate has increased.

The wrong approach is to think, “The score isn't very high, so I'll repeat it later.”

The safer approach is to recognise that new confusion and a changing respiratory rate are clinical changes, repeat or verify observations as appropriate, inform the registered nurse and follow the local escalation pathway.

Now imagine a different patient returning from orthopaedic surgery. Their NEWS2 is stable, but they report rapidly worsening pain in the operated limb with altered sensation.

That requires a neurovascular assessment and urgent escalation. A reassuring NEWS2 does not exclude a limb-threatening problem.

6. What should a student nurse escalate?

Escalate promptly to the registered nurse or appropriate clinician when observations are outside expected parameters, when a NEWS2 escalation threshold is reached, when neurological or neurovascular findings deteriorate, or whenever you are concerned about the patient.

Particular red flags include:

• new confusion or reduced consciousness
• a deteriorating GCS or new focal neurological signs
• new pupil inequality or abnormal pupil response
• increasing oxygen requirement or worsening respiratory observations
• severe escalating limb pain, especially pain on passive stretch
• new sensory or motor deficit in a limb
• unexpectedly low or falling urine output
• a rapidly rising NEWS2
• any sudden clinical deterioration.

As a student, you are not expected to diagnose the cause of deterioration independently. You are expected to recognise abnormal findings, communicate them clearly, work within your competence and seek help when needed, in line with the NMC Code.

The key thing to remember

“Obs” are not just numbers to enter on a chart. They are repeated assessments designed to show you whether the patient is changing.

Ask yourself three questions:

1. Which observations does this patient need?
2. What has changed since the last assessment?
3. Does anything here need escalation now?

That is the difference between completing an observation chart and actually using observations to recognise deterioration.

References

• National Institute for Health and Care Excellence (NICE) (2023) Head injury: assessment and early management (NG232). Available at: NICE NG232.
• National Institute for Health and Care Excellence (NICE) (2019) Acute kidney injury: prevention, detection and management (NG148). Available at: NICE NG148.
• Nursing and Midwifery Council (NMC) (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Available at: NMC Code.
• O'Driscoll, B.R., Howard, L.S., Earis, J. and Mak, V. (2017) 'BTS guideline for oxygen use in adults in healthcare and emergency settings', Thorax, 72(Suppl 1), pp. ii1–ii90.
• Royal College of Physicians (2017) National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. London: RCP. Available at: Royal College of Physicians NEWS2.