Clinical assessment, NEWS2, risk tools, care planning
ACVPU: The addition of
Respiratory rate: 12–20/min · SpO2: ≥95% · BP: 90–140 systolic · Heart rate: 60–100/min · Temperature: 36.1–37.2°C · Consciousness: Alert (ACVPU)
Alert=0 · new Confusion=3 · Voice=3 · Pain=3 · Unresponsive=3. A score of 3 on any single parameter triggers urgent clinical review regardless of total.
0–4: ward monitoring · 5–6 or any single 3: urgent review by competent clinician · ≥7: emergency response, consider HDU/ICU
BMI <18.5=2pts, 18.5–20=1pt, >20=0 · Weight loss >10% in 3–6m=2pts, 5–10%=1pt · Acute illness=2pts. Score 0=low, 1=medium, ≥2=high risk.
≤9: not at risk · 10–14: at risk · 15–19: high risk · ≥20: very high risk. Includes build/weight, skin type, sex/age, special risks.
NRS 0–10 (adults, self-report) · FLACC 0–10 (children under 5 or non-verbal: Face, Legs, Activity, Cry, Consolability) · Abbey Scale (non-verbal adults, dementia)
Physical (clinical symptoms, observations) · Psychological (mental health, coping) · Social (housing, relationships, support) · Spiritual/cultural (beliefs, values)
NICE recommends multifactorial assessment including: gait, balance, medication review, vision, cognitive impairment, environment. Bed rails are NOT recommended as a routine prevention measure.