I did observations on James, I firstly cleaned my equipment I was going to use then I used the nhs 12 step washing hand technique and put my ppe on to ensure of infection prevention. I then introduced myself to James, comfirmed his details and told him what I was going to do today and why. With his consent I then took his blood pressure, temperature, pulse, respiration and o2 sats. I used the news 2 score to document the readings I gathered. I endured James was comfortable during these different observations. When I finished I thanked James, cleaned my equipment, took my ppe off, washed my hands and documented my findings on the news2 chart. I fount that James was scoring on the news 2 chart as his respirations were high, his oxygen was low, his heart rate was increasing and his blood pressure was to. I then informed the nurse in charge of this.

Harmony

Date:03/03/2026 Time: 12:27

Mr James Thompson reviewed on ward following admission. Patient appears frail, tired, and poorly groomed with soiled clothing and strong smell of urine noted. Awake and able to communicate but mildly confused about date, although oriented to person and place. Denies pain. Skin dry with dry mucous membranes suggesting dehydration. Patient reports poor appetite and low fluid intake recently; encouraged oral fluids and patient took small sips.

Mobility reduced and patient requires assistance when mobilising due to weakness and unsteadiness. Falls risk precautions in place and call bell left within reach. Urine malodorous possible UTI suspected, awaiting urinalysis and blood results. Mood appeared low and patient withdrawn during interaction.

Pressure area assessment completed Waterlow score 20 (high risk). Skin intact but redness noted to sacral area. Pressure-relieving mattress in use and repositioning commenced. Fluid balance chart started, observations completed, and findings reported to nurse in charge. Plan to continue monitoring hydration, mobility, cognition, and skin integrity and follow MDT referrals.

Signature: I.o

HCA

03.03.26 - 12:23

Today I went to see Mr.James Thompson. On admission there were concerns due to functional decline, dehydration. Due to this I completed a waterlow assessment where he scored 19 which is high risk. I have give him a pressure reliving mattress with an ASU pump and REPOSE boots to relieve pressure. I also conferred with the nurse to change set his repositioning to 2 hourly as a pressure sore prevention strategy. Whilst going through admission we noticed a pressure sore on his sacrum which is currently a grade 2. I shared this concern to the nurse who applied a dressing. The doctors were consulted about prescribing a cream for the sore.

After taking his observations his oxygen was at 92 which is low, his blood pressure was elevated, his respiratory rate was 24 which is also elevated and his heart rate was slightly higher than previous at 84. The patient looked in pain so I escalated my concerns to the nurse to provide some pain relief.

James, 80, had his observations done. His breathing was 24, oxygen was 92% on room air, blood pressure 150/90, heart rate 86 and temp 36.9°C. I was a bit worried about his high breathing, low oxygen and high blood pressure.

Observations were done following infection control and trust rules. I wrote everything down and told the nurse in charge. I’ll keep an eye on him and check his observations every 30 minutes, encourage him to sit up and take slow breaths, make sure he’s comfortable and drinking enough, and escalate to the nurse straight away if anything changes. (C.ALMOITE - HCA)