What is Clinical Observation and its Importance in Healthcare Find Out

Clinical observation has been part of healthcare for thousands of years, but it looked very different in ancient times compared to today. Clinical observations are routine monitoring and recording of a patient’s vital signs to assess their current health status.

If you’ve ever been to a hospital, you’ll notice that nurses and doctors often check vital signs like your temperature, heart rate, blood pressure, and breathing rate.

These observations are necessary for finding early signs of health decline or improvement in a patient’s condition and serve as the basis for patient care.

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A good physician should be a good observer and always pay attention to the subtle signals the body gives - Thomas Sydenham

What Is Clinical Observation?

Clinical observation means checking and recording a patientā€™s basic health signs regularly.

These signs help doctors and nurses understand how a patient is doing. The main signs checked are:

  • Oxygen saturation: The amount of oxygen in the blood.
  • Temperature: The bodyā€™s internal heat.
  • Pulse rate (heart rate): The number of heartbeats per minute.
  • Blood pressure: The pressure of blood against artery walls.
  • Respiratory rate: The number of breaths taken per minute.
Early physicians observed patients' symptoms, such as fever, pain, or breathing problems, to diagnose illnesses.

Healthcare Staff use standardised equipment and techniques to ensure reliable measurements of these fundamental vital signs.

Clinical observation is more than just writing down numbers – it means understanding what the numbers mean, looking for changes in how the patient is doing, and making good choices about how to help them get better.

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The Importance of Clinical Observations

Clinical observations are essential to patient care and act as the first line of defence in spotting potential health problems. Their importance can be seen in several key areas:

1. Finding Health Problems Early

Regularly monitoring vital signs helps healthcare staff notice small changes in a patient’s condition before they become serious.

Finding this problems early can lead to quick treatment, potentially avoiding complications.

For example, if someone’s temperature goes up a little, it might mean they’re getting sick, and the doctors can treat them right away.

2. Saving Lives

When nurses and doctors do regular clinical observations, fewer people die in hospitals. By finding problems early, they can give medicine or treatment before things get too serious.

Research shows that effective clinical observations can identify up to 60% of possible problems before they happen.

3. Keeping People Out of Emergency Care

Identifying problems early through clinical observations can cut down ICU admissions by up to 30%. This not only improves patient outcomes but also helps healthcare facilities manage resources more efficiently, easing pressure on intensive care units.

4. Making Patients Safer

By closely monitoring patients, healthcare staff can identify risks early and prevent them from turning into serious issues, improving overall patient safety. This approach reduces serious health problems and improves the quality of care.

5. Making Better Decisions for Patients

Clinical observations provide key data that guide further testing and treatment. They offer early clues about a patientā€™s condition, helping healthcare workers make informed decisions about the best course of care. For example, a sudden drop in blood pressure may prompt further checks for possible heart problems.

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The whole art of medicine is in observationā€¦ but to educate the eye to see, the ear to hear and the finger to feel takes time, and to make a beginning, to start a man on the right path, is all that you can do. - William Osler

Clinical Observation in History

Key Moments

  • Hippocrates (400 BCE): Known as the “father of medicine,” he taught that observing patients is vital for diagnosing illness.
  • William Harvey (1628): Discovered how blood circulates in the body, linking pulse to heart health.
  • Florence Nightingale (1850s): Made clinical observation a regular part of nursing care.

Ancient Times (3,000 BCEā€“500 CE)

In ancient Egypt, Greece, China, and India, early healers looked at symptoms like fever, pain, or trouble breathing to figure out what was wrong. For example:

  • The Egyptians (around 1600 BCE) wrote medical books on how to check a person’s pulse, wounds, and skin colour.
  • Hippocrates (Greece, around 400 BCE) taught doctors to closely watch patients and write down their symptoms.

Middle Ages (500ā€“1500 CE)

  • Islamic Golden Age: Doctors like Al-Razi (around 900 CE) stressed the importance of tracking symptoms over time.
  • Europe: Monks and healers used simple checks like body temperature or pulse but didnā€™t have the modern tools we use today.

1700sā€“1800s: The Birth of Modern Clinical Observation

  • Stethoscope (1816): Invented by RenĆ© Laennec, this tool allowed doctors to listen to heart and lung sounds.
  • Thermometer (1860s): Became commonly used to measure body temperature.
  • Florence Nightingale (1850s): During the Crimean War, she showed that keeping track of things like cleanliness, diet, and vital signs helped save lives.

1900sā€“Today

  • Vital Signs: By the early 1900s, hospitals made checking pulse, temperature, breathing, and blood pressure a standard practice.
  • Technology: New tools like blood pressure cuffs (1901), EKGs (1903), and pulse oximeters (1970s) made observations faster and more accurate.
  • Early Warning Systems (2000s): Tools like the NEWS (National Early Warning Score) help doctors quickly notice when patients may be getting worse.

In the UK, clinical observations are regulated by various organisations and guidelines to ensure high standards of care:

1. Care Quality Commission (CQC)

The CQC oversees all health and social care services in England, ensuring that they are safe, effective, compassionate, and provide high-quality care.

Their guidelines for clinical observations include:

  • Regular monitoring of patients.
  • Accurate measurements.
  • A prompt response to any signs of deterioration.

2. National Institute for Health and Care Excellence (NICE)

NICE provides evidence-based recommendations on health and social care.

Their guidelines for clinical observations focus on:

  • The importance of proper training for healthcare professionals.
  • The use of standardised equipment.
  • Including observations in the patientā€™s care plan.

3. Health and Social Care Act 2008

This legislation governs healthcare practices in the UK, including clinical observations. It sets out guides for health and care providers to follow, making sure they meet basic standards of safety and quality.

A good physician should be a good observer and always pay attention to the subtle signals the body gives - Thomas Sydenham

Best Practices for Clinical Observations

To make sure clinical observations are helpful and accurate, healthcare providers should follow these simple practices:

1. Consistency and Accuracy

Always use the same tools and methods to get reliable results. This means checking the equipment regularly and following the same steps when measuring things like temperature or pulse.

2. Timely and Regular Checks

Check on patients at set times or more often if they are at risk. How often you check depends on the patientā€™s condition and how serious their health is.

3. Train Staff

Make sure all healthcare workers know the best ways to do observations. This includes learning how to use the tools, understand the results, and spot early signs of problems.

4. Be Kind to Patients

Adapt observations to each patientā€™s needs. Always think about their comfort and dignity. This might mean explaining what is happening and answering any questions they have.

5. Communicate Clearly

Make sure everyone on the healthcare team shares clear information about the patientā€™s condition. This includes writing down important details and passing the information on properly when needed.

6. Use Early Warning Systems

Use tools like the National Early Warning Score (NEWS) to check how serious a patientā€™s health problem is and catch any issues early.

7. Use Technology

Use technology, like digital health records and monitoring devices, to make observations more accurate and help with quick decisions.

To truly improve the patient experience, we must understand the patient journey from the patient's perspective - Jason A. Wolf

Understanding Clinical Observations

To understand clinical observations, it’s important to know what each of these basic health checks mean and how they relate to each other:

1. Temperature

Normal body temperature is between 36.5Ā°C and 37.5Ā°C. If itā€™s too high or too low, it can show that something is wrong:

  • Fever (above 38Ā°C): This usually means the body is fighting an infection.
  • Low body temperature (below 35Ā°C): This can be very serious and might show the person is too cold or has health problems.

2. Pulse Rate

A normal heart rate is between 60 and 100 beats per minute when youā€™re resting. If the heart rate is too fast or too slow, it can mean:

  • Fast heart rate: This could be caused by stress, worry, or heart problems.
  • Slow heart rate: This might show thereā€™s a problem with the heart or be a side effect of some medicines.

3. Blood Pressure

Normal blood pressure is below 120/80 mmHg. If itā€™s too high or too low, it can cause:

  • High blood pressure: This can increase the risk of heart disease or stroke.
  • Low blood pressure: This can make you feel dizzy or faint and, in serious cases, cause shock.

4. Breathing Rate

Normal breathing is about 12 to 20 breaths per minute when youā€™re resting. If breathing is faster or slower than usual, it could mean:

  • Fast breathing: This might show that there is trouble with breathing or other health issues.
  • Slow breathing: This could mean thereā€™s a problem with the brain or nervous system.

5. Oxygen Levels

Normally, oxygen levels in the blood should be above 95%. If itā€™s lower, it can mean:

  • Low oxygen: This might show that the lungs or heart arenā€™t working well.

When doctors or nurses check all these signs together, they can see if something is wrong.

For example, if someone has a high temperature, fast heart rate, and fast breathing, it could mean a serious illness that needs quick treatment.

Clinical Observation Case Example

Patient Scenario:

Mrs. Smith, a 68-year-old patient, was admitted to the medical ward after falling at home. Hereā€™s how clinical observation helped track her condition:

Initial Observation (Day 1, 9:00 AM):

  • Temperature: 36.8Ā°C (normal)
  • Heart Rate: 82 beats per minute (normal)
  • Blood Pressure: 138/85 mmHg (slightly elevated)
  • Respiratory Rate: 16 breaths per minute (normal)
  • Oxygen Saturation: 97% on room air (normal)
  • Mental Status: Alert and aware of surroundings
  • Skin: Bruising on right hip area

Change in Condition (Day 1, 2:00 PM):

The nurse noticed:

  • Temperature increased to 37.8Ā°C
  • Heart Rate rose to 98 beats per minute
  • Respiratory Rate increased to 22 breaths per minute
  • Patient reported feeling more tired than usual

Clinical Response:

Because of these changes, the healthcare team:

  • Increased observation to every 2 hours
  • Ordered blood tests to check for infection
  • Started monitoring fluid intake and output
  • Checked skin for any new changes

This example shows how regular clinical observation helps catch problems early, leading to better patient care. Monitoring vital signs and other changes in the patient’s condition helps doctors and nurses respond quickly when needed.

Observation, Reason, Human Understanding, Courage; these make the physician.

Challenges in Implementing Clinical Observations

Even though clinical observations are important, there are several challenges when trying to carry them out effectively:

  • Time pressures: Healthcare settings can be very busy, and staff may struggle to find time for regular observations.
  • Lack of standard rules: Different healthcare facilities may not use the same methods, making it harder to ensure consistency.
  • Resistance to change: Some staff may be used to older ways of working and might be reluctant to adopt new practices.
  • Inadequate training or resources: There may not be enough training or equipment available to carry out clinical observations properly.
  • Balancing observation with comfort and privacy: It can be difficult to check on patients frequently without making them uncomfortable or invading their privacy.

To overcome these challenges, healthcare organisations need to focus on staff training, clear communication, and ongoing review of observation practices.

The Future of Clinical Observations

As healthcare continues to change, clinical observations will also develop. Some of the trends include:

  • Wearable technology: Devices that can continuously monitor patientsā€™ health.
  • Artificial intelligence: Using computers to predict changes in vital signs before they happen.
  • Remote monitoring: The ability to check patientsā€™ health from a distance, especially for those not in hospital.
  • Patient-reported outcomes: Including patients’ own views about their health in clinical observations.
  • Better data visualisation: Using charts or graphs to make it easier to understand health trends over time.

These new developments will help make clinical observations more accurate, faster, and easier for patients.

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Conclusion

Clinical observations are crucial in patient care, providing important information that helps doctors and nurses make decisions.

By understanding how these observations work, following best practices, and keeping up to date with regulations, healthcare providers can improve patient care.

As technology improves and our knowledge grows, clinical observation will continue to evolve, always aiming to give patients the best care possible.

Take Your Clinical Observation Skills to the Next Level with Caring for Care

Improve your patient care skills with our certified clinical observation course!

At Caring for Care, we offer:

  • Hands-on training with modern monitoring equipment
  • Trainer-Led Classes on understanding vital signs
  • Practice with early warning systems
  • Case studies
  • Nationally Recognised certification when you complete the course

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For healthcare staff looking to advance their clinical skills, proper clinical training courses in clinical observation can truly make a difference in patient care.

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