A Airway
- Airway patency (talking? obstruction?)
- Listen for gurgling / snoring / stridor (document findings)
B Breathing
- Respiratory rate (resps)
- Oxygen saturations (SpO₂)
- Oxygen therapy details (air / device / flow)
C Circulation
- Pulse (rate / rhythm / strength)
- Blood pressure (BP)
- 3‑lead ECG (rhythm monitoring)
D Disability
- GCS
- Pupils (size / equal / reactive)
- BM (blood glucose)
- Pain score
E Exposure / Everything else
- Temperature
- Look for bleeding, rashes, injuries, swelling, medical alert info
- Prevent heat loss; maintain dignity
NEWS2 – core components
Respiratory rate
SpO₂
Supplemental O₂
Systolic BP
Pulse
Temperature
Consciousness (AVPU/new confusion)
Record the score and escalation action per local pathway.
Quick tick list
| ✓ | Observation |
|---|---|
| □ | Pulse |
| □ | Respirations |
| □ | SpO₂ (and O₂ device/flow if used) |
| □ | Temperature |
| □ | Blood pressure |
| □ | BM (blood glucose) |
| □ | Pupils |
| □ | Pain score |
| □ | 3‑lead ECG (rhythm) |
| □ | GCS |
| □ | NEWS2 total + action |
•
St John Ambulance – Coleraine • Quick reference sheet
For training/support use. Follow local clinical governance & escalation policy.