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Adult Vital Signs Chart Respiratory rate

(breaths/min)

Date: Time (24 hour):


36 31 - 35 21 - 30 9 - 20 5-8 4

Date Time (24 hour)


36 31 - 35 21 - 30 9 - 20 5-8 4 L/min %

THE WELLINGTON ADULT VITAL SIGNS CHART


P a t i e n t L a b e l H e r e

L a b e l H e r e

write value in box

MEDICAL STAFF: MODIFICATION TO EWS


If the patient is not for Medical Emergency Team calls +/- Not For Resuscitation please document in the clinical record and indicate by completing the box on the right & below. Any Early Warning Score (EWS) modification must be made by a Doctor and should be regularly reviewed by the primary team. NOT FOR MET

O2 Flow rate O2 Sat (%) Blood Pressure


(mmHg)

L/min %

P a t i e n t

NOT FOR CPR


Doctors name

180 170 160 150 140 130 120 110 100 90 80

180 170 160 150 140 130 120 110 100 90 80 70 60 50 140 130 120 110 100 90 80 70 60 50 40 40 39 38 37 36 35 120 80 - 119 79 Alert Voice Agitation/confusion Pain Unresponsive Pain at rest Pain on Movement Respiratory rate Systolic BP Heart rate 4 hour urine output Consciousness TOTAL EWS

Respiratory Rate Systolic BP Heart rate 4 hour urine output Level of consciousness

Apply score to systolic only


Heart rate
(beats/min)

70 60 50 140 130 120 110

to to to to to

Doctors designation and pager number

Date and time

Write the acceptable ranges outside which abnormal vital signs are tolerated for the patients clinical condition - the EWS will be 0

EARLY WARNING SCORE KEY

100 90 80 70 60 50 40

2 3

777 MET

NURSING ACTION REQUIRED FOR PATIENTS TRIGGERING EARLY WARNING SCORE


Early Warning Scores (EWS) should be calculated when any vital sign falls into a coloured zone (see colour key above). Vital signs should be recorded at the beginning of each shift with the ongoing frequency determined by the patients clinical condition. Any vital sign in the pink zone or total score 8 or more Any vital sign in the orange zone or total score 6-7 Any vital sign in the gold zone or total score 4-5 Any vital sign in the yellow zone or total score 1-3 Dial 777 & state Medical Emergency Team (MET): STAY WITH THE PATIENT Registrar review within 20 minutes: inform PAR Nurse (page 6785), House Officer and Nurse in charge House Officer review within 60 minutes: discuss with Nurse in charge and inform PAR Nurse (page 6785) Manage pain, fever or distress: consider increasing frequency of vital sign observations and discussion with Nurse in charge/referral for review

(If heart rate >140 or <40 write value in box)

Temperature (oC) X

40 39 38 37 36 35

4 hour urine output


(write mL total)

120 80 - 119 79 Alert Voice Agitation/confusion Pain Unresponsive

Level of Consciousness

Pain score (0 to 10)

Rest Movement

CALL 777 MET FOR ANY PATIENT YOU ARE SERIOUSLY CONCERNED ABOUT REGARDLESS OF VITAL SIGNS/EWS
At the time of referral to a House Officer, Registar or PAR Nurse complete an Activation of EWS sticker and place it in the patient record. If there is no timely response to your request for review escalate to the next coloured zone.

Early Warning Score (EWS)


(please check blue modifications box)

Respiratory rate Systolic BP Heart rate 4 hour urine output Consciousness TOTAL EWS