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The weLLINGTON AduLT MedICAL hIGh dePeNdeNCY ChART

Patient Label Here


DATE DAY NO
Height (cm): ............................................ Weight (kg): ............................................... Diagnosis: ............................................................................................................................. Past Medical History: ......................................................................................................... Allergies: ............................................................................................................................... Adult Vital Signs Chart Respiratory rate
(breaths/min) write values in box Date Time (24 hour): 36 31 35 21 30 9 20 58 4 Date Time (24 hour) 36 31 35 21 30 9 20 58 4 L/min % 180 170 160 150 140 130 120 110 100 90 80 70 60 50 1300 1300 1400 1500 8 hr 1600 1700 1800 1900 2000 2100 2200 2300 8 hr 24 hr 0500 0600 0700 8 hr total 0800 0900 0500 0600 0700 8 hr 0800 0900 1000 1100 1200 0200 0300 180 170 160 150 140 130 120 110 100 90 80 70 0400 0200 0300 0400

FLUID BALANCE
Date: Previous Fluid Balance Total date
(see key below)

Input (mls)
Oral/NG/NJ Fluid Type Fluid Type Volume (mls) Line 1 (I/V) Hourly Total Fluid Type Running Total Line 2 (I/V) Hourly Total Fluid Type Running Total Line 3 (I/V) Hourly Total

Output (mls)
Bowels / Stoma
(from separate drain chart)

Time
2400 0100

Time
2400 0100

O2 Flow Rate O2 Sat (%)

L/min %

Blood Pressure
(mmHg)

PLAN

1000 1100 1200

Apply score to systolic only

60 50

Heart rate
(beats/min)

140 130 120 110 100

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

1400 1500 8 hr total 1600 1700 1800 1900 2000 2100 2200 2300

90 80 70 60

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

50 40 40 39 38

Temperature (C)
X

37 36 35

4 hour urine output


(write mL total)

120 80 119 79 Alert Voice Agitation / confusion Pain Unresponsive

CPAP ANd huMIdIFIeR deLIVeRY CheCKLIST


Have medical staff charted PEEP & aim Sp02? Is 15cm H2O safety valve in circuit? Is oxygen analyser calibrated to room air? Baseline obs and blood gas?

8 hr total 24 hr total

Input

Intravenous Fluid Type Abbreviations


NS = 0.9% Saline / D5W = 5% Dextrose / D10W = 10% Dextrose / DS = Dex Saline / P148 = Plasmalyte / Har = Hartmanns / Vol = Voluven / Gel = Gelofusine / Alb = Albumin / RBC = Blood / Plt = Platelets / FFP = Fresh Frozen Plasma / TPN

Output Balance

Level of Consciousness

(indicate + or -)

Pain score (010)

Rest Movement Respiratory rate Systolic BP Heart rate 4 hour urine output Consciousness TOTAL ewS

COMBINed BI-LeVeL & CPAP OBSeRVATIONS


date/Time CPAP Observations 02 .....% on Oxygen analyser Mask has blue valve flat and white cap closing air inlet. Breath felt at mask PEEP valve on exhalation and slightly on inhalation Circuit leak free PEEP at mask humidifier Water in bag and in chamber Temperature probes inserted Correct temperature setting Bi-Level NIV Settings Oxygen (L/min) BPM (breaths per minute) setting Mask & Tubing Air leaks (L/min) CO2 outlet & anti-asphyxia outlet patent Blood Gases

Early Warning Score (EWS)


(please check blue modifications box)

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 to the right). 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 67 Any vital sign in the gold zone or total score 45 Any vital sign in the yellow zone or total score 13

e A R LY w A R N I N G S C O R e K e Y

3
NOT FOR MeT

Dial 777 and 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

MeT

777

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 and below. Any early warning Score (EWS) modification must be made by a Doctor and should be regularly reviewed by the primary team.

NOT FOR CPR


Doctors name

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

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 to escalate to the next coloured zone.
ZX2309 EXCEL AUG 2011

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

Bicarbonate

Air filter not obstructed

Ti (time of inspiration) setting

EPAP

IPAP

pCO2

pO2

pH

Running Total

Drain(s) Total

Vomit / NGT Loss

Hourly Total

Total Input

Total Output

Balance

Running Total

Urine

NIGhT
Nurse Signature Nurse

AM
Signature Nurse

PM
Signature

A B

AIRwAY
Asymmetrical Symmetrical

NOTeS:

A B

AIRwAY
Asymmetrical Symmetrical

NOTeS:

A B

AIRwAY
Asymmetrical Symmetrical

NOTeS:

Type of airway/O2 delivery type Air Entry

Type of airway/O2 delivery type Air Entry

Type of airway/O2 delivery type Air Entry

INSPIRATORY/eXPIRATORY NOISeS
RIGHT LEFT APEX MIDZONE BASES

INSPIRATORY/eXPIRATORY NOISeS
RIGHT LEFT APEX MIDZONE BASES

INSPIRATORY/eXPIRATORY NOISeS
RIGHT LEFT APEX MIDZONE BASES

AUSCULTATION

AUSCULTATION

AUSCULTATION

wORK OF BReAThING
Cyanosis Accessory Muscle Usage NO/YES NO/YES Diaphragmatic Breathing NO/YES

wORK OF BReAThING
Cyanosis Accessory Muscle Usage NO/YES NO/YES Diaphragmatic Breathing NO/YES

wORK OF BReAThING
Cyanosis Accessory Muscle Usage NO/YES NO/YES Diaphragmatic Breathing NO/YES

CARdIOVASCuLAR
Rhythm NO/YES Present Weak Absent Thready Bounding Full ON/OFF Seconds NO/YES NO/YES NO/YES NO/YES C Suction @

CARdIOVASCuLAR
Rhythm NO/YES Present Weak Absent Thready Bounding Full ON/OFF Seconds NO/YES NO/YES NO/YES NO/YES C Suction @

CARdIOVASCuLAR
Rhythm NO/YES Present Weak Absent Thready Bounding Full ON/OFF Seconds NO/YES NO/YES NO/YES NO/YES C Suction @

ECG Rate Pacemaker Checked Peripheral Pulses

ECG Rate Pacemaker Checked Peripheral Pulses

ECG Rate Pacemaker Checked Peripheral Pulses

TEDS Capillary Refill Time Oedema Obvious Signs of Bleeding Chest Drains Other Drains Temperature

TEDS Capillary Refill Time Oedema Obvious Signs of Bleeding Chest Drains Other Drains Temperature

TEDS Capillary Refill Time Oedema Obvious Signs of Bleeding Chest Drains Other Drains Temperature

NeuROLOGICAL
S 1
NO/YES NO/YES NO/YES

Alert / Voice / Pain / Unresponsive

NeuROLOGICAL
S 1
NO/YES NO/YES NO/YES

Alert / Voice / Pain / Unresponsive

NeuROLOGICAL
S 1
NO/YES NO/YES NO/YES

Alert / Voice / Pain / Unresponsive

Sedation Score
Pain Assessment Made Advanced Analgesia Confused

3
PCA

4
NO/YES NO/YES

Sedation Score
Pain Assessment Made Advanced Analgesia Confused

3
PCA

4
NO/YES NO/YES

Sedation Score
Pain Assessment Made Advanced Analgesia Confused

3
PCA

4
NO/YES NO/YES

Agitated

Agitated

Agitated

GASTROINTeSTINAL
Soft Firm Hard Distended Bowel Sounds Active Hypoactive Absent Free Drainage X-Ray NBM TPN Litmus NO/YES NO/YES NO/YES

GASTROINTeSTINAL
Soft Firm Hard Distended Bowel Sounds Active Hypoactive Absent Free Drainage X-Ray NBM TPN Litmus NO/YES NO/YES NO/YES

GASTROINTeSTINAL
Soft Firm Hard Distended Bowel Sounds Active Hypoactive Absent Free Drainage X-Ray NBM TPN Litmus NO/YES NO/YES NO/YES

Abdomen

Abdomen

Abdomen

Enteric Tube in Place Position Confirmed Feeding Protocol Stoma Present Abdominal Drains

NO/YES NO/YES NO/YES NO/YES NO/YES

Enteric Tube in Place Position Confirmed Feeding Protocol Stoma Present Abdominal Drains

NO/YES NO/YES NO/YES NO/YES NO/YES

Enteric Tube in Place Position Confirmed Feeding Protocol Stoma Present Abdominal Drains

NO/YES NO/YES NO/YES NO/YES NO/YES

Last Bowel Movement

Last Bowel Movement

Last Bowel Movement

Gu I
Skin Temp

GeNITO uRINARY
NO/YES U.O. > 0.5ml / kg / hr NO/YES

PLAN:

Gu I
Skin Temp

GeNITO uRINARY
NO/YES U.O. > 0.5ml / kg / hr NO/YES

PLAN:

Gu I
Skin Temp

GeNITO uRINARY
NO/YES U.O. > 0.5ml / kg / hr NO/YES

PLAN:

Urinary Catheter

Urinary Catheter

Urinary Catheter

INTeGuMeNT
Warm Cool Dry Clammy Diaphoretic Skin Colour Normal Pale Flushed Jaundiced Mottled Mouth Dry Moist Sores Thrush

INTeGuMeNT
Warm Cool Dry Clammy Diaphoretic Skin Colour Normal Pale Flushed Jaundiced Mottled Mouth Dry Moist Sores Thrush

INTeGuMeNT
Warm Cool Dry Clammy Diaphoretic Skin Colour Normal Pale Flushed Jaundiced Mottled Mouth Dry Moist Sores Thrush

wOuNdS / IV ACCeSS
Site

Pressure Areas Pressure Relieving Aids

wOuNdS / IV ACCeSS
Site

Pressure Areas Pressure Relieving Aids

wOuNdS / IV ACCeSS
Site

Pressure Areas Pressure Relieving Aids

Inspected

Inspected

Inspected

SAFeTY

SAFeTY

SAFeTY

O2 Level Correct and Functioning Suction, Connected and Correctly Functioning Emergency Equipment Correct Emergency Trolley and Defib. Checked Monitor Alarms On, Limits Set Intubation Drugs Checked Drug Infusions Checked and Lines Labelled Patient ID In Place Shift Nurse Completing Assessment

O2 Level Correct and Functioning Suction, Connected and Correctly Functioning Emergency Equipment Correct Emergency Trolley and Defib. Checked Monitor Alarms On, Limits Set Intubation Drugs Checked Drug Infusions Checked and Lines Labelled Patient ID In Place Shift Nurse Completing Assessment

O2 Level Correct and Functioning Suction, Connected and Correctly Functioning Emergency Equipment Correct Emergency Trolley and Defib. Checked Monitor Alarms On, Limits Set Intubation Drugs Checked Drug Infusions Checked and Lines Labelled Patient ID In Place Shift Nurse Completing Assessment