Adult Vital Signs Date: Chart Time: (24 Hour

)
Eyes opening 4 Spontaneously 3 To speech 2 To pain 1 None

THE WELLINGTON ADULT VITAL SIGNS CHART

NEUROLOGICAL
Patient Label Here

GLASCOW COMA SCALE

Best Verbal Response

5 Orientated 4 Confused 3 Inappropriate words 2 Incomprehensible sounds 1 None

Tracheostomy =T

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
NOT FOR MET

Best Motor Response

6 Obeys commands 5 Localise pain 4 Flexion withdrawal 3 Flexion abnormal 2 Extension 1 None

Usually record the best arm response

NOT FOR CPR

Total GCS Pupils
++ + C Brisk Sluggish No Reaction Closed Right
Size Reaction

Any Early Warning Score (EWS) modification must be made by a doctor and should be regularly reviewed by the primary team. Doctor’s name Respiratory Rate Systolic BP Heart rate 4 hour urine output Level of consciousness Write the acceptable ranges outside which abnormal vital signs are tolerated for the patient’s clinical condition - the EWS will be 0
to

Left

Size Reaction

to

Doctor’s designation and pager number

to

Arms

Normal Power
to

Record right (R) and Mild Weakness left (L) separately if Severe Weakness there is a difference Flexion between the two sides Extension No Response

Date and time

Legs

Normal Power

Record right (R) and Mild Weakness left (L) separately if Severe Weakness there is a difference Extension between the two sides No Response

EWS KEY
0

1

2

3

777 MET

Respiratory rate
(breaths/min)

≥ 36 31 - 35 21 - 30 9 - 20

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 patient’s 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 IF TOTAL GCS DROPS BY 2 OR MORE OR IF MOTOR SCORE DROPS BY 1. 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.

write value in box

5-8 ≤4

O2 Flow rate O2 Sat (%) Blood Pressure
(mmHg)

RA orL/min % ≥ 180 170 160 150 140 130 120 110 100 90 80 70

House Officer review with 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

Apply score to systolic only

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 in the patient record. If there is no timely response to your request for review escalate to the next coloured zone.

60 ≤ 50

Heart rate
(beats/min) ≥ 170 160 150 140 130 X 120 110 100 90 80 (If heart rate >140 or <40 write value in box) 70 60 50 ≤ 40

NOTES

Temperature (°C)

40 39 38

X

37 36 35

4 hour urine output if < 120ml
(write mL total)

≥120 80 - 119 ≤ 79

Pain Score (0 to 10) Early Warning Score (EWS)

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

TOTAL EWS

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