VITAL SIGNS

PATIENT STICKER
VITAL SIGNS
VITAL SIGNS Mid Cheshire Hospitals NHS
PATIENT STICKER
VITAL
WARD:
SIGNS NHS Foundation Trust

WARD:
PATIENT STICKER
WARD:
WEIGHT:

VITAL SIGNS
WEIGHT:

CHART
DATE WEIGHT:
DATE
TIME
DATE
TIME
40 40
TIME
40 40
40
39 40
39
39 39
39
38
40 39
38
40
38 38
TEMP C 38
37
39 38
37
39
37 37
TEMP C 37
36
38 37
36
38
36 36
TEMP C 36
35
37 36
35
37
35 35
35
34
36 35
34
36
34 34
34
240
35 34
240
35
SYSTOLIC 240 240
240
230
34 240
230
34
SYSTOLIC
230 230
230
220
240 230
220
240
SYSTOLIC 220 220
220
210
230 220
210
230
210 210
210
200
220 210
200
220
200 200
200
190
210 200
190
210
190 190
190
180
200 190
180
200
180 180
180
170
190 180
170
190
H B 170 170
170
160
180 170
160
180
E L
H
A B
O 160 160
160
150
170 160
150
170
E
R L
O
A
T
H O
D
B 150 150
150
140
160 150
140
160
R
E O
L
TMEAN
A
MMHg
D
O 140 140
140
130
150 140
130
150
R
MEAN O
MMHg
T D 130 130
R P 130
120
140 130
120
140
A
MEAN R
MMHg 120 120
R
T P
E 120
110
130 120
110
130
A
E R
S 110 110
T
R E
S
P 110
100
120 110
100
120
E
A S
U
R 100 100
T S
R
E 100
90
110 100
90
110
E U
E
S 90 90
R
S 90
80
100 90
80
100
E
U 80 80
R 80
70
90 80
70
90
E 70 70
70
60
80 70
60
80
60 60

60
50
70 60
50
70
50 50
50 50


DIASTOLIC 40
60 40
60


DIASTOLIC
40
40 30
50
40
40
30
50
RESP. RATE
DIASTOLIC 
 30
30
40
 30
30
40
RESP. RATE Telephone Number Religion
HR SCORE
30
 30
RESP. RATE Marital Status Ethnicity
Telephone Number Religion
HR SCORE
RR
RR
BP Next ofStatus
Kin:
HR SCORE
SCORE Marital Ethnicity
PATIENT LABEL Name
BP
RR SCORE
TEMP SCORE
SCORE Next of Kin:
TEMP
CNS SCORE
SCORE Relationship
BP SCORE PATIENT LABEL Name
CNS
UOP SCORE
TEMP SCORE Address
Relationship
UOP
CNS SCORE
TOTAL EWS
SCORE Address
When
TOTAL EWS is 2 or more your patientContact
EWS
O2% SCORE
UOP MUST be screened for sepsis - see reverse.
No(s)


Sepsis
O 2%
SATS
TOTAL tool 3
EWS Contact No(s)
O22%
DateSATS
of Arrival
BOWELS
O Time of Arrival

BOWELS
PAIN ofSCORE
Patient
O2 SATS
Date Location
Arrival Source
Time of of Referral (GP/A&E/OPD/etc)
Arrival
PAIN
On CallSCORE
BOWELS Consultant Acute
SourcePhysician On(GP/A&E/OPD/etc)
Call
Patient Location
- EARLY WARNING SCORE
of Referral
- PAIN SCORE KEY
PAIN
On CallSCORE 
Consultant
- EARLY
TRIGGER SCORE IS FOUR WARNING
OR HIGHER,OR 3 SCORE
IN ANY
Acute Physician
-
ONE PARAMETER
On Call
PAIN SCORE KEY
NO PAIN 0
TRIGGER SCORE
IS FOUR 1 3 IN ANY
3 
OR 2HIGHER,OR 0 ONE PARAMETER
1 all appropriate
Circle 2 3 MILD PAIN
NO PAIN 1
0
HR (Heart Rate)SCORE
-3 EARLY 23
WARNING
21
<40
SCORE
1 0 51-100
41-50 0
-1
1101-110 22
111-130 33
>130
PAIN SCORE KEY
MODERATE
MILD PAIN PAIN 2
1
TRIGGER 
SCORE IS FOUR OR HIGHER,OR 3 IN ANY ONE PARAMETER Circle all appropriate NO PAIN 0
RR
HR
HeartRespiratory
Rate Rate)Rate
(Heart <40 <8
41–50
<40 41-5051–100 9 - 19 101–110
51-100 101-110 111–13020-29
111-130 >30
>130
>130 SEVERE
MODERATE PAIN
PAIN 3
2
SCORE 3 23 2 1 1 0 0 1 1 2 2 33 MILD PAIN 1
BP
RR
Resp (Systolic)
Respiratory
Rate Rate <70
<8 71-80
<8 81-1009–19 101-199 9 - 19 >200
20–29
20-29 >30
>30 *
SEVEREOXYGEN
PAIN SATURATIONS BELOW3
Heart
HR Rate Rate)
(Heart <
<40 41–50
<40 41-5051–10051-100 101–110 101-110 111–130
111-130 >130
>130 MODERATE PAIN 2
TEMP
BP Systolic
BP
Resp(Systolic)
Rate
<70 71–80
<70
<<8
81–100 35.1
<35
71-80 81-100 101–199
- 35.5 35.6 - 38.0
9–19 101-199
>200
>38.1
>200
20–29 <
>30 * 90% INFORM DOCTOR
OXYGEN SATURATIONS BELOW
RR Respiratory Rate
Temperature <35 <8
35.1–35.5 35.6–38.09Alert

- 19 20-29
>38.1 >30 SEVERE PAIN 3
CNS
TEMP (AVPU)
BP Systolic <
<70 71–80 <35
81–100 35.1 - 35.5 101–199 35.6 - 38.0 Voice < Pain
>38.1
>200
Unresponsive 90% INFORM DOCTOR
BP (Systolic)
Central Nervous System <70 CONFUSED
71-80 81-100 101-199 >200 * OXYGEN SATURATIONS BELOW
URINE (measured)
Temperature
CNS (AVPU)
Responses
NIL <
<35 <0.5ml/kg/hour
35.1–35.5
AGITATED
ALERT

<1ml/kg/hour
35.6–38.01ml/kg/hour VOICE
Alert
>6ml/kg/hour
Voice <
PAIN
>38.1
Pain
UNRESP
Unresponsive * OXYGEN SATURATIONS BELOW
* OXYGEN SATURATIONS BELOW
TEMP <35 35.1 urine
- 35.5 35.6than
- 38.0 >38.1 90% INFORM DOCTOR
Central Nervous System
URINE (self voiding) CONFUSED
SCORE 2 if patient has not
Only passed
apply urine output for more
measurement 6 hours:
section to commence fluid balance monitoring. 90%85%INFORM DOCTOR
INFORM DOCTORR AND
+ OUTREACH
ADVICE(measured)Always apply urine outputNIL measurement <0.5ml/kg/hour <1ml/kg/hour ALERT 1ml/kg/hour VOICE PAIN
>6ml/kg/hourFrequent assessmentsUNRESP
must be * OXYGEN SATURATIONS BELOW
Responses
CNS ON
(AVPU) AGITATED
uncatheterised patients in the following circumstances:
section to patients with a urinary catheter Alert Pain for a Unresponsive
Voice made to assess full bladder
URINE OUTPUT
URINE (self voiding) SCORE 2 if patient•Only
when
has urine
not outputoutput
passed is nil for
urine for less
morethan 6 section
than hours and
6 hours:
to commence and/or
fluidassessments
balance monitoring. 85% INFORM DOCTORR AND
+ OUTREACH
* OXYGEN
* OXYGENSATURATIONS BELOW
apply urine measurement
Urine (self voiding)(always
Always assess
apply SCORE
urinecatheter
2
output ifpatency)
patient
measurementhas not passed • urine
to for
patients more
with low then
urine 6 hours:
output. commence fluid
Frequent urinemonitoring
balance retention
must be
URINE
ADVICE(measured)
ON NIL
section to patients with a urinary catheter
<0.5ml/kg/hour
uncatheterised<1ml/kg/hour 1ml/kg/hour
patients in the following >6ml/kg/hour
circumstances:
made to assess for a full bladder SATURATIONS BELOW
URINE OUTPUT
Urine(self
Urine (measured)
Output (always assess catheterLess
NIL
NIL SCORE
than
patency)
<0.5ml.kg.hr
2 if patient
• whenthan
Less
has
urine output is nil for less than 6 hours
<1ml/kg/hr
not passed 1ml/kg/hr
1ml/kg/hr
urine for more than
Moreand than
>6ml/kg/hr
6 hours: commence
and/or urine retention
fluid balance monitoring. 85%85%INFORM DOCTOR
INFORM DOCTOR ++
R ANDOUTREACH
OUTREACH
URINE voiding) ½ml/kg/hr
•
1ml/kg/hr
to patients with low urine output.
6ml/kg/hr
Less than Less than More than
Urine Output TOTALS NIL
½ml/kg/hr 1ml/kg/hr
1ml/kg/hr
6ml/kg/hr
WPG304
TOTALS EWS TOTAL SCORE
EWS TOTAL SCORE
Mid Ches - WPG304 Vital Signs new.indd 1 EWS SCORE 17/01/2012 10:55:12
 
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 
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 
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 
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 
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
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



    


   

 

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 




     
    
       
         

 
 










Mid Ches - WPG304 Vital Signs new.indd 2 17/01/2012 10:55:13