Adult Vital Signs Chart Temperature (C) Respiratory rate

(breaths/min)

Date: Time: (24 Hour)

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

WELLINGTON WARD 6 SOUTH ADULT VITAL SIGNS & FLUID CHART

CARDIOLOGY
Patient Label Here
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

write value in box

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

O2 Flow rate O2 Sat (%) Blood Pressure

(mmHg)

NOT FOR CPR

Any Early Warning Score (EWS) modification must be made by a doctor and should be regularly reviewed by the primary team. Doctors name Respiratory Rate Systolic BP Heart rate 4 hour urine output Level of consciousness
to to to to to

Doctors designation and pager number

Apply score to systolic only

60 50 40

Date and time

Heart rate
(beats/min)

180 170 160 150 140 130

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

120 110 100 90 80 70

Procedure: Date of Procedure: EWS KEY 0 1

(If heart rate >180 or <30 write value in box)

60 50 40 30

777 MET

Cardiac Rhythm N&V BSL (mmol/L) Significant Events IV Site Check Pain score (0 to 10) Site:
Rest Activity Ooze Haematoma Colour Warmth Movement Sensation Pulse Pressure

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 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

I.V Fluids & Meds

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. Oral Fluid Intake

DAILY WEIGHT
Total Input 1 hour urine output 4 hour urine output if < 120ml
(write mL) Hourly Total 120 80 - 119 79

Date

Weight

Other Loss (BO/Vomit/NG/Drain) Total Output 24 FLUID BAL. Level of Consciousness

Alert Voice Agitation/confusion Pain Unresponsive

PACING
Date Time/Shift Pacing Mode Pacing Rate Sens. Threshold Output Threshold

Early Warning Score (EWS)

Respiratory rate Systolic BP Heart rate 4 hour urine output Consciousness

TOTAL EWS