Adult Vital Signs Chart Date: Time: (24 Hour) Temperature (C) 36 Respiratory rate

(breaths/min) 31 - 35 21 - 30 9 - 20 write value in box 5-8 4 RA orL/min or % % 180 170 160 150 140 130 120 110 100 90 80 70

WELLINGTON WARD 6 SOUTH ADULT VITAL SIGNS & FLUID CHART

CARDIOTHORACIC
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

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
to to to to to

Doctors designation and pager number

Apply score to systolic only Heart rate

(beats/min)

60 50 180 170 160 150 140 130 120 110 100 90 80 70

Date and time

Level of consciousness

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:

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

60 50 40 30

Procedure: Date of Procedure: EWS KEY 0 1

Cardiac Rhythm N&V BSL (mmol/L) Significant Events Pain score (0 to 10) Epidural Block L) side Block R) side Motor Block PCA PCA Volume I.V Fluids & Meds 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
Upper Limbs Lower Limbs Injections Attempts Rest Activity Rate Total

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 Dial 777 & state Medical Emergency Team (MET): mandatory notification of cardiothoracic consultant by ICU reg 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

Oral Fluid Intake Total Input 1 hour urine output 4 hour urine output if < 120ml
(write mL)
Hourly Total

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.

120 80 - 119 79

Other Loss (BO/Vomit/NG/Drain) Drain Site 1:

Suction 1 Drainage Drain Level 24 Total Swing Bubble

DAILY WEIGHT
Date

Drain Site 2:

Suction 1 Drainage Drain Level 24 Total Swing Bubble

Weight

PACING
Date Time/Shift

Total Output 24 FLUID BAL. Level of Consciousness

Alert Voice Agitation/confusion Pain Unresponsive

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