Adult Vital Signs Date

Chart Time: (24 Hour)

Eyes opening
4 Spontaneously
3 To speach
2 To pain
1 None
Best Verbal 5 Oriented
Response
4 Confused
GLASCOW COMA SCALE

3 Inappropriate
words
Tracheostomy =
T 2 Incomprehensible
sounds
1 None
Best Motor
Response 6
Obeys commands
5 Localise pain

4
Flexion withdrawal
Usually record 3 Flexion abnormal
the best arm
response 2 Extension
1 None
Total GCS
Pupils
++ Brisk Size
Right
+ Sluggish Reaction
- No Reaction Size
Lef
C Closed Reaction
Arms Normal Power
Mild Weakness

Record right (R) and Severe Weakness

lef (L) separately if
there is a difference Flexion
between the two sides Extension

No Response

Legs Normal Power

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

Resplratory rate ≥ 36
(breaths/min)
31 - 35

21 - 30

9 - 20
Write value in box
5-8

≤4
O2 Flow rate RA orL/min
 O2 Sat (%) %

Blood Pressure ≥ 180

(mmHg)
170

160

150

140

130

120

110

100

90

80

70

Apply score to 60
systolic only
≤ 50

Heart rate ≥ 170

(beats/min)
160

150

140

130

120

110

100

90

80

70

(if hearts rate > 140 60

or < 40 write value
in vox
50

≤ 40

Temperature (°C) 40

39

38

37
 37

36

35

4 hour urine ≥ 120

output if < 120ml 80 - 90
(write mL
total) ≤ 79
Rest
Pain Score
( 0 to 10 ) Movement
Respiratory rate

Systolic BP
Early Warning
Score ( EWS ) Heart rate
4 hour urin output
Level of consciousness
 THE WELLINGTON ADULT VITAL SIGNS CHART
NEUROLOGICAL

Patien Label Here

MEDICAL STAFF : MODIFICATION TO EWS

if the patient is not for Medical Emerdency Team calls +/-

Noot For Resuctitation please document in the clinical record
and indicate be completing the box on the right & below

Any Early Warning Score (EWS) modification must be made by

a doctor and should be regularly reviewed by the primary
team.

Respiratory Rate
to

Systolic BP to

Heart rate to

4 hour urine output to

level of consciousness

Write the acceptable ranges outside which abnormal vital sigs are tolerated for
patient's clinical condition - the EWS will be 0

EWS KEY
0 1 2 3
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 shif with the ongoing frequency determined by
the patient’s clinical condition.

Any vital sign in the Dial 777 & state ‘Medical Emergency
orange zone or total
Team ' ( MET) : STAY WITH PATIENT
score 8 0r nore

Any vital sign in the

orange zone or total
score 6 - 7 IF TOTAL GCS Registrar review within 20 minutes
inform PAR nurse ( page 6785), House
DROPS BY 2 OR MORE Office and nurse in charge
OR IF MOTOR SCORE
DROPS BY 1

House Offi cer review with 60

Any vital sign in the
minutes: discuss with nurse in
gold zone or total
charge and inform PAR nurse
score 4-5
(page 6785).

Manage pain, fever or distress:

consider increasing frequency

Any vital sign in the gold of vital sign observations and
zone or total score 1 - 3
discussion with nurse in charge/

referral for review

CALL 77 MET FOR ANY PATIENT YOU ARE SERIOUSLY CONCERNED ABOUT
REGARDLESS OF VITAL SIGNS/EWS

At the time of referal to a House Officer, Register ot 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.

NOTES
NOTES
 LT VITAL SIGNS CHART
OGICAL

bel Here

DIFICATION TO EWS

NOT FOR MET

NOT FOR CPR

Doctor's name

Doctor's designation and

pager number

Date and time

h abnormal vital sigs are tolerated for the

on - the EWS will be 0

777
MET

RED FOR PATIENTS

WARNING SCORE
culated when any vital sign falls
e). Vital signs should be recorded
going frequency determined by

777 & state ‘Medical Emergency

m ' ( MET) : STAY WITH PATIENT

strar review within 20 minutes

m PAR nurse ( page 6785), House
Office and nurse in charge

Offi cer review with 60

es: discuss with nurse in

and inform PAR nurse

e pain, fever or distress:

er increasing frequency

sign observations and

sion with nurse in charge/

SERIOUSLY CONCERNED ABOUT

Register ot PAR nurse complete

place in the patient record.

quest for review escalate to the

zone.

ES
ES