Adult Vital Signs Date: Date THE WELLINGTON ADULT VITAL SIGNS CHART

Chart Time (24 hour): Time (24 hour)

Respiratory rate 36 36
(breaths/min)
31 - 35 31 - 35 P a t i e n t L a b e l H e r e
L a b e l H e r e

write value in box 21 - 30 21 - 30

9 - 20 9 - 20
5-8 5-8
4 4
MEDICAL STAFF: MODIFICATION TO EWS
O2 Flow rate L/min L/min If the patient is not for Medical Emergency NOT FOR MET
O2 Sat (%) % % Team calls +/- Not For Resuscitation please
Blood Pressure document in the clinical record and indicate by NOT FOR CPR
P a t i e n t

(mmHg) 180 180

completing the box on the right & below.
170 170 Any Early Warning Score (EWS) modification Doctor’s name
160 160 must be made by a Doctor and should be
150 150 regularly reviewed by the primary team.
140 140
Doctor’s designation and
130 130 Respiratory Rate to pager number
120 120
Systolic BP to
110 110
100 100
Heart rate to
90 90 4 hour urine output to Date and time
80 80

70 70
Level of consciousness to
Apply score to 60 60

systolic only 50 50 Write the acceptable ranges outside which abnormal vital signs are
tolerated for the patient’s clinical condition - the EWS will be 0
Heart rate
(beats/min) 140 140
130 130 EARLY WARNING SCORE KEY
0 1 2 3 777
120 120
110 110
MET
X 100 100
90 90 NURSING ACTION REQUIRED FOR PATIENTS
80 80 TRIGGERING EARLY WARNING SCORE
70 70 Early Warning Scores (EWS) should be calculated when any vital sign
60
(If heart rate >140 or
60 falls into a coloured zone (see colour key above). Vital signs should be
<40 write value in box) 50 50 recorded at the beginning of each shift with the ongoing frequency
40 40 determined by the patient’s clinical condition.

Temperature (oC) 40 40 Any vital sign in the pink Dial 777 & state ‘Medical
39 39
zone or total score 8 or Emergency Team’ (MET): STAY
more WITH THE PATIENT
38 38
X
37 37 Any vital sign in the Registrar review within 20 minutes:
36 36 orange zone or total inform PAR Nurse (page 6785), House
35 35 score 6-7 Officer and Nurse in charge
4 hour urine output 120 120
(write mL total)
80 - 119 80 - 119
Any vital sign in the House Officer review within 60
gold zone or total minutes: discuss with Nurse in charge
79 79
score 4-5 and inform PAR Nurse (page 6785)
Level of Alert Alert
Consciousness Voice Voice Any vital sign in the Manage pain, fever or distress:
Agitation/confusion Agitation/confusion yellow zone or total consider increasing frequency of vital
Pain Pain score 1-3 sign observations and discussion with
Unresponsive Unresponsive
Nurse in charge/referral for review
Pain score (0 to 10) Rest Pain at rest CALL 777 MET FOR ANY PATIENT YOU ARE SERIOUSLY
Movement Pain on Movement CONCERNED ABOUT REGARDLESS OF VITAL SIGNS/EWS
Early Respiratory rate Respiratory rate
Systolic BP Systolic BP At the time of referral to a House Officer, Registar or PAR Nurse complete
Warning Heart rate Heart rate an ‘Activation of EWS’ sticker and place it in the patient record.
Score (EWS) 4 hour urine output 4 hour urine output
(please check blue Consciousness Consciousness
If there is no timely response to your request for review escalate to
modifications box)
TOTAL EWS TOTAL EWS
the next coloured zone.