Date Time of observations Initials of staff performing observations above 30 25 30 – Rate minute 21 24 – 10 20 18 – per and 8 9 – less than 8 Respiration breaths 94 100 95 – Breathing Airway 90 93 – 85 89 SPO2 – Oxygen less than 84 more than 130 111 129 – – 101 110 – per rate 51 100 75 – minute (pulse) Beats 40 50 – Heart less than 40 Above 201 191 200 – in 181 190 – 171 180 – pressure 161 170 – Measured 151 160 – blood 141 150 145 – Pressure 131 140 – Circulation concern. 121 130 – systolic mmHG 111 120 Blood – 101 110 – amber above 81 100 – an is Systolic 71 80 75 – is rate 61 70 – this 51 60 – heart 41 50 then – If Less than 40 Alert awake and responding Voice responds to verbal commands or new confusion Pain - new responds to verbal stimulus complete neurological observation chart – observation Unresponsive Unresponsive must complete neurological observation chart Neurological – None = 1 Slight = 2 Moderate = 3 May require treatment alteration or further pain relief, speak to doctor Pain NEW Severe =4 Requires immediate action, call doctor for action less than 2 - Between 3 4 – Between 5 9 5.2 – Sugar mmol/L 10 19 Disability – Over 20 or if BM Blood device reads high Above 41 39 40 – 37.6 38.9 – Celsius 36 37.5 37 – 35.1 35.9 – Temperature Degrees Less than 35
Date Time of observations Initials of staff performing observations Airway and Breathing Respiration Rate breaths per minute above 30 25 – 30 21 – 24 10 – 20 18 8 – 9 less than 8 Oxygen SPO2 94 – 100 95 90 – 93 85 – 89 less than 84 Circulation Heart rate – (pulse) Beats per minute more than 130 111 – 129 101 – 110 51 – 100 75 40 – 50 less than 40 Systolic Blood Pressure If heart rate is above systolic blood pressure then this is an amber concern. Measured in mmHG Above 201 191 – 200 181 – 190 171 – 180 161 – 170 151 – 160 141 – 150 145 131 – 140 121 – 130 111 – 120 101 – 110 81 – 100 71 – 80 75 61 – 70 51 – 60 41 – 50 Less than 40 Disability Neurological observation Alert awake and responding Voice responds to verbal commands or new confusion Pain - new responds to verbal stimulus – complete neurological observation chart Unresponsive Unresponsive – must complete neurological observation chart NEW Pain None = 1 Slight = 2 Moderate = 3 May require treatment alteration or further pain relief, speak to doctor Severe =4 Requires immediate action, call doctor for action Blood Sugar - BM mmol/L less than 2 Between 3 – 4 Between 5 – 9 5.2 10 – 19 Over 20 or if device reads high Temperature Degrees Celsius Above 41 39 – 40 37.6 – 38.9 36 – 37.5 37 35.1 – 35.9 Less than 35