National Early Warning Score Adult Patient Observation Chart - Health Service Executive Page 2
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1
2
3Patient Name:
Early Warning Score System
Date of Birth:
Healthcare Record No:
0
1
2
3
Addressograph
Consultant:
Screen for Sepsis if NEWS ≥4 (5 on supplementary O
) or if infection is suspected
Ward:
2
Frequency of observations
Date
Year _________
Time
ABCDE Assessment
AB
≥ 25
≥ 25
21-24
21-24
12-20
12-20
9-11
9-11
RESPIRATORY DISTRESS
≤ 8
≤ 8
Consider:
• Airway
Respiration Score
• Hypoxia
≥ 96
≥ 96
• Acidosis
94-95
94-95
Intervention:
• Immediate medical review
92-93
92-93
• ABCDE assessment
≤ 91
≤ 91
• Give Oxygen to target:
SpO
Score
90% in COPD patients,
2
96% or more in all other patients
Room Air
RA
• Request CXR & ABG
%
%
• Airway Obstruction: activate
or
or
Emergency Response System
L/min
L/min
• Respiratory Acidosis:
F
O
Score
Consider early non-invasive
i
2
ventilation
250
250
C
240
240
230
230
Systolic BP
220
220
≥ 200:
Doctor
210
210
to review
HYPERTENSION
200
200
Consider:
• Pain
190
190
• Hypercapnia
180
180
Intervention:
170
170
• Immediate medical review
160
160
• 12-lead ECG
150
150
HYPOTENSION
Consider:
140
140
• Bleeding
130
130
• Myocardial Infarction
120
120
• Sepsis
Intervention:
110
110
• Immediate medical review
100
100
• Check BP manually
90
90
• 12-lead ECG
• If no heart failure, stat IV
80
80
fluids - 500ml
70
70
• If no improvement after
60
60
20ml/kg: immediate review
by doctor
50
50
• Systolic BP ≤ 90: consider
40
40
activating ERS
BP Score
TACHYCARDIA
180
180
Consider:
170
170
• Seagull Sign**
• Loss of conciousness
160
160
• Myocardial ischaemia on ECG
150
150
• Heart failure. If YES -
consider activating ERS
140
140
Intervention:
130
130
• Immediate medical review
120
120
• ACLS Algorithm as appropriate
110
110
BRADYCARDIA
100
100
Consider:
• Electrolyte Disturbance
90
90
• Drug Side-effect
80
80
• Complete Heart Block
70
70
Intervention:
Heart Rate
• Immediate medical review
60
60
≤ 40:
• 12-lead ECG
Immediate
50
50
• Telemetry
medical review
40
40
• Heart Rate ≤ 40: consider
activating ERS
30
30
• Document irregular Heart Rate
Heart Rate Score
D
Alert (A)
(A)
Voice (V)
(V)
Pain (P)
(P)
NEUROLOGICAL DETERIORATION
Unresponsive (U)
(U)
Consider:
• Hypoglycaemia
AVPU Score
• Acute brain injury
39.0
39.0
• Pupil response
Intervention:
38.5
38.5
• Immediate medical review
38.0
38.0
• Capillary glucose
37.5
37.5
• Sudden fall in level of
consciousness: consider
37.0
37.0
activating ERS
E
36.5
36.5
36.0
36.0
35.5
35.5
35.0
35.0
PYREXIA OR HYPOTHERMIA
34.5
34.5
Consider:
Temp Score
• Sepsis
Total EWS
Intervention:
• Immediate medical review
Blood Glucose
• C-Reactive protein
Bowel Movement
• Two or more Sepsis
Weight (kg)
indicators present
Initials
• Commence SEPSIS SIX
Regimen
Urine Output: If there are concerns about urine output (< 0.5 ml/kg/hr), contact Doctor for review
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