NEW symptoms

4

3

2

1

0

1

2

3

4

Nurse concerned

 

 

NEW

 

N
O
R
M
A
L

R
A
N
G
E

 

 

 

 

Chest pain

 

NEW

 

 

 

 

 

 

AAA Pain

 

NEW

 

 

 

 

 

 

SOB

 

NEW

 

 

 

 

 

 

Physiology

 

 

Pulse

< 45

45 - 49

50 - 54

55 - 60

90 - 99

100 - 119

120 - 139

> 139

Temperature-core
(rectal / tympanic)

< 34

34.0 - 34.5

34.6 - 35.0

35.0 - 35.9

 

38.5 - 39.9

40.0 - 40.4

> 40.4

Respiratory rate

< 8

8 - 9

10 - 11

 

21 - 25

26 - 30

31 - 36

> 36

SpO2 (O2)

< 88

88 - 91

92 - 95

 

 

 

 

 

SpO2 (Air)

< 86

86 - 89

90 - 93

94 - 96

 

 

 

 

SBP (mmHg)

or

Falls to
< 90
Falls
> 40

Falls to
90 - 99
Falls by
31 - 40

Falls to
100 -1109
Falls by
20 - 30

 

Rises by
20 - 29
Pulse pressure
narrows 10

Rises by
30 - 40

Rises by
> 40

 

Pulse pressure narrows
> 10

Level of consciousness

GCS
< 13

 

GCS
13 - 14

 

 

confused or agitated

 

 

Urine output

< 10mls/hr
for 2 hrs

< 20mls/hr
for 2 hrs

 

 

 

> 250mls/hr

 

 

Biochemistry

 

 

K+

 

< 2.5

2.5 - 3.0

 

 

5.6 - 5.9

6.0 - 6.2

> 6.2

Na+

< 120

120 - 125

126 - 129

 

146 - 147

148 - 152

153 - 160

> 160

pH

< 7.21

7.21 - 7.25

7.26 - 7.30

7.31 - 7.34

7.46 - 7.48

7.49 - 7.50

7.51 - 7.60

> 7.60

pCO2 (acute changes)

 

< 3.5

3.5 - 3.9

4.0 - 4.4

 

 

6.1 - 6.9

> 6.9

SBE

< -5.9

-4.9 - -5.8

-3.8 - -4.8

-3 - -3.7

 

 

 

 

pO2 (acute changes)

< 9.0

9.0 - 9.4

9.5 - 9.9

10 - 11

 

 

 

 

Creatinine

 

 

 

 

121 - 170

171 - 299

300 - 440

> 440

Hb

< 80

80 - 89

90 - 100

 

 

 

 

 

Urea

 

 

< 2

2.0 - 2.4

7.6 - 20

21 - 30

31 - 40

> 40

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