Table 1.
Score | 3 | 2 | 1 | 0 | 1 | 2 | 3 |
---|---|---|---|---|---|---|---|
Respiratory rate (min−1) | ≤ 8 | 9–14 | 15–20 | 21–29 | > 29 | ||
Heart rate (min−1) | ≤ 40 | 41–50 | 51–100 | 101–110 | 111–129 | > 129 | |
Systolic BP (mmHg) | ≤ 70 | 71–80 | 81–100 | 101–199 | ≥ 200 | ||
Urine output (ml/kg/h) | Nil | < 0.5 | |||||
Temperature (°C) | ≤ 35 | 35.1–36 | 36.1–38 | 38.1–38.5 | ≥ 38.6 | ||
Neurological | Alert | Reacting to voice | Reacting to pain | Unresponsive |
The scores for each parameter are recorded at the time that observations are taken. If the total is 4 or more then the ward doctor is informed.