Patient Observations
Observation
Usual
Caution
Danger
Action
Continue to monitor
Increase monitoring
Call for help
Increase monitoring
Respiratory Rate
10 - 24 / min
6 - 9 / min OR
25 - 29 / min
< 5 / min OR
> 30 / min
Pulse Oximetry (SpO2)
96 - 100 %
(+/- oxygen)
91 - 95 %
(despite oxygen)
< 90%
(despite oxygen)
Systolic Blood Pressure
(top BP measurement)
100 - 180 mmHg
91 - 99 mmHg OR
181 - 199 mmHg
< 90 mmHg OR
> 200 mmHg
Heart Rate
51 - 119 / min
41 - 50 / min OR
120 - 139 / min
< 40 / min OR
> 140 / min
Response and Cognition
Alert
Responds to voice
Responds to pain
OR
No response
Temperature
35.6 - 37.9 ºC
< 35.5 ºC OR
> 38.5 ºC
No red zone for temperature
Pain
No pain
New pain
Severe pain
Blood Glucose
4 - 19 mmol/L
< 4 mmol/L OR
> 20 mmol/L
< 4 mmol/L OR
> 20 mmol/L and reduced LOC
Level of consciousness
(LOC)
Normal LOC for
patient
Slow decrease or New confusion
Sudden decrease in LOC +/- confusion
Family/staff
concerns
No concerns from resident/staff or family
Some concerns from resident/staff or family
Serious concerns from resident/staff or family
If the resident is acutely unwell, please apply First Aid.