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.