3
2
1
0
1
2
3
Resp rate
Less than 8
9–18
19–25
26–30
More than 30
Pulse rate
Less than 40
40–50
51–100
101–110
111–129
More than 129
BP Systolic
Less than 70
71–80
81–100
101–159
160–199
200
More than 200
BP Diastolic
Less than 95
95–109
More than 110
Conscious level
Unresponsive
Responds to pain
Responds to voice
Alert
Irritated
Urine hourly (ml/h) or in 24-h rate
0
Less than 30 (less than 720 ml)
Less than 45 (less than 1000 ml)
More
V6.1
Nov 2011
Originally adapted from Morgan et al. [12]
Action to be taken
0 | Repeat observations when appropriate for clinical scenario – at least daily |
1 | Minimum of 4 hourly observations as there is potential for deterioration
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