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CG87 - Appendix 1: The MEWS Chart

Form 3.33-07.CP

If vital signs need to be increased please indicate below giving reasons:

Date Frequency of observations and any modification of thresholds for scoring

Reason for increase/modification

Signature of nurse/doctor

ESCALATION PROCEDURE

The MEWS and escalation procedure have been designed to assist in identifying potential physical deterioration of the patient and acts as a trigger to ensure that appropriate interventions and management are commenced as soon as possible. Staff should always use their clinical judgement and seek advice from senior nursing / medical colleagues if there are any concerns about a patient, regardless of the calculated score.

Last Name First Name

NHS No. Date of Birth Unit / Ward

Baseline clinical observations and calculations of MEWS are to be recorded every 24 hours for the first 72 hours of admission unless more frequently recommended by the admitting doctor. If baseline clinical observations are considered to be within normal range after 72 hours, observations must then be recorded as a minimum: Daily BD Weekly Other (please specify): ………………………………

Total Score 0

Total Score 1 and above

Any single score of 3

OR Total Score of 4 or above

Inform medical staff of patient deterioration, report and document using the SBAR tool

Assessment of patient within an agreed timeframe according to clinical urgency

Continue observation as before

Inform the nurse in charge immediately.

The nurse in charge reviews the patient and:

Documents MEWS score

Alerts medical team if concerned

Determines frequency of further observations

SAMPLE - DO NOT USE

2

MODIFIED EARLY WARNING SCORING SYSTEM (MEWS)

Last Name First Name

NHS No. Date of Birth Unit / Ward

IF YOU ARE UNABLE TO CARRY OUT AN OBSERVATION, RECORD: R = Refused OR other code Date

Time (24hours)

≥40 3 ≥40

Temperature If refusing record skin colour code: F=flushed, B=pale / blue, N=no change.

38 – 39.9 3 38 – 39.9

37.5 - 37.9 2 37.5 – 37.9

37 – 37.4 0 37 – 37.4

36.1 – 36.9 0 36.1 - 36.9

35.1 - 36 1 35.1 – 36

≤35 3 ≤35

Score

Blood Pressure

(Record both Systolic and Diastolic BUT Score Systolic only

≥190 3 ≥190

180 - 189 3 180 - 189

170 - 179 2 170 - 179

160 - 169 2 160 - 169

150 - 159 1 150 - 159

140 - 149 1 140 - 149

130 - 139 0 130 - 139

120 - 129 0 120 - 129

110 - 119 0 110 - 119

100 - 109 2 100 - 109

90 - 99 2 90 - 99

80 - 89 3 80 - 89

70 - 79 3 70 - 79

60 - 69 3 60 - 69

50 - 59 3 50 - 59

Score

Pulse Rate

Beats per min

≥131 3 ≥131

121-130 2 121 - 130

111-120 2 111 - 120

101-110 1 101 - 110

91-100 1 91 - 100

81-90 0 81 - 90

71-80 0 71 - 80

61-70 0 61 - 70

51-60 0 51 - 60

41-50 1 41 - 50

31-40

3

31 - 40

< 30 3 < 30

Score

Respiration Rate If refusing record: S=short of breath /wheezing, SG=sitting /standing, W=walking, N = No change.

≥25 3 ≥25

21 - 24 2 21 - 24

12 - 20 0 12 - 20

9 - 11 1 9 - 11

< 8 3 < 8

Score

SpO2

If refusing record skin colour code: F=flushed, B=pale / blue, N=no change.

96 - 100 0 96 - 100

94 - 95 1 94 - 95

< 93

3

< 93

SpO2 Score

Conscious Level

Alert 0 Alert

C/V/P/U C=New Confusion

3

C/V/P/U C=New Confusion

Score

TOTAL MEWS SCORE

INITIALS

DR INITIALS WHEN MEWS ≥ 4 OR SINGLE SCORE 3

SAMPLE - DO NOT USE

3

FOLLOWING RAPID TRANQUILISATION: Record hydration status and fluid intake

Dehydration increases the risks of rapid tranquilisation, particularly cardiovascular and respiratory collapse. Physical symptoms may include: headache, dizziness, tiredness, fatigue, dry lips/mouth/eyes, cold hands/feet, sunken eyes, dark and infrequent urination, low blood pressure, rapid/weak pulse, fits. Mental symptoms may include: confusion, irritability, anxiety, agitation, reduced level of consciousness, hallucinations.

Date & Time

Hyd

rati

on

an

d S

ym

pto

m N

ote

s

Initials

Last Name First Name

NHS No. Date of Birth Unit / Ward

Record what you observe every 10 minutes. Ask the patient if they are thirsty and offer them a drink of water. Record the patient’s response and how much is consumed. Record urine output (if possible) and describe colour/odour. Record any of the symptoms noted above.

SAMPLE - DO NOT USE

4

Last Name First Name

NHS No. Date of Birth Unit / Ward

NEUROLOGICAL OBSERVATION CHART On Older Adult Wards a GCS should be assessed on admission

Minimum frequency of neurological observations and MEWS post fall

½ hourly for 2 hours, 1 hourly for 4 hours then 2 hourly for 24 hours (See Slips, Trips & Falls Guideline for more detail)

DATE TIME

GLASGOW COMA SCALE (GCS)

Eye opening

Spontaneously 4

To sound 3

To pressure 2

None 1

Non testable NT

Best verbal response

Orientated 5

Confused 4

Words 3

Sounds 2

None 1

Non testable NT

Best motor Response

Obeys commands 6

Localising 5

Normal Flexion 4

Abnormal flexion 3

Extension 2

None 1

Non testable NT

Total Score

PUPILS (C=EYE CLOSED)

R Size

+or

Reaction

L Size

+or

Reaction

LIMB MOVEMENT

Arms

Normal power

Mild weakness

Severe weakness

Spastic flexion

Extension

No response

Legs

Normal power

Mild weakness

Severe weakness

Spastic flexion

Extension

No response

INITIALS

Pupil Scale (mm)

1 2 3 4 5 6 7 8

SAMPLE - DO NOT USE