How to use it
- Enter respiration rate, SpO₂, systolic blood pressure and pulse as charted.
- Choose SpO₂ scale 1 unless scale 2 has been prescribed, and whether the patient is on air or oxygen.
- Choose alert or not, and enter the temperature in °C or °F.
- Read the total and the risk band.
How the score works
| Parameter | 3 | 2 | 1 | 0 | 1 | 2 | 3 |
|---|---|---|---|---|---|---|---|
| Respiration rate (/min) | ≤ 8 | 9–11 | 12–20 | 21–24 | ≥ 25 | ||
| SpO₂ scale 1 (%) | ≤ 91 | 92–93 | 94–95 | ≥ 96 | |||
| Air or oxygen | Oxygen | Air | |||||
| Systolic BP (mmHg) | ≤ 90 | 91–100 | 101–110 | 111–219 | ≥ 220 | ||
| Pulse (/min) | ≤ 40 | 41–50 | 51–90 | 91–110 | 111–130 | ≥ 131 | |
| Consciousness | Alert | C, V, P or U | |||||
| Temperature (°C) | ≤ 35.0 | 35.1–36.0 | 36.1–38.0 | 38.1–39.0 | ≥ 39.1 |
SpO₂ scale 2: ≤ 83 % → 3, 84–85 → 2, 86–87 → 1, 88–92 or 93 and above on air → 0; on oxygen 93–94 → 1, 95–96 → 2, 97 or more → 3.
The total runs from 0 to 20. Risk: 0–4 low (low–medium if any single parameter scores 3), 5–6 medium, 7 or more high.
Worked example
Respiration rate 22 (2), SpO₂ 94 % on scale 1 (1), on oxygen (2), blood pressure 105 systolic (1), pulse 115 (2), alert (0), temperature 38.5 °C (1): 2 + 1 + 2 + 1 + 2 + 0 + 1 = 9, high risk.
A patient whose observations are all normal except new confusion scores only 3, but that single 3 makes the risk low–medium.
Tips
- Use observations taken at the same time, not a mix of the day’s readings.
- Choose scale 2 only when it has been prescribed; using it for other patients hides low oxygen levels.
- Temperatures in °F are converted to °C and read to one decimal, as on the chart.
- The score is a learning and support tool. Any concern about a patient warrants review whatever the number.