The New Zealand Early Warning Score (NZEWS) can be used to evaluate a hospitalized patient in New Zealand.
Parameters:
(1) respiratory rate in breaths per minute
(2) oxygen source
(3) oxygen saturation in percent
(4) body temperature in °C
(5) systolic blood pressure in mm Hg
(6) heart rate in beats per minute
(7) level of consciousness as AVPU
|
Parameter |
Finding |
Points |
|
respiratory rate |
>= 36 breaths per minute |
777 |
|
25 to 35breaths per minute |
3 |
|
|
21 to 24breaths per minute |
2 |
|
|
12 to 20breaths per minute |
0 |
|
|
9 to 11breaths per minute |
1 |
|
|
5 to 8breaths per minute |
3 |
|
|
< 5breaths per minute |
777 |
|
|
oxygen |
room air |
0 |
|
supplemental |
2 |
|
|
oxygen saturation |
>= 96 percent |
0 |
|
94 to 95 percent |
1 |
|
|
92 to 93 percent |
2 |
|
|
<= 91 percent |
3 |
|
|
temperature |
>= 39°C |
2 |
|
38.0 to 38.9°C |
1 |
|
|
36.0 to 37.9°C |
0 |
|
|
35 to 35.9°C |
1 |
|
|
< 35°C |
2 |
|
|
blood pressure systolic |
>= 220 mm Hg |
3 |
|
110 to 219 mm Hg |
0 |
|
|
100 to 109 mm Hg |
1 |
|
|
90 to 99 mm Hg |
2 |
|
|
70 to 89 mm Hg |
3 |
|
|
< 70 mm Hg |
777 |
|
|
heart rate |
>= 140 beats per minute |
777 |
|
130 to 139beats per minute |
3 |
|
|
110 to 129beats per minute |
2 |
|
|
90 to 109beats per minute |
1 |
|
|
50 to 89beats per minute |
0 |
|
|
40 to 49beats per minute |
2,"hous |
|
|
< 40beats per minute |
777 |
|
|
AVPU |
A (alert) |
0 |
|
V (responds to voice) |
3 |
|
|
P (responds to pain) |
3 |
|
|
U (unresponsive) |
777 |
total score =
= SUM(all results not equal to 777)
Interpretation:
• 777 is the emergency number in New Zealand. The presence of any 777 (blue zone) result indicates the need for rapid response.
• minimum non-777 score: 0
• maximum non-777 score: 19
|
Total Score |
Alternate |
Response |
|
0 |
|
continue routine monitoring |
|
1 to 5 |
|
discuss with senior nurse |
|
6 to 7 |
|
house officer review within 30 minutes |
|
8 or 9 |
any result in red zone (3) |
house officer review within 15 minutes |
|
>= 10 |
any result in blue zone (777) |
rapid response |
