| |
grade 0 |
grade 1 |
grade 2 |
grade 3 |
grade 4 |
| Fever |
Temperature is 36 to 37.5 |
|
Temperature of 37.5 to 37.9
and/or Shivering or Shaking or feeling unwell |
Temperature of 38 degrees or
greater. Shivering and shaking and feeling unwell |
Continuous fever |
| Bleeding |
None |
Explained bruise
E.g. Aware of how you got the bruise |
Unexplained bruises, bleeding from gums, urine, faeces, spontaneous nosebleeds |
Bleeding that continues for more than 10
minutes |
Continuous bleeding |
| Vomiting |
None |
Once in 24 hours |
2–5 episodes in 24 hours |
More than 5 episodes in 24
hours |
Continuous |
| Nausea |
None |
Loss of appetite, but able to eat |
Eating less, but no weight loss or dehydration |
Nibbling at food, small sips of
water |
Unable to eat or drink |
| Breathlessness |
None |
Slightly breathless on exertion, can walk a flight of stairs |
Slightly breathless on exertion, cannot walk a flight of stairs |
Breathless during showering and
dressing |
Breathless when at rest |
| Cough |
None |
Dry cough |
A cough that produces sputum
Or
A persistant dry cough |
A persistent cough that produces sputum that is green.
Interfere with sleep and daily living |
|
| Urine |
None |
Change in colour Double the usual
amount you
would normally urinate |
Blood noted in urine. Stinging, burning and a another increase in urinating
Smelly urine, changes in urine colour. Difficulty in urinating |
Urinating every hour
Unable to urinate |
|
| Diarrhoea |
None |
More than normal, but less than 4 stools a day |
4–6 stools a day, but able to continue daily activities |
Over 6 stools a day, interfering
with daily activities |
Constant |
| Constipation |
None |
Occasional, though controlled with laxatives |
Continued despite laxative / enema use |
Interfering with daily activities.
No bowel motion
for >2 days |
Stomach distended, nausea &/or vomiting, feeling unwell |
| Diet |
Normal |
Mild loss of appetite |
Eating 50% less not hungry |
Losing Weight, eating much |
Unable/not not wanting to eat |
| Skin |
None |
Dry slight itch to skin |
Very dry with notable rash
or peeling |
Itchy Pain or swelling
to any wounds or
drip sites |
Skin red and Ulcerated or
painful with bleeding skin, some broken any pus wounds
Swelling pain and area is reddened and raised |
| Mouth |
None |
Mouth sore and tender. Able to eat and drink |
Difficulty eating and drinking. Mouth is painful |
Mouths painful, ulcers present and impacting on your daily activities |
Ulcers and unable to swallow |
| Headaches |
None |
Mild pain, not interfering with daily activities |
Moderate pain Not Interfering with daily activities |
Severe pain, not relieved and interfering with daily living |
Bedridden |
| Feeling in hands or feet |
Normal sensation |
Slightly odd tingling or numbness sensation |
Numbness and tingling that is continual and affecting normal living activities |
Severe cramping, pain tingling and loss of feeling |
Crippling
Pain, cramping or numbness |
| Mobility |
Normal |
Able to perform usual housework or work |
Difficulty moving while performing housework |
Difficulty moving while performing basic tasks
Toileting |
Bedridden |
| Fatigue |
Normal |
Able to complete task but needs a rest or nap |
Able to complete a small task but is exhausted after completion |
Constant Exhausted Unable to
complete any
task |
Bedridden |
| Confusion |
None |
Some confused episodes, occasional disorientation, occasional difficulties concentrating |
Occasional confusion,
disorientation, occasional difficulties concentrating. Interferes at the time, but not with attending to self cares |
Confused or delirious continually |
Harmful to self or others reliant upon self |
| Memory |
None |
Slightly absent minded. Does not interfere with functioning |
Interfering with functioning but not with self caring |
Forgetting to eat or self care (e.g. showering) |
Unable to recall most events |
| Mood |
Normal |
Mild changes to mood but not interefering with housework or work |
Moderate changes starting to infere with housework or work and general hygiene |
Severe changes to mood that affect all areas including general hygiene and cares |
Danger to self or others |
| Behaviour |
Normal |
Changed but not adversely affecting patient or family |
Change adversely affecting patient and family |
Severe changes |
Danger to self or others |
| Eyes |
None |
Dry eyes Watery eyes |
Dry or watery eyes that interfere with function Eye sight |
Deteriorating eye sight that interferes with daily living |
Unable to eat or drink |
| Hearing |
None |
Ringing in the ears, but not affecting hearing |
Hearing loss not requiring hearing aid, not interfering with activities |
Hearing loss requiring hearing aid, interfering with activities |
Profound hearing loss |