Behavior

0 Playing / appropriate

1 Sleeping

2 Irritable

Cardiovascular Pink or capillary refill 1-2 seconds

Grey or capillary refill 4 seconds. Tachycardia of 20 above normal rate Respiratory Within >10 above >20 above 5 below normal normal normal normal parameters with parameters, n parameters, parameters; sterna recession, recession or using recessing, tracheal tug or tracheal tug accessory tracheal tug, grunting. 50% muscles, 40+% FiO2 or FiO2 or 8+ liters / 30+% FiO2 or 6+ liters / minute 4+ liters / minute minute Score 2 extra for hourly nebulizers or persistent vomiting following surgery Royal Alexandra Hospital for Sick Children, Brighton: Paediatric early warning score. Adapted from Detecting and managing deterioration in children, by A. Monaghan, 2005, Paediatric Nursing, 17(1), p. 34.

Pale or capillary refill 3 seconds

3 Lethargic / confused Reduced response to pain Grey and mottled or capillary refill 5 seconds or above. Tachycardia of 30 above normal rate or bradycardia

Score