Paediatric Date: Surname: ..................................

NHI: ....................

PEWS
score
Vital sign Time (24 hour): Time (24 hour): First Names: . . ..........................................................
3
50 50 D ate of Bir th: ......... / . . ...... / . . ....... Sex: . . ....................
3
45 45
40
2
40
PL ACE PATIENT ID HERE
Respiratory rate 1
35 35
(breaths/min) 1
30 30
0
Add >50 write value
25
20
0
25
20
PAEDIATRIC VITAL SIGNS CHART: 5-11 YEARS
in box 0
15 15
1
10 10
5
2
5 Medical Staff Modification to Early Warning Score (PEWS) Triggers
PET
Any modification to the PEWS must be made by a Consultant or Registrar and regularly
Severe 3 Severe
reviewed by the primary team. Ignore any modification that is not signed & dated.
Respiratory Moderate 2 Moderate
distress Mild 1 Mild Accepted Values & Date Doctors name,
Vital Sign
Nil 0 Nil Adjusted PEWS & time designation, contact details
≥ 15 > 50% 3 ≥ 15 > 50% / /
11-14 40-50% 2 11-14 40-50% :
O2 L/min / /
2-10 30-39% 1 2-10 30-39%
≤ 2 21-30% 0 ≤2 21-30% :
/ /
O2 Delivery Method*
:
93-100 0 93-100
/ /
SpO2 89-92 1 89-92
:
write value in box 85-88 2 85-88 / /
< 85 3 < 85 Not for CPR Not for PET :
2
Blood Pressure 130 130 All limitations must be documented in the patient’s clinical record.
2
125 125
(mmHg) 2
120
115
0
120
115
Mandatory Early Warning Score Escalation Pathway
0 Total PEWS Action
110 110
0 • Inform nurse in charge
105 105
0 • Optimise appropriate treatment as prescribed
100 100
95
0
95
PEWS 1-3 • Manage anxiety/pain
0 or any vital sign in yellow zone
90 90 • Observations at least 4 hourly or more frequently if required
0 • Review oxygen requirement
85 85
1
80 80 PEWS 4-5
1 or any vital sign in orange zone • Notify nurse in charge
75 75
2 • HO Review within
70 70 Acute illness or unstable
2 60 minutes • Calculate full PEWS score
Score systolic 65 65 chronic disease
3 • Optimise treatment
60 60 • Notify nurse in charge
ONLY 55 3 55 • Plan to be formulated and
PET • Registrar review documented including timeframe
3 within 15 minutes and criteria for review and
Heart rate 170 170 PEWS 6-7 • Paediatric & PAR team
160 2 160 frequency of vital signs
(beats/min) or any vital sign in red zone referral #6785
150 2 150 • Recalculate PEWS after interventions
1 Likely to deteriorate rapidly • If patient is is about • Consider ICU referral
140 140 to trigger a PET call,
130 1 130
0 please contact SMO
X 120 120 before dialing 777
110 0 110
0 • DIAL 777
100 100 • STATE ‘PAEDIATRIC MEDICAL EMERGENCY’
90 0 90 PEWS 8+ • Vital signs Q15mins
80 0 80 or any vital sign in blue zone
If heart rate
1 • Document plan which includes timeframe and criteria for review
>180 or <50 70 70 Immediately life threatening • Recalculate PEWS after interventions
write value in box 60 2 60 critical illness
3 • CONTACT PRIMARY CARE TEAM
• Consider transfer to ICU
39.5 39.5
39 39
CALL A PAEDIATRIC MEDICAL EMERGENCY REQUEST URGENT REVIEW IF:
38.5 38.5
Temperature IMMEDIATELY IF: Apnoea
38 38
(oC) Respiratory or cardiac arrest is imminent Unexpected seizure
37.5 37.5
37 37 Any observations in PET Zone If score has increased by >4 in last hour
X 36.5 36.5 Major Bleeding Nurse concerned about patient
36 36 Airway threat
35.5 35.5
FACES PAIN SCALE: Children > 5 years old
Level of Alert 0 Alert 0 1 2 3 4 5 6 7 8 9 10
Resources courtesy of Canterbury DHB

Consciousness Voice 1 Voice

No pain Pain
Pain 3 Pain
Unresponsive PET Unresponsive
Pain score 0 to 10 0 to 10
Capital Docs ID 1.101904
Issued October 2014
Review March 2015

Each patient will have blood pressure done on admission,

TOTAL PEWS TOTAL PEWS and once per shift if stable or as clinically indicated.
Initials Initials
 FLUID AMOUNT (please tick) Surname: .................................. NHI: ....................
PAEDIATRICS FLUID BALANCE CHART Date: / / Full maintenance First Names: . . ..........................................................
⅔ maintenance D ate of Bir th: ......... / . . ...... / . . ....... Sex: . . ....................
24 hours 5-11 YEARS Weight: ½ maintenance
.................................. mls/hr PL ACE PATIENT ID HERE

Input (mls) Output (mls)

Oral / Bolus (I/V) Nappy weight: Urinalysis:
Line 1 (I/V) Line 2 (I/V) Line 3 (I/V)

2 hrly Phlebitis score

enteral intake (pushed)

Nurse’s signature
Total volume infused

Total volume infused

Total volume infused

Feeding Method

Rate / amount

Volume given

Running total
RUNNING
Total volume

Total volume
pH Aspirate

(read from pump)

(read from pump)

(read from pump)

(PO/NG/NJ/PEG)
Fluid type

Fluid type

Fluid type

Fluid type

Fluid type

Bowels /
TOTAL

Drain(s)
Vomit /
NG loss
infused

stoma
Urine
given
Time

Time
Rate

Rate

Rate
0800 0800
0900 0900

1000 1000

1100 1100

1200 1200
1300
1300
1400
1400
1500
1500
8 hr
8 hr total
total
1600
1600
1700
1700
1800
1800
1900
1900
2000
2000
2100
2100
2200
2200
2300
2300
16 hr
16 hr total
total 0000
0000
0100
0100
0200
0200 0300
0300 0400
0400 0500
0500 0600
0600 0700
0700 24 hr Input
0800 24 hr Output
24 hr 24 hr Balance
total (indicate + or -)

INTRAVENOUS ‘FLUID TYPE’ ABBREVIATIONS PHLEBITIS SCORE: 0 1 2 3 4 5

• NS = 0.9% Saline • DSK = 0.45% Saline + 5% Dextrose + KCL • IVM  = IV medications • D5 = 5% dextrose • LIP = Lipids • Alb = Albumin • FFP = Fresh Frozen Plasma All of 4 and:
Slight: Two of: All of: All of 3 and:
exudate,
• DS = 0.9% Saline + 5% Dextrose • IVAB = IV antibiotics • D10 = 10% dextrose • TPN = Aqueous • RBC = Blood • Plt = Platelets IV SITE: Site healthy pain or pain, redness pain, redness, palpable
thrombosis
redness or swelling swelling venous cord
and/or pyrexia