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File 1697159609
File 1697159609
ISBAR
• Gasping, grunting
Identify Situation Background Assessment Recommendation
Other
• Extreme pallor, cyanosis
Communication Tool • Apnoea
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Paediatric Sepsis 6
Version N3 | 2016
PEWS Score Key
5-11 Years Chart Date D D / M M / Y Y
0 1 2 3
Date / Time Clinical Parameters New Acceptable Range Next Medical Review Doctor
Signature/Print name /MCRN
Addressograph
Ward
Parameter
Amendment
For Chronic Conditions
Consultant
Frequency of observations 40
RR Number 16
RR Score 0 RR Score
Severe Severe
Respiratory Moderate Moderate
Effort Mild Mild
Normal Normal
RE Score 0 RE Score
Mode of O2 delivery Mode RA Mode
Room air (RA) Oxygen Pressure
Pressure
Nasal Cannula (NC)
Face mask (FM)
Therapy >2L >2L
/0LQV
Tracheostomy (T) / /
HHFNC (H)
CPAP (C) / BiPAP (B) O2 T Score 0 O2 T Score
98
SpO2
SpO2 Score 0 SpO2 Score
150 150
140 140
C
CIRCULATION 130 130
Heart Rate
(beats per minute) 120 120
If HR scores 1 or more
consider central CRT Assess for 110 110
and BP and refer to 60 seconds 100 100
Sepsis 6 Protocol
90 90
80 80
70 70
*HR <60 with no signs of
life - begin CPR and 60 60
call the emergency team
50 50
40 40
HR Number 96
HR Score 0 HR Score
Central Capillary >2 >2
Refill Time (seconds)
CRT Score 0 CRT Score
150 150
140 140
Blood Pressure 130 130
(mmHg)
Score systolic BP 120 120
110 110
Cuff Size: 100 100
________ 90 90
80 80
BP Number 109
BP Score 0 BP Score
PK - pink M - mottled
P - pale C - cyanosed Skin Colour PK Colour
6FRUH¶·LIQRWDVVHVVHG Alert A
and put a vertical line Voice V
through column
AVPU
D Pain P
DISABILITY Unresponsive U
If not Alert, consider GCS AVPU Score 0 AVPU Score