Date:

Time: 0800
Location: Ward
Prescribed 15
freq of min
observation:

70 70
60 ● 60
50 50
Respiratory 40
Rate 40 RR
30 30
20 20
10 10
0 0
actual 56 actual

94+ 94+
92-93 SpO2 ● 92-93
SpO2
Less than 92 Less
than 92
Actual 92 Actual

Oxygen Air
Air
l/min 02 4L l/min
02
Mode of FM Mode
Delivery eg of
facemask,nasal Delivery
cannulae

190 190
180 ● 180
170 170
160 160
150 150
140 140
130 130
Heart Heart
Rate Rate
120 120
110 110
100 100
90 90
80 80
70 70
60 60
actual 185 actual

140 140
Blood 130
Pressure(Plot
systolic and
diastolic but
score
SYSTOLIC
only)130
120 120
110 110
100 100 BP
90 90
80 80
BP cuff 70
size:70
60 60
50 50
40 40
30 30
actual 82/46 actual

Less than 2 secs ● Less than 2

 secs
Capillary
return(central Capillary
in seconds)2-4 return(central
sec in seconds)2-
4 sec
More than 4
secs More than 4
secs

Alert Alert
Concius level Concius level
Asleep Asleep
(if V/P/U (if V/P/U
Verbal Verbal
Complete Complete
GCS chart) GCS chart)
Pain Pain
Unresponsive Unresponsive

40 40
39 39
38 38
Temperture◦C ● Temperture◦C
37 37
36 36
35 35
34 34
actual 36.8 actual

Staff or carer concerns C Staff or

(staff=S,Carer=C,None=N) carer
concerns
(staff=S,Ca
rer=C,Non
 e=N)

PEWS 6 PEWS
Initials ABC Initials
Time of 08.15 Time of
medical medical
review if review if
score score
elevated elevated

Pain 0 Pain
Blood 4.6 Blood
Glucose Glucose

Name…………………………………

DOB……………………………………
PAEDIATRIC EARLY WARNING SCORE(PEWS)
CHI…………………………………….

Affix patient ID label

12-23 MONTHS

(To be used from 12 months until day before 2nd birthday)

PEWS is a tool to aid recognition of sick and deterlorating children.

PEWS should be calculated every time observations

are recorded.

How to calculate score :

 Add total points score

 Record total score in PEWS box at bottom of chart
 Score should be taken as below

PEWS Level of Action to be taken

escalations Concerns include,but are not restricted to;
Regardless of PEWS always escalate if concerned about about a patient’s condition
0 0 ●gut feeling
1-2 1
3-4 or any in red 2 ●looks unwell
zone
5 or more 3 ●apnoea
Bradycardia cardiac
or respiratory ●airway threat

●increased work of breathing,

●significant↑in 0₂ requirement

●Poor perfusion/blue/mottled/cool peripheries

●seizures

●confusion/irritability/altered behavior

●hypoglycaemia
If observations are as expected for patient’s clinical condition,please note below accepted parameters for future calls
●high pain score despite appropriate analgesia
 Acceptable parameters RR 02 Saturation HR BP Temperature°C

Upper acceptable
Normal range
Lower acceptable

Doctor’s signature Date & Time

PAEDIATRIC SEPSIS 6 If YES respond with Paediatric Sepsis 6 within 1 hour:

Recognition:Suspected or proven
infection +2 of :
 Core temperature <36°C >
38°C
 Inappropriate Tachycardia
 Altered mental state:
Sleepy/irritable/floopy
 Periphal perfusion,CRT >2
sec,cool,mottled
Lower threshold in vulnerable groups
Think could this be sepsis?
IF NOT then why is this child unwell?
 Give high flow oxygen
 IV or IO acces and blood cultures,glucose,lactate
 Give IV or IO antibiotics
 Consider fluid resuscitation
 Consider onotropic support early
 Involve senior clinicials/specialist EARLY

Assesment of Acute Pain in Children

No Pain Mild Pain Moderate Pain Severe Pain

😊 😐 😔 😭
Faces Scale Score

Ladder Score 0 1-3 4-6 7-10

Behaviour  Normal activity  Rubbing affected area *Protectived of affected *No movement or defensive of
Spontaneously  No↓movement  Decreased movement area affected part
4  Happy  Neutral expression *↓movement/quiet *Looking frightened Eyes closed by
Eyes To speech 3  Able to play/talk *Complining of pain *Very quiet swelling=C
Open To pain 2 normally *Consonable crying *Restless/unsettled
None 1 *Grimaces when *Complining of lots of pain
Alert,Coos,and affected part *Inconsable crying
babbles,word move/touched
to usual ability
 5
Irritable
cries,less than
Best normal ability Endotracheal
verbal 4 tube or
Response Cries in tracheostomy=T
response to
pain 3
Moans to pain
2
Coma No response 1
Sales Moves
purposefully
and
spontaneously
6
Withdraws to
touch 5
Withdraws in Usually record
Best response to the best arm
Motor pain 4 response
Response Flxion to pain
3
Extension to
pain 2
None 1
Score

Right Size
Reactio
Pupils n
Left Size
reaction
LIMB ARMS Normal power
MOVEMENT Mild weakness Reacts+No
Severe weakness reaction-Eye
Spastic flexion closed C
Extenstion
No response
LEGS Normal power Record right®
Mild weakness and left (L)
Severe weakness separately if
Extension there is a
No response difference
Pupil Scale (m.m) 8 7 6 5 4 3 2 1 between the two
sides