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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 66 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 HR
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
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
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…………………………………….
are recorded.
●seizures
●confusion/irritability/altered behavior
●hypoglycaemia
Upper acceptable
Normal range
Lower acceptable
😊 😐 😔 😭
Faces Scale Score
Spontaneously
4 Eyes closed by
Eyes To speech 3 swelling=C
Open To pain 2
None 1
Alert,Coos,and
babbles,word
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 (R)
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