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 35 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
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
50 actual
40
actual 146

170 170
Blood 160
Pressure(Plo
t systolic and
diastolic but
score
SYSTOLIC
only)160
150 150
140 140
130 130 BP
120 120
110 110
BP cuff 100
size:100
90 90
80 80
70 70
60 60
actual 100/60 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…………………………………….
5-11 YEARS
Affix patient ID label
(To be used from 5 years until day before 12th birthday)

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

PEWS should be calculated every time observations

are recorded. Ward………..Consultant

How to calculate score :
Chart Number…………………….
 Record observation at intervals as prescribed
 Record observations in black pen with a dot
Date……………………………………
 Score as per the colour key
0 1 3
 Add total points score
 Record total score in PEWS box at bottom of chart
Concerns include,but are not restricted to;
 Score should be taken as below
●gut feeling
PEWS Level of Action to be taken
escalations ●looks unwell
Regardless of PEWS always escalate if concerned about about a patient’s condition
0 0
●apnoea
1-2 1
3-4 or any in red 2
●airway threat
zone
5 or more 3
●increased work of breathing,
Bradycardia cardiac
or respiratory
●significant↑in 0₂ requirement

●Poor perfusion/blue/mottled/cool peripheries

●seizures

●confusion/irritability/altered behavior

●hypoglycaemia

●high pain score despite appropriate analgesia

 If observations are as expected for patient’s clinical condition,please note below accepted parameters for future calls
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 Lower threshold in vulnerable groups  Give high flow oxygen
infection +2 of :  IV or IO acces and blood cultures,glucose,lactate
Think could this be sepsis?
 Core temperature <36°C >  Give IV or IO antibiotics
38°C IF NOT then why is this child unwell?  Consider fluid resuscitation
 Inappropriate Tachycardia  Consider onotropic support early
 Altered mental state:  Involve senior clinicials/specialist EARLY
Sleepy/irritable/floopy
 Periphal perfusion,CRT >2
sec,cool,mottled

Assesment of Acute Pain in Children

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
 No↓movement  Decreased movement area affected part
 Happy  Neutral expression *↓movement/quiet *Looking frightened
 Able to play/talk *Complining of pain *Very quiet
normally *Consonable crying *Restless/unsettled
*Grimaces when *Complining of lots of pain
affected part *Inconsable crying
move/touched
Neurological Observations

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