I Time:

N
T
A
K
E Cumulative Total IN:

O
U
T
P
U Bristol Stool Score:
(Document in NN if abnormal)

T Cumulative Total OUT:

12 hour balance: Calculated Maintenance Fluids _____ mL//hr 12 hour balance:

Calculated Maintenance Fluids _____ mL//hr  Total Fluids _____ mL/kg/hr  Urine Output _____ mL/kg/hr
Total Fluids _____ mL/kg/hr  Urine Output _____ mL/kg/hr
24 hour balance:
INTRAVENOUS INITIATION: Other Measurements:
(For example: height, abdominal girth, head Previous 24 hour balance:
Time Insertion Site Catheter Size # of Attempts Signature circumference, photometer, peak flows)

ADMISSION WEIGHT: kg

PREVIOUS 24 HR WEIGHT: kg

TODAY’S WEIGHT: kg kg

Strike a line through any assessment data to indicate that it does not apply or has not been assessed
Assessment Time: Initials: Check boxes ☑ to indicate assessment findings.

PSYCHOSOCIAL / BEHAVIORAL CARDIOVASCULAR HYDRATION

AFFECT / MOOD BREATH SOUNDS CHEST MOVEMENT CENTRAL COLOUR PERIPHERAL COLOUR Central edema present: ☐ Yes  ☐ No
☐☐Happy ☐ Calm ☐ Anxious ☐☐Clear to bases ☐☐Equal & adequate ☐☐Pink ☐ Pale ☐ Mottled ☐☐Pink ☐ Pale ☐ Mottled Peripheral edema present: ☐ Yes  ☐ No
☐☐Withdrawn ☐ Upset ☐ Irritable ☐☐Crackles ☐☐See Nurses’ Notes ☐☐Jaundiced ☐ Flushed ☐☐Jaundiced ☐ Flushed Skin turgor: ☐ Elastic ☐ Poor
☐☐Flat ☐ Other ☐☐RUL ☐ RML ☐ RLL ☐☐Other ☐☐Other Skin: ☐ Dry ☐ Diaphoretic
☐☐Mental Health Status Exam ☐☐LUL ☐ LLL ☐ Throughout CHEST DRAINAGE DEVICE ☐☐See Nurses’ Notes ☐☐See Nurses’ Notes Mucous membranes: ☐ Moist  ☐ Dry
☐☐See Nurses’ Notes ☐☐Wheezes: ☐☐N / A
☐☐Inspiratory  ☐ Expiratory ☐☐Insitu: ☐ Chest tube PERIPHERAL APICAL PULSE ☐☐See Nurses’ Notes
☐☐Location: ☐ Blake drain TEMPERATURE ☐☐Regular  ☐ Irregular
RESPIRATORY FONTANELLE  ☐ N / A
☐☐Respirations even and unlaboured ☐☐RUL ☐ RML ☐ RLL ☐ Pigtail Warm to:  ☐ Extremities ☐☐Murmur ☐☐Closed ☐ Flat & soft
☐☐Respiratory distress: ☐☐LUL ☐ LLL ☐ Throughout Site: ☐ Mediastinal ☐ RUL ☐ RML ☐☐Other ☐☐Other ☐☐Full / bulging ☐ Sunken
☐☐Mild  ☐ Moderate  ☐ Severe ☐☐Stridor ☐ Grunting ☐ RLL ☐ LUL ☐ LLL ☐☐See Nurses’ Notes ☐☐See Nurses’ Notes
☐☐Nasal flaring ☐☐Referred upper airway sounds ☐☐See Nurses’ Notes
☐☐ cm H2O suction
☐☐Cough: ☐ Dry ☐ Loose
Nurses’

☐☐Tracheal tug ☐☐Underwater seal

Normal

PERIPHERAL PULSES
Notes

☐☐Head bobbing ☐☐Productive Drainage is:

☐☐Indrawing: ☐☐Nasal congestion ☐☐Sanguinous ☐ Serous
☐☐Intercostal  ☐ Subcostal ☐☐See Nurses’ Notes ☐☐Serosanguinous ☐ Chylous Left radial / ulnar / brachial
☐☐Substernal Air leak:  ☐ Yes  ☐ No
☐☐Abdominal breathing AIR ENTRY Right radial / ulnar / brachial
☐☐Scalene contractions ☐☐Equal to bases ☐☐See Nurses’ Notes
Left femoral / D pedis / P tibialis / popliteal
☐☐Decreased to:
☐☐See Nurses’ Notes Right femoral / D pedis / P tibialis / popliteal
☐☐RUL ☐ RML ☐ RLL
☐☐LUL ☐ LLL ☐ Throughout
☐☐See Neurovascular assessment record
☐☐See Nurses’ Notes
GASTROINTESTINAL GENITOURINARY MUSCULO-SKELETAL
ABDOMEN BOWEL SOUNDS GASTRIC TUBE  ☐ N / A BLADDER REPRODUCTIVE  ☐ N / A GAIT
☐☐Flat ☐ Rounded ☐ Soft ☐☐Present ☐ Absent ☐☐Insitu ☐☐Self-voiding ☐ Diaper ☐☐Menses at present ☐☐Steady ☐ Unsteady
☐☐Firm ☐ Distended ☐ Shiny Location of bowel sounds: ☐☐Location ☐☐Catheter: Size ☐☐See Nurses’ Notes ☐☐Not observed
☐☐Tenderness: ☐☐RUQ ☐ LUQ ☐ RLQ ☐ LLQ ☐☐Type ☐☐Intermittent ☐ Continuous ☐☐Ambulatory/Walker
☐☐RUQ ☐ LUQ ☐ RLQ ☐ LLQ ☐☐See Nurses’ Notes ☐☐Length ☐☐See Nurses’ Notes ☐☐Wheelchair
☐☐Guarding ☐☐Tube placement verified pH ☐☐See Nurses’ Notes
☐☐See Nurses’ Notes NUTRITION ☐☐Straight drainage ☐ Intermittent suction URINE  ☐ N / A
☐☐Oral ad lib ☐ Breastfeeding  ☐ NPO ☐☐Clamped ☐ Open barrel ☐☐Dilute ☐ Concentrated DEVICES  ☐ N / A
BOWELS ☐☐Nausea ☐ Vomiting ☐☐Suction: ☐☐Traction ☐ Cast
Colour: ☐☐Splint ☐ Brace
☐☐Last bowel movement ☐☐Meal Plan  ☐☐Continuous ☐ Intermittent ☐☐Clear ☐ Cloudy ☐ Amber ☐☐Other
☐☐See stool chart ☐☐See Nurses’ Notes
☐☐See Nurses’ Notes ☐☐Yellow ☐ Other ☐☐See Nurses’ Notes
☐☐Ostomy site FEEDING  ☐ N / A ☐☐Hematuria:
Drainage:  ☐ Yes  ☐ No ☐☐Continuous ☐ Bolus ☐☐Slight ☐ Moderate ☐ Marked
☐☐See Nurses’ Notes ☐☐Intermittent q   h ☐☐See Nurses’ Notes
☐☐See Nurses’ Notes
INTEGUMENT QUALITY CHECKS & SCORES PERSONAL SAFETY PRECAUTIONS
☐☐Skin clear DRESSINGS  ☐ N / A Indicate completed check with a ✓ and insert actual score into box ☐☐None  ☐ Suicidal  ☐ Elopement
☐☐Bruising ☐ Petechiae ☐ Rash Site: Alarms on & reviewed Braden Q Score ☐☐Siderails Up
Location ☐☐Dry & intact ☐☐Other
☐☐VAC continuous / intermittent at mm Hg Identification Band on Mobility ☐☐Violence Prevention Care Plan insitu
☐☐See Nurses’ Notes
☐☐See Nurses’ Notes Allergy Band on Activity ☐☐See Nurses’ Notes
PHOTOTHERAPY  ☐ N / A
DRAINAGE  ☐ N / A Bedside Safety Check Sensory Perception SAFETY
Start date   Type
Irradiance
☐☐Fresh ☐ Old ☐ Sanguinous
☐☐Serous ☐ Serosanguinous ☐ Purulent Violence Prevention Screen Moisture ISOLATION:  ☐ Yes  ☐ No
☐☐See Nurses’ Notes ☐☐None Type: ☐ Contact ☐ Droplet
Patient plan of care updated Friction & Shear
☐☐See Nurses’ Notes ☐ Droplet & contact ☐ Contact Plus
MUCOUS MEMBRANES
Falls Risk Assessment score Nutrition ☐ Airborne ☐ Airborne & contact
☐☐Pink ☐ Intact ☐ Lesions DRAIN  ☐ N / A
☐☐Painful ☐ Drooling Family orientation / Tissue Perfusion ☐☐See Nurses’ Notes
☐☐Insitu Education to area / Diagnosis
☐☐Stomatitis / Mucositis Grade ☐☐Location Seizure chart Total Score
☐☐See Nurses’ Notes ☐☐Type

Strike a line through any assessment data to indicate that it does not apply or has not been assessed
Assessment Time: Initials: Check boxes ☑ to indicate assessment findings.

PSYCHOSOCIAL / BEHAVIORAL CARDIOVASCULAR HYDRATION

AFFECT / MOOD BREATH SOUNDS CHEST MOVEMENT CENTRAL COLOUR PERIPHERAL COLOUR Central edema present: ☐ Yes  ☐ No
☐☐Happy ☐ Calm ☐ Anxious ☐☐Clear to bases ☐☐Equal & adequate ☐☐Pink ☐ Pale ☐ Mottled ☐☐Pink ☐ Pale ☐ Mottled Peripheral edema present: ☐ Yes  ☐ No
☐☐Withdrawn ☐ Upset ☐ Irritable ☐☐Crackles ☐☐See Nurses’ Notes ☐☐Jaundiced ☐ Flushed ☐☐Jaundiced ☐ Flushed Skin turgor: ☐ Elastic ☐ Poor
☐☐Flat ☐ Other ☐☐RUL ☐ RML ☐ RLL ☐☐Other ☐☐Other Skin: ☐ Dry ☐ Diaphoretic
☐☐Mental Health Status Exam ☐☐LUL ☐ LLL ☐ Throughout CHEST DRAINAGE DEVICE ☐☐See Nurses’ Notes ☐☐See Nurses’ Notes Mucous membranes: ☐ Moist  ☐ Dry
☐☐See Nurses’ Notes ☐☐Wheezes: ☐☐N / A
☐☐Inspiratory  ☐ Expiratory ☐☐Insitu: ☐ Chest tube PERIPHERAL APICAL PULSE ☐☐See Nurses’ Notes
☐☐Location: ☐ Blake drain TEMPERATURE ☐☐Regular  ☐ Irregular
RESPIRATORY FONTANELLE  ☐ N / A
☐☐Respirations even and unlaboured ☐☐RUL ☐ RML ☐ RLL ☐ Pigtail Warm to:  ☐ Extremities ☐☐Murmur ☐☐Closed ☐ Flat & soft
☐☐Respiratory distress: ☐☐LUL ☐ LLL ☐ Throughout Site: ☐ Mediastinal ☐ RUL ☐ RML ☐☐Other ☐☐Other ☐☐Full / bulging ☐ Sunken
☐☐Mild  ☐ Moderate  ☐ Severe ☐☐Stridor ☐ Grunting ☐ RLL ☐ LUL ☐ LLL ☐☐See Nurses’ Notes ☐☐See Nurses’ Notes
☐☐Nasal flaring ☐☐Referred upper airway sounds ☐☐See Nurses’ Notes
☐☐ cm H2O suction
☐☐Cough: ☐ Dry ☐ Loose
Nurses’

☐☐Tracheal tug ☐☐Underwater seal

Normal

PERIPHERAL PULSES
Notes

☐☐Head bobbing ☐☐Productive Drainage is:

☐☐Indrawing: ☐☐Nasal congestion ☐☐Sanguinous ☐ Serous
☐☐Intercostal  ☐ Subcostal ☐☐See Nurses’ Notes ☐☐Serosanguinous ☐ Chylous Left radial / ulnar / brachial
☐☐Substernal Air leak:  ☐ Yes  ☐ No
☐☐Abdominal breathing AIR ENTRY Right radial / ulnar / brachial
☐☐Scalene contractions ☐☐Equal to bases ☐☐See Nurses’ Notes
Left femoral / D pedis / P tibialis / popliteal
☐☐Decreased to:
☐☐See Nurses’ Notes Right femoral / D pedis / P tibialis / popliteal
☐☐RUL ☐ RML ☐ RLL
☐☐LUL ☐ LLL ☐ Throughout
☐☐See Neurovascular assessment record
☐☐See Nurses’ Notes
GASTROINTESTINAL GENITOURINARY MUSCULO-SKELETAL
ABDOMEN BOWEL SOUNDS GASTRIC TUBE  ☐ N / A BLADDER REPRODUCTIVE  ☐ N / A GAIT
☐☐Flat ☐ Rounded ☐ Soft ☐☐Present ☐ Absent ☐☐Insitu ☐☐Self-voiding ☐ Diaper ☐☐Menses at present ☐☐Steady ☐ Unsteady
☐☐Firm ☐ Distended ☐ Shiny Location of bowel sounds: ☐☐Location ☐☐Catheter: Size ☐☐See Nurses’ Notes ☐☐Not observed
☐☐Tenderness: ☐☐RUQ ☐ LUQ ☐ RLQ ☐ LLQ ☐☐Type ☐☐Intermittent ☐ Continuous ☐☐Ambulatory/Walker
☐☐RUQ ☐ LUQ ☐ RLQ ☐ LLQ ☐☐See Nurses’ Notes ☐☐Length ☐☐See Nurses’ Notes ☐☐Wheelchair
☐☐Guarding ☐☐Tube placement verified pH ☐☐See Nurses’ Notes
☐☐See Nurses’ Notes NUTRITION ☐☐Straight drainage ☐ Intermittent suction URINE  ☐ N / A
☐☐Oral ad lib ☐ Breastfeeding  ☐ NPO ☐☐Clamped ☐ Open barrel ☐☐Dilute ☐ Concentrated DEVICES  ☐ N / A
BOWELS ☐☐Nausea ☐ Vomiting ☐☐Suction: ☐☐Traction ☐ Cast
Colour: ☐☐Splint ☐ Brace
☐☐Last bowel movement ☐☐Meal Plan  ☐☐Continuous ☐ Intermittent ☐☐Clear ☐ Cloudy ☐ Amber ☐☐Other
☐☐See stool chart ☐☐See Nurses’ Notes
☐☐See Nurses’ Notes ☐☐Yellow ☐ Other ☐☐See Nurses’ Notes
☐☐Ostomy site FEEDING  ☐ N / A ☐☐Hematuria:
Drainage:  ☐ Yes  ☐ No ☐☐Continuous ☐ Bolus ☐☐Slight ☐ Moderate ☐ Marked
☐☐See Nurses’ Notes ☐☐Intermittent q   h ☐☐See Nurses’ Notes
☐☐See Nurses’ Notes
INTEGUMENT QUALITY CHECKS & SCORES PERSONAL SAFETY PRECAUTIONS
☐☐Skin clear DRESSINGS  ☐ N / A Indicate completed check with a ✓ and insert actual score into box ☐☐None  ☐ Suicidal  ☐ Elopement
☐☐Bruising ☐ Petechiae ☐ Rash Site: Alarms on & reviewed Braden Q Score ☐☐Siderails Up
Location ☐☐Dry & intact ☐☐Other
☐☐VAC continuous / intermittent at mm Hg Identification Band on Mobility ☐☐Violence Prevention Care Plan insitu
☐☐See Nurses’ Notes
☐☐See Nurses’ Notes Allergy Band on Activity ☐☐See Nurses’ Notes
PHOTOTHERAPY  ☐ N / A
DRAINAGE  ☐ N / A Bedside Safety Check Sensory Perception SAFETY
Start date   Type
Irradiance
☐☐Fresh ☐ Old ☐ Sanguinous
☐☐Serous ☐ Serosanguinous ☐ Purulent Violence Prevention Screen Moisture ISOLATION:  ☐ Yes  ☐ No
☐☐See Nurses’ Notes ☐☐None Type: ☐ Contact ☐ Droplet
Patient plan of care updated Friction & Shear
☐☐See Nurses’ Notes ☐ Droplet & contact ☐ Contact Plus
MUCOUS MEMBRANES
Falls Risk Assessment score Nutrition ☐ Airborne ☐ Airborne & contact
☐☐Pink ☐ Intact ☐ Lesions DRAIN  ☐ N / A
☐☐Painful ☐ Drooling Family orientation / Tissue Perfusion ☐☐See Nurses’ Notes
☐☐Insitu Education to area / Diagnosis
☐☐Stomatitis / Mucositis Grade ☐☐Location Seizure chart Total Score
☐☐See Nurses’ Notes ☐☐Type

Signatures &
Initials

ABBREVIATIONS
BiPAP Bilevel Positive Airway Pressure L Left N No RLL Right Lower Lobe
°C Degrees Celsius LLL Left Lower Lobe NA Not Applicable RLQ Right Lower Quadrant
PATIENT IDENTIFICATION

cm Centimeter(s) LLQ Left Lower Quadrant NG Nasogastric RML Right Middle Lobe
CPAP Continuous Positive Airway Pressure LUL Left Upper Lobe NJ Nasojejunal RUL Right Upper Lobe
EVD External Ventricular Drain LUQ Left Upper Quadrant NN Nurses’ Notes RUQ Right Upper Quadrant
GT Gastrostomy Tube M Mask NP Nasal Prongs VAC Vacuum Assisted Closure
HFNP High Flow Nasal Prongs MAP Mean Arterial Pressure q __ h Every ___ hours Y Yes
JT Jejunostomy tube mL Milliliters R Right
kg Kilograms MRP Most Responsible Physician RA Room Air

52578 CHBC Flowsheet.indd 1 8/4/16 2:07 PM

 Patient Identification

Daily Flowsheet
0 – 3 MONTHS
PEWS Scoring Legend: 0 1 2 3

Date:Initials:

Time:

80 80
70 70
Respiratory Rate 60 60
(1 minute) 50 50

Resp: • 40 40
Respiratory

30 30
20 20

O2 Saturation (%)
< 3L or 30%
Supplemental
O2 ≥ 3L or 30%
Concentration ≥ 6L or 40%
Delivered ≥ 8L or 50%
Mode of Delivery
None
Respiratory Mild
Distress Moderate
Severe
PEWS Score for Respiratory
(record most severe score)

190 190
Heart Rate (1 minute) 180 180
& Blood Pressure 170 170
160 160
Systolic: V V 150 150
Diastolic:
140 140
(Do not score blood pressure)
Cardiovascular

130 130
Normal Parameters: 120 120
Systolic (mmHg): 110 110
60 – 84 (0 – 28 days)
73 – 105 (1 – 3 mos) 100 100

Diastolic (mmHg): 90 90
30 – 53 (0 – 28 days) 80 80
36 – 68 (1 – 3 mos)
70 70
Apex: • 60 60
Monitor: * 50 50

MAP
1 – 2 seconds
Capillary Refill 3 seconds
Time 4 seconds
≥ 5 seconds
Pink
Pale
Skin Colour
Grey / Cyanotic
Grey & Mottled
PEWS Score for Cardiovascular
(record most severe score)
Playing / Appropriate
PEWS Behaviour

Sleeping
Irritable
Lethargic / Confused
Reduced response to pain
PEWS Score for Behaviour
(record most severe score)
Persistent vomiting following surgery
Bronchodilator every 15 minutes
Total PEWS Score
(R + C + B + vomiting + bronchodilator)

•
Situational Temperature

40 40

A - Axilla 39 39
R - Rectal
°C

38 38
O - Oral
T - Temporal 37 37

E - Esophageal 36 36

Patient/Family/Caregiver concern
Awareness
Factors

Unusual therapy

Watcher patient

Communication breakdown

PEWS Score ≥ 2

PEWS Escalation Process
Activated (time) See NN
Sepsis Screen

Screen for sepsis if PEWS score increases or temperature is > 38.5°C / < 36.0°C. (Indicate with a ✓ & document findings & actions in Nurses’ Notes.)

Score 0 – 1 Continue to monitor & document as Score 3 Increase Score 4 Notify MRP / delegate. Score 5 – 13 Immediate assessment by MRP /
Pediatric Early per orders & routine protocols. frequency of and / or score Consider pediatrician consult. or score of delegate (& pediatrician if available).
Warning assessments & increases MRP / delegate to communicate “3” in any one MRP / delegate to communicate a
System (PEWS) Score 2 Review with more experienced healthcare documentation
by 2 after
a plan of care. Increase
category
plan of care. Increase nursing care
or any one of interventions
Escalation Aid 5 Situational professional. Escalate if further consultation as per assessments. Reassess with increasing interventions as per
Awareness required or resources do not allow. Continue plan from adequacy of resources & plan. Consider internal or external
Factors to monitor as per orders / protocols. consultation. escalate to meet deficits. transfer to higher level of care.

PUPILS Size Right

Left

B = Brisk Reaction Right

S = Sluggish
F = Fixed Left

N E
Spontaneous 4

To speech 3
Y
E E To pain 2

C = Closed None 1

U V Coos / Oriented 5

E
R
Irritable Cry / Confused 4
R
Cries to pain / Inappropriate 3
B

O A Moans to pain/Incomprehensible 2
L None 1

L M
Normal spontaneous / Obeys 6

Withdraws to touch / Localized 5

O O
T
Withdraws to pain / Withdraws 4

S O Abnormal flexion 3

G R Abnormal extension 2

P Flaccid 1

I TOTAL SCORE GCS

I
C Muscle Strength Right Arm
Refer to rating scale below

N
Left Arm
Rate 0 – 5

A Right Leg

A Left Leg

L COLOR, WARMTH Right Arm

L & SENSATION OF
EXTREMITIES
Left Arm

Right Leg
✓ = Normal
NN = Nurses’ Notes Left Leg
BLADDER ✓ = Normal
FUNCTION NN = Nurses’ Notes

Time

Pain Tool  Pain Score

(q4h &
PRN) Location of Pain

Arousal Score
Enteral / Gastric Tube
Regular IV Site to Source:
Checks Touch, look & compare q1h

C
Patient Safety Check q1h

PRAM Score (Asthma patients only)

A
Phototherapy / Eye Shields

R Repositioning q h

E Ambulation

Foley Care / Pericare

Routine Shower (S) / Bath (B)

Nursing
Care Mouth care

Oximeter site probe change q4h

Family presence
CH 00086423  29-JULY-2016

PUPIL SIZE (mm) MUSCLE STRENGTH GRADING SYSTEM LEVEL OF AROUSAL SCORE
Movement overcoming gravity, but 1 2 3 4 5
0 / 5 No movement 3 / 5
not against resistance Does Not
Normal Sleep,
Movement overcoming gravity & Difficult to Responds Only Respond
1 / 5 Trace movement 4 / 5 Awake & Alert, Easy to Arouse
some resistance Arouse to Verbal to Physical to Verbal
Oriented to Verbal
Movement only Stimulation Stimulation or Physical
1 2 3 4 5 6 7 8 2 / 5 5 / 5 Normal strength against resistance Stimulation
(not against gravity) Stimulation

52578 CHBC Flowsheet.indd 2 8/4/16 2:07 PM

 Patient Identification

Daily Flowsheet
4 – 11 MONTHS
PEWS Scoring Legend: 0 1 2 3

Date:Initials:

Time:

80 80
70 70
Respiratory Rate 60 60
(1 minute) 50 50

Resp: • 40 40
Respiratory

30 30
20 20

O2 Saturation (%)
< 3L or 30%
Supplemental
O2 ≥ 3L or 30%
Concentration ≥ 6L or 40%
Delivered ≥ 8L or 50%
Mode of Delivery
None
Respiratory Mild
Distress Moderate
Severe
PEWS Score for Respiratory
(record most severe score)

190 190
Heart Rate (1 minute) 180 180
& Blood Pressure 170 170
160 160
Systolic: V V 150 150
Diastolic: 140 140
Cardiovascular

130 130
(Do not score blood pressure)
120 120
Normal Parameters: 110 110
Systolic (mmHg):
100 100
82 – 105
Diastolic (mmHg): 90 90
46 – 68 80 80

•
70 70
Apex:
60 60
Monitor: * 50 50

MAP
1 – 2 seconds
Capillary Refill 3 seconds
Time 4 seconds
≥ 5 seconds
Pink
Pale
Skin Colour
Grey / Cyanotic
Grey & Mottled
PEWS Score for Cardiovascular
(record most severe score)
Playing / Appropriate
PEWS Behaviour

Sleeping
Irritable
Lethargic / Confused
Reduced response to pain
PEWS Score for Behaviour
(record most severe score)
Persistent vomiting following surgery
Bronchodilator every 15 minutes
Total PEWS Score
(R + C + B + vomiting + bronchodilator)

•
Situational Temperature

40 40

A - Axilla 39 39
R - Rectal
°C

38 38
O - Oral
T - Temporal 37 37

E - Esophageal 36 36

Patient/Family/Caregiver concern
Awareness
Factors

Unusual therapy

Watcher patient

Communication breakdown

PEWS Score ≥ 2

PEWS Escalation Process
Activated (time) See NN
Sepsis Screen

Screen for sepsis if PEWS score increases or temperature is > 38.5°C / < 36.0°C. (Indicate with a ✓ & document findings & actions in Nurses’ Notes.)

Score 0 – 1 Continue to monitor & document as Score 3 Increase Score 4 Notify MRP / delegate. Score 5 – 13 Immediate assessment by MRP /
Pediatric Early per orders & routine protocols. frequency of and / or score Consider pediatrician consult. or score of delegate (& pediatrician if available).
Warning assessments & increases MRP / delegate to communicate “3” in any one MRP / delegate to communicate a
System (PEWS) Score 2 Review with more experienced healthcare documentation
by 2 after
a plan of care. Increase
category
plan of care. Increase nursing care
or any one of interventions
Escalation Aid 5 Situational professional. Escalate if further consultation as per assessments. Reassess with increasing interventions as per
Awareness required or resources do not allow. Continue plan from adequacy of resources & plan. Consider internal or external
Factors to monitor as per orders / protocols. consultation. escalate to meet deficits. transfer to higher level of care.

PUPILS Size Right

Left

B = Brisk Reaction Right

S = Sluggish
F = Fixed Left

N E
Spontaneous 4

To speech 3
Y
E E To pain 2

C = Closed None 1

U V Coos / Oriented 5

E
R
Irritable Cry / Confused 4
R
Cries to pain / Inappropriate 3
B

O A Moans to pain/Incomprehensible 2
L None 1

L M
Normal spontaneous / Obeys 6

Withdraws to touch / Localized 5

O O
T
Withdraws to pain / Withdraws 4

S O Abnormal flexion 3

G R Abnormal extension 2

P Flaccid 1

I TOTAL SCORE GCS

I
C Muscle Strength Right Arm
Refer to rating scale below

N
Left Arm
Rate 0 – 5

A Right Leg

A Left Leg

L COLOR, WARMTH Right Arm

L & SENSATION OF
EXTREMITIES
Left Arm

Right Leg
✓ = Normal
NN = Nurses’ Notes Left Leg
BLADDER ✓ = Normal
FUNCTION NN = Nurses’ Notes

Time

Pain Tool  Pain Score

(q4h &
PRN) Location of Pain

Arousal Score
Enteral / Gastric Tube
Regular IV Site to Source:
Checks Touch, look & compare q1h

C
Patient Safety Check q1h

PRAM Score (Asthma patients only)

A
Phototherapy / Eye Shields

R Repositioning q h

E Ambulation

Foley Care / Pericare

Routine Shower (S) / Bath (B)

Nursing
Care Mouth care

Oximeter site probe change q4h

Family presence
CH 00086423  29-JULY-2016

PUPIL SIZE (mm) MUSCLE STRENGTH GRADING SYSTEM LEVEL OF AROUSAL SCORE
Movement overcoming gravity, but 1 2 3 4 5
0 / 5 No movement 3 / 5
not against resistance Does Not
Normal Sleep,
Movement overcoming gravity & Difficult to Responds Only Respond
1 / 5 Trace movement 4 / 5 Awake & Alert, Easy to Arouse
some resistance Arouse to Verbal to Physical to Verbal
Oriented to Verbal
Movement only Stimulation Stimulation or Physical
1 2 3 4 5 6 7 8 2 / 5 5 / 5 Normal strength against resistance Stimulation
(not against gravity) Stimulation

52578 CHBC Flowsheet.indd 3 8/4/16 2:07 PM

 Patient Identification

Daily Flowsheet
1 – 3 YEARS
PEWS Scoring Legend: 0 1 2 3

Date:Initials:

Time:

70 70
60 60
Respiratory Rate
(1 minute) 50 50

•
40 40
Resp:
Respiratory

30 30
20 20

O2 Saturation (%)
< 3L or 30%
Supplemental
O2 ≥ 3L or 30%
Concentration ≥ 6L or 40%
Delivered ≥ 8L or 50%
Mode of Delivery
None
Respiratory Mild
Distress Moderate
Severe
PEWS Score for Respiratory
(record most severe score)

190 190
Heart Rate (1 minute) 180 180
& Blood Pressure 170 170
160 160
Systolic: V V 150 150
Diastolic: 140 140
Cardiovascular

130 130
(Do not score blood pressure)
120 120
Normal Parameters: 110 110
Systolic (mmHg):
100 100
85 – 109
Diastolic (mmHg): 90 90
37 – 67 80 80

•
70 70
Apex:
60 60
Monitor: * 50 50

MAP
1 – 2 seconds
Capillary Refill 3 seconds
Time 4 seconds
≥ 5 seconds
Pink
Pale
Skin Colour
Grey / Cyanotic
Grey & Mottled
PEWS Score for Cardiovascular
(record most severe score)
Playing / Appropriate
PEWS Behaviour

Sleeping
Irritable
Lethargic / Confused
Reduced response to pain
PEWS Score for Behaviour
(record most severe score)
Persistent vomiting following surgery
Bronchodilator every 15 minutes
Total PEWS Score
(R + C + B + vomiting + bronchodilator)

•
Situational Temperature

40 40

A - Axilla 39 39
R - Rectal
°C

38 38
O - Oral
T - Temporal 37 37

E - Esophageal 36 36

Patient/Family/Caregiver concern
Awareness
Factors

Unusual therapy

Watcher patient

Communication breakdown

PEWS Score ≥ 2

PEWS Escalation Process
Activated (time) See NN
Sepsis Screen

Screen for sepsis if PEWS score increases or temperature is > 38.5°C / < 36.0°C. (Indicate with a ✓ & document findings & actions in Nurses’ Notes.)

Score 0 – 1 Continue to monitor & document as Score 3 Increase Score 4 Notify MRP / delegate. Score 5 – 13 Immediate assessment by MRP /
Pediatric Early per orders & routine protocols. frequency of and / or score Consider pediatrician consult. or score of delegate (& pediatrician if available).
Warning assessments & increases MRP / delegate to communicate “3” in any one MRP / delegate to communicate a
System (PEWS) Score 2 Review with more experienced healthcare documentation
by 2 after
a plan of care. Increase
category
plan of care. Increase nursing care
or any one of interventions
Escalation Aid 5 Situational professional. Escalate if further consultation as per assessments. Reassess with increasing interventions as per
Awareness required or resources do not allow. Continue plan from adequacy of resources & plan. Consider internal or external
Factors to monitor as per orders / protocols. consultation. escalate to meet deficits. transfer to higher level of care.

PUPILS Size Right

Left

B = Brisk Reaction Right

S = Sluggish
F = Fixed Left

N E
Spontaneous 4

To speech 3
Y
E E To pain 2

C = Closed None 1

U V Coos / Oriented 5

E
R
Irritable Cry / Confused 4
R
Cries to pain / Inappropriate 3
B

O A Moans to pain/Incomprehensible 2
L None 1

L M
Normal spontaneous / Obeys 6

Withdraws to touch / Localized 5

O O
T
Withdraws to pain / Withdraws 4

S O Abnormal flexion 3

G R Abnormal extension 2

P Flaccid 1

I TOTAL SCORE GCS

I
C Muscle Strength Right Arm
Refer to rating scale below

N
Left Arm
Rate 0 – 5

A Right Leg

A Left Leg

L COLOR, WARMTH Right Arm

L & SENSATION OF
EXTREMITIES
Left Arm

Right Leg
✓ = Normal
NN = Nurses’ Notes Left Leg
BLADDER ✓ = Normal
FUNCTION NN = Nurses’ Notes

Time

Pain Tool  Pain Score

(q4h &
PRN) Location of Pain

Arousal Score
Enteral / Gastric Tube
Regular IV Site to Source:
Checks Touch, look & compare q1h

C
Patient Safety Check q1h

PRAM Score (Asthma patients only)

A
Phototherapy / Eye Shields

R Repositioning q h

E Ambulation

Foley Care / Pericare

Routine Shower (S) / Bath (B)

Nursing
Care Mouth care

Oximeter site probe change q4h

Family presence
CH 00086423  29-JULY-2016

PUPIL SIZE (mm) MUSCLE STRENGTH GRADING SYSTEM LEVEL OF AROUSAL SCORE
Movement overcoming gravity, but 1 2 3 4 5
0 / 5 No movement 3 / 5
not against resistance Does Not
Normal Sleep,
Movement overcoming gravity & Difficult to Responds Only Respond
1 / 5 Trace movement 4 / 5 Awake & Alert, Easy to Arouse
some resistance Arouse to Verbal to Physical to Verbal
Oriented to Verbal
Movement only Stimulation Stimulation or Physical
1 2 3 4 5 6 7 8 2 / 5 5 / 5 Normal strength against resistance Stimulation
(not against gravity) Stimulation

52578 CHBC Flowsheet.indd 4 8/4/16 2:07 PM

 Patient Identification

Daily Flowsheet
4 – 6 YEARS
PEWS Scoring Legend: 0 1 2 3

Date:Initials:

Time:

50 50
Respiratory Rate
(1 minute) 40 40

•
30 30
Resp:
20 20
Respiratory

O2 Saturation (%)
< 3L or 30%
Supplemental
O2 ≥ 3L or 30%
Concentration ≥ 6L or 40%
Delivered
≥ 8L or 50%
Mode of Delivery
None
Respiratory Mild
Distress Moderate
Severe
PEWS Score for Respiratory
(record most severe score)

160 160
Heart Rate (1 minute)
& Blood Pressure 150 150

140 140
Systolic: V V 130 130
Diastolic:
120 120
Cardiovascular

(Do not score blood pressure) 110 110

100 100
Normal Parameters:
Systolic (mmHg): 90 90
91 – 114
80 80
Diastolic (mmHg):
50 – 80 70 70

Apex: • 60

50
60

50
Monitor: *
MAP
1 – 2 seconds
Capillary Refill 3 seconds
Time 4 seconds
≥ 5 seconds
Pink
Pale
Skin Colour
Grey / Cyanotic
Grey & Mottled
PEWS Score for Cardiovascular
(record most severe score)
Playing / Appropriate
Behaviour

Sleeping
Irritable
Lethargic / Confused
Reduced response to pain
PEWS Score for Behaviour
(record most severe score)
Persistent vomiting following surgery
PEWS

Bronchodilator every 15 minutes

Total PEWS Score
(R + C + B + vomiting + bronchodilator)

•
Situational Temperature

40 40

A - Axilla 39 39
R - Rectal
°C

38 38
O - Oral
T - Temporal 37 37

E - Esophageal 36 36

Patient/Family/Caregiver concern
Awareness
Factors

Unusual therapy

Watcher patient

Communication breakdown

PEWS Score ≥ 2

PEWS Escalation Process
Activated (time) See NN
Sepsis Screen

Screen for sepsis if PEWS score increases or temperature is > 38.5°C / < 36.0°C. (Indicate with a ✓ & document findings & actions in Nurses’ Notes.)

Score 0 – 1 Continue to monitor & document as Score 3 Increase Score 4 Notify MRP / delegate. Score 5 – 13 Immediate assessment by MRP /
Pediatric Early per orders & routine protocols. frequency of and / or score Consider pediatrician consult. or score of delegate (& pediatrician if available).
Warning assessments & increases MRP / delegate to communicate “3” in any one MRP / delegate to communicate a
System (PEWS) Score 2 Review with more experienced healthcare documentation
by 2 after
a plan of care. Increase
category
plan of care. Increase nursing care
or any one of interventions
Escalation Aid 5 Situational professional. Escalate if further consultation as per assessments. Reassess with increasing interventions as per
Awareness required or resources do not allow. Continue plan from adequacy of resources & plan. Consider internal or external
Factors to monitor as per orders / protocols. consultation. escalate to meet deficits. transfer to higher level of care.

PUPILS Size Right

Left

B = Brisk Reaction Right

S = Sluggish
F = Fixed Left

N E
Spontaneous 4

To speech 3
Y
E E To pain 2

C = Closed None 1

U V Coos / Oriented 5

E
R
Irritable Cry / Confused 4
R
Cries to pain / Inappropriate 3
B

O A Moans to pain/Incomprehensible 2
L None 1

L M
Normal spontaneous / Obeys 6

Withdraws to touch / Localized 5

O O
T
Withdraws to pain / Withdraws 4

S O Abnormal flexion 3

G R Abnormal extension 2

P Flaccid 1

I TOTAL SCORE GCS

I
C Muscle Strength Right Arm
Refer to rating scale below

N
Left Arm
Rate 0 – 5

A Right Leg

A Left Leg

L COLOR, WARMTH Right Arm

L & SENSATION OF
EXTREMITIES
Left Arm

Right Leg
✓ = Normal
NN = Nurses’ Notes Left Leg
BLADDER ✓ = Normal
FUNCTION NN = Nurses’ Notes

Time

Pain Tool  Pain Score

(q4h &
PRN) Location of Pain

Arousal Score
Enteral / Gastric Tube
Regular IV Site to Source:
Checks Touch, look & compare q1h

C
Patient Safety Check q1h

PRAM Score (Asthma patients only)

A
Phototherapy / Eye Shields

R Repositioning q h

E Ambulation

Foley Care / Pericare

Routine Shower (S) / Bath (B)

Nursing
Care Mouth care

Oximeter site probe change q4h

Family presence
CH 00086423  29-JULY-2016

PUPIL SIZE (mm) MUSCLE STRENGTH GRADING SYSTEM LEVEL OF AROUSAL SCORE
Movement overcoming gravity, but 1 2 3 4 5
0 / 5 No movement 3 / 5
not against resistance Does Not
Normal Sleep,
Movement overcoming gravity & Difficult to Responds Only Respond
1 / 5 Trace movement 4 / 5 Awake & Alert, Easy to Arouse
some resistance Arouse to Verbal to Physical to Verbal
Oriented to Verbal
Movement only Stimulation Stimulation or Physical
1 2 3 4 5 6 7 8 2 / 5 5 / 5 Normal strength against resistance Stimulation
(not against gravity) Stimulation

52578 CHBC Flowsheet.indd 5 8/4/16 2:07 PM

 Patient Identification

Daily Flowsheet
7 – 11 YEARS
PEWS Scoring Legend: 0 1 2 3

Date:Initials:

Time:

50 50
Respiratory Rate
(1 minute) 40 40

•
30 30
Resp:
20 20
Respiratory

O2 Saturation (%)
< 3L or 30%
Supplemental
O2 ≥ 3L or 30%
Concentration ≥ 6L or 40%
Delivered
≥ 8L or 50%
Mode of Delivery
None
Respiratory Mild
Distress Moderate
Severe
PEWS Score for Respiratory
(record most severe score)

Heart Rate (1 minute) 150 150

& Blood Pressure 140 140
130 130
Systolic: V V 120 120
Diastolic:
110 110
Cardiovascular

(Do not score blood pressure)

100 100
Normal Parameters: 90 90
Systolic (mmHg):
96 – 121 80 80
Diastolic (mmHg): 70 70
57 – 80

•
60 60
Apex: 50 50
Monitor: *
MAP

1 – 2 seconds
Capillary Refill 3 seconds
Time 4 seconds
≥ 5 seconds
Pink
Pale
Skin Colour
Grey / Cyanotic
Grey & Mottled
PEWS Score for Cardiovascular
(record most severe score)
Playing / Appropriate
Behaviour

Sleeping
Irritable
Lethargic / Confused
Reduced response to pain
PEWS Score for Behaviour
(record most severe score)
Persistent vomiting following surgery
PEWS

Bronchodilator every 15 minutes

Total PEWS Score
(R + C + B + vomiting + bronchodilator)

•
Situational Temperature

40 40

A - Axilla 39 39
R - Rectal
°C

38 38
O - Oral
T - Temporal 37 37

E - Esophageal 36 36

Patient/Family/Caregiver concern
Awareness
Factors

Unusual therapy

Watcher patient

Communication breakdown

PEWS Score ≥ 2

PEWS Escalation Process
Activated (time) See NN
Sepsis Screen

Screen for sepsis if PEWS score increases or temperature is > 38.5°C / < 36.0°C. (Indicate with a ✓ & document findings & actions in Nurses’ Notes.)

Score 0 – 1 Continue to monitor & document as Score 3 Increase Score 4 Notify MRP / delegate. Score 5 – 13 Immediate assessment by MRP /
Pediatric Early per orders & routine protocols. frequency of and / or score Consider pediatrician consult. or score of delegate (& pediatrician if available).
Warning assessments & increases MRP / delegate to communicate “3” in any one MRP / delegate to communicate a
System (PEWS) Score 2 Review with more experienced healthcare documentation
by 2 after
a plan of care. Increase
category
plan of care. Increase nursing care
or any one of interventions
Escalation Aid 5 Situational professional. Escalate if further consultation as per assessments. Reassess with increasing interventions as per
Awareness required or resources do not allow. Continue plan from adequacy of resources & plan. Consider internal or external
Factors to monitor as per orders / protocols. consultation. escalate to meet deficits. transfer to higher level of care.

PUPILS Size Right

Left

B = Brisk Reaction Right

S = Sluggish
F = Fixed Left

N E
Spontaneous 4

To speech 3
Y
E E To pain 2

C = Closed None 1

U V Coos / Oriented 5

E
R
Irritable Cry / Confused 4
R
Cries to pain / Inappropriate 3
B

O A Moans to pain/Incomprehensible 2
L None 1

L M
Normal spontaneous / Obeys 6

Withdraws to touch / Localized 5

O O
T
Withdraws to pain / Withdraws 4

S O Abnormal flexion 3

G R Abnormal extension 2

P Flaccid 1

I TOTAL SCORE GCS

I
C Muscle Strength Right Arm
Refer to rating scale below

N
Left Arm
Rate 0 – 5

A Right Leg

A Left Leg

L COLOR, WARMTH Right Arm

L & SENSATION OF
EXTREMITIES
Left Arm

Right Leg
✓ = Normal
NN = Nurses’ Notes Left Leg
BLADDER ✓ = Normal
FUNCTION NN = Nurses’ Notes

Time

Pain Tool  Pain Score

(q4h &
PRN) Location of Pain

Arousal Score
Enteral / Gastric Tube
Regular IV Site to Source:
Checks Touch, look & compare q1h

C
Patient Safety Check q1h

PRAM Score (Asthma patients only)

A
Phototherapy / Eye Shields

R Repositioning q h

E Ambulation

Foley Care / Pericare

Routine Shower (S) / Bath (B)

Nursing
Care Mouth care

Oximeter site probe change q4h

Family presence
CH 00086423  29-JULY-2016

PUPIL SIZE (mm) MUSCLE STRENGTH GRADING SYSTEM LEVEL OF AROUSAL SCORE
Movement overcoming gravity, but 1 2 3 4 5
0 / 5 No movement 3 / 5
not against resistance Does Not
Normal Sleep,
Movement overcoming gravity & Difficult to Responds Only Respond
1 / 5 Trace movement 4 / 5 Awake & Alert, Easy to Arouse
some resistance Arouse to Verbal to Physical to Verbal
Oriented to Verbal
Movement only Stimulation Stimulation or Physical
1 2 3 4 5 6 7 8 2 / 5 5 / 5 Normal strength against resistance Stimulation
(not against gravity) Stimulation

52578 CHBC Flowsheet.indd 6 8/4/16 2:07 PM

 Patient Identification

Daily Flowsheet
12+ YEARS
PEWS Scoring Legend: 0 1 2 3

Date:Initials:

Time:

40 40
Respiratory Rate
(1 minute) 30 30

•
20 20
Resp:
10 10
Respiratory

O2 Saturation (%)
< 3L or 30%
Supplemental
O2 ≥ 3L or 30%
Concentration ≥ 6L or 40%
Delivered
≥ 8L or 50%
Mode of Delivery
None

Respiratory Mild
Distress Moderate
Severe
PEWS Score for Respiratory
(record most severe score)

Heart Rate (1 minute) 140 140

& Blood Pressure 130 130

120 120
Systolic: V V
Diastolic: 110 110
Cardiovascular

(Do not score blood pressure) 100 100

Normal Parameters: 90 90
Systolic (mmHg): 80 80
105 – 136
Diastolic (mmHg): 70 70
62 – 87 60 60
Apex: • 50 50
Monitor: *
MAP
1 – 2 seconds

Capillary Refill 3 seconds

Time 4 seconds
≥ 5 seconds
Pink
Pale
Skin Colour
Grey / Cyanotic
Grey & Mottled
PEWS Score for Cardiovascular
(record most severe score)
Playing / Appropriate
Behaviour

Sleeping
Irritable
Lethargic / Confused
Reduced response to pain
PEWS Score for Behaviour
(record most severe score)
Persistent vomiting following surgery
PEWS

Bronchodilator every 15 minutes

Total PEWS Score
(R + C + B + vomiting + bronchodilator)

•
Situational Temperature

40 40

A - Axilla 39 39
R - Rectal
°C

38 38
O - Oral
T - Temporal 37 37

E - Esophageal 36 36

Patient/Family/Caregiver concern
Awareness
Factors

Unusual therapy

Watcher patient

Communication breakdown

PEWS Score ≥ 2

PEWS Escalation Process
Activated (time) See NN
Sepsis Screen

Screen for sepsis if PEWS score increases or temperature is > 38.5°C / < 36.0°C. (Indicate with a ✓ & document findings & actions in Nurses’ Notes.)

Score 0 – 1 Continue to monitor & document as Score 3 Increase Score 4 Notify MRP / delegate. Score 5 – 13 Immediate assessment by MRP /
Pediatric Early per orders & routine protocols. frequency of and / or score Consider pediatrician consult. or score of delegate (& pediatrician if available).
Warning assessments & increases MRP / delegate to communicate “3” in any one MRP / delegate to communicate a
System (PEWS) Score 2 Review with more experienced healthcare documentation
by 2 after
a plan of care. Increase
category
plan of care. Increase nursing care
or any one of interventions
Escalation Aid 5 Situational professional. Escalate if further consultation as per assessments. Reassess with increasing interventions as per
Awareness required or resources do not allow. Continue plan from adequacy of resources & plan. Consider internal or external
Factors to monitor as per orders / protocols. consultation. escalate to meet deficits. transfer to higher level of care.

PUPILS Size Right

Left

B = Brisk Reaction Right

S = Sluggish
F = Fixed Left

N E
Spontaneous 4

To speech 3
Y
E E To pain 2

C = Closed None 1

U V Coos / Oriented 5

E
R
Irritable Cry / Confused 4
R
Cries to pain / Inappropriate 3
B

O A Moans to pain/Incomprehensible 2
L None 1

L M
Normal spontaneous / Obeys 6

Withdraws to touch / Localized 5

O O
T
Withdraws to pain / Withdraws 4

S O Abnormal flexion 3

G R Abnormal extension 2

P Flaccid 1

I TOTAL SCORE GCS

I
C Muscle Strength Right Arm
Refer to rating scale below

N
Left Arm
Rate 0 – 5

A Right Leg

A Left Leg

L COLOR, WARMTH Right Arm

L & SENSATION OF
EXTREMITIES
Left Arm

Right Leg
✓ = Normal
NN = Nurses’ Notes Left Leg
BLADDER ✓ = Normal
FUNCTION NN = Nurses’ Notes

Time

Pain Tool  Pain Score

(q4h &
PRN) Location of Pain

Arousal Score
Enteral / Gastric Tube
Regular IV Site to Source:
Checks Touch, look & compare q1h

C
Patient Safety Check q1h

PRAM Score (Asthma patients only)

A
Phototherapy / Eye Shields

R Repositioning q h

E Ambulation

Foley Care / Pericare

Routine Shower (S) / Bath (B)

Nursing
Care Mouth care

Oximeter site probe change q4h

Family presence
CH 00086423  29-JULY-2016

PUPIL SIZE (mm) MUSCLE STRENGTH GRADING SYSTEM LEVEL OF AROUSAL SCORE
Movement overcoming gravity, but 1 2 3 4 5
0 / 5 No movement 3 / 5
not against resistance Does Not
Normal Sleep,
Movement overcoming gravity & Difficult to Responds Only Respond
1 / 5 Trace movement 4 / 5 Awake & Alert, Easy to Arouse
some resistance Arouse to Verbal to Physical to Verbal
Oriented to Verbal
Movement only Stimulation Stimulation or Physical
1 2 3 4 5 6 7 8 2 / 5 5 / 5 Normal strength against resistance Stimulation
(not against gravity) Stimulation

52578 CHBC Flowsheet.indd 7 8/4/16 2:07 PM