Paediatric Date: Surname: ..................................

NHI: ....................

PEWS
score
Vital sign Time (24 hour): Time (24 hour): First Names: . . ..........................................................
PET
60 60 D ate of Bir th: ......... / . . ...... / . . ....... Sex: . . ....................
3
55 55
3
50 PL ACE PATIENT ID HERE
50
2
45 45
Respiratory rate 2
40 40
1
(breaths/min)
35
30
0
35
30
PAEDIATRIC VITAL SIGNS CHART: 1-4 YEARS
Add >50 write value 0
in box 25 0 25
20
20
15
0
15
Medical Staff Modification to Early Warning Score (PEWS) Triggers
2
10 10 Any modification to the PEWS must be made by a Consultant or Registrar and regularly
3
5 5 reviewed by the primary team. Ignore any modification that is not signed & dated.
PET
Severe 3 Severe Accepted Values & Date Doctors name,
Vital Sign
Respiratory Moderate 2 Moderate Adjusted PEWS & time designation, contact details
distress Mild 1 Mild / /
Nil 0 Nil :
≥ 15 > 50% 3 ≥ 15 > 50% / /
11-14 40-50% 2 11-14 40-50% :
O2 L/min / /
2-10 30-39% 1 2-10 30-39%
:
≤ 2 21-30% 0 ≤2 21-30%
/ /
O2 Delivery Method*
:
93-100 0 93-100 / /
SpO2 89-92 1 89-92 Not for CPR Not for PET :
write value in box 85-88 2 85-88
All limitations must be documented in the patient’s clinical record.
< 85 3 < 85
Blood Pressure 120
2
0
120 Mandatory Early Warning Score Escalation Pathway
(mmHg) 115 115 Total PEWS Action
0
110 110 • Inform nurse in charge
0
105 105 • Optimise appropriate treatment as prescribed
0 PEWS 1-3
100 100 • Manage anxiety/pain
0 or any vital sign in yellow zone
95 95 • Observations at least 4 hourly or more frequently if required
0
90 90 • Review oxygen requirement
0
85 0 85 PEWS 4-5
80 80 or any vital sign in orange zone • Notify nurse in charge
1 • HO Review within
75 1 75
Acute illness or unstable 60 minutes • Calculate full PEWS score
70 2 70 chronic disease
65 65 • Optimise treatment
3 • Notify nurse in charge • Plan to be formulated and
60 3 60 • Registrar review
Score systolic 55 55 documented including timeframe
PET within 15 minutes and criteria for review and
ONLY 50 PET 50 PEWS 6-7 • Paediatric & PAR team frequency of vital signs
3 or any vital sign in red zone referral #6785
180 180 • Recalculate PEWS after interventions
Heart rate 3 Likely to deteriorate rapidly • If patient is is about • Consider ICU referral
170 170
(beats/min) 2 to trigger a PET call,
160 160
1 please contact SMO
150 150
1 before dialing 777
140 140
0 • DIAL 777
130 0 130
X • STATE ‘PAEDIATRIC MEDICAL EMERGENCY’
120 0 120 PEWS 8+ • Vital signs Q15mins
110 110 or any vital sign in blue zone
0 • Document plan which includes timeframe and criteria for review
100 0 100 Immediately life threatening • Recalculate PEWS after interventions
90 1 90 critical illness • CONTACT PRIMARY CARE TEAM
If heart rate
>180 or <50 80 2 80 • Consider transfer to ICU
write value in box 70 3 70
CALL A PAEDIATRIC MEDICAL EMERGENCY REQUEST URGENT REVIEW IF:
60 PET 60
IMMEDIATELY IF: Apnoea
39.5 39.5 Respiratory or cardiac arrest is imminent Unexpected seizure
39 39 Any observations in PET Zone If score has increased by >4 in last hour
38.5 38.5 Major Bleeding Nurse concerned about patient
Temperature Airway threat
(oC) 38 38
37.5 37.5 FLACC 0 1 2
X 37 37 Face No particular expression or Occasional grimace or frown, Frequent to constant frown,
36.5 36.5 smile withdrawn, disinterested clenched jaw, quivering chin
36 36 Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up
Resources courtesy of Canterbury DHB

35.5 35.5
Activity Lying quietly, normal position, Squirming, shifting back and Arched, rigid or jerking
Level of Alert 0 Alert moves easily forth, tense
Consciousness Voice 1 Voice Cry No cry (awake or asleep) Moans or whimpers: occasional Crying steadily, screams or
Pain 3 Pain
Capital Docs ID 1.101903

compliant sobs, frequent complaints

Unresponsive PET Unresponsive Consolability Content, relaxed Reassured by occasional Difficult to console or comfort
Issued October 2014
Review March 2015

Pain score 0 to 10 0 to 10 touching, hugging or being

talked to, distractible
TOTAL PEWS TOTAL PEWS Each patient will have blood pressure done on admission,
Initials Initials and once per shift if stable or as clinically indicated.
 FLUID AMOUNT (please tick) Surname: .................................. NHI: ....................
PAEDIATRICS FLUID BALANCE CHART Date: / / Full maintenance First Names: . . ..........................................................
⅔ maintenance D ate of Bir th: ......... / . . ...... / . . ....... Sex: . . ....................
24 hours 1-4 YEARS Weight: ½ maintenance
.................................. mls/hr PL ACE PATIENT ID HERE

Input (mls) Output (mls)

Oral / Bolus (I/V) Nappy weight: Urinalysis:
Line 1 (I/V) Line 2 (I/V) Line 3 (I/V)

2 hrly Phlebitis score

enteral intake (pushed)

Nurse’s signature
Total volume infused

Total volume infused

Total volume infused

Feeding Method

Rate / amount

Volume given

Running total
RUNNING
Total volume

Total volume
pH Aspirate

(read from pump)

(read from pump)

(read from pump)

(PO/NG/NJ/PEG)
Fluid type

Fluid type

Fluid type

Fluid type

Fluid type

Bowels /
TOTAL

Drain(s)
Vomit /
NG loss
infused

stoma
Urine
given
Time

Time
Rate

Rate

Rate
0800 0800
0900 0900

1000 1000

1100 1100

1200 1200
1300
1300
1400
1400
1500
1500
8 hr
8 hr total
total
1600
1600
1700
1700
1800
1800
1900
1900
2000
2000
2100
2100
2200
2200
2300
2300
16 hr
16 hr total
total 0000
0000
0100
0100
0200
0200 0300
0300 0400
0400 0500
0500 0600
0600 0700
0700 24 hr Input
0800 24 hr Output
24 hr 24 hr Balance
total (indicate + or -)

INTRAVENOUS ‘FLUID TYPE’ ABBREVIATIONS PHLEBITIS SCORE: 0 1 2 3 4 5

• NS = 0.9% Saline • DSK = 0.45% Saline + 5% Dextrose + KCL • IVM  = IV medications • D5 = 5% dextrose • LIP = Lipids • Alb = Albumin • FFP = Fresh Frozen Plasma All of 4 and:
Slight: Two of: All of: All of 3 and:
exudate,
• DS = 0.9% Saline + 5% Dextrose • IVAB = IV antibiotics • D10 = 10% dextrose • TPN = Aqueous • RBC = Blood • Plt = Platelets IV SITE: Site healthy pain or pain, redness pain, redness, palpable
thrombosis
redness or swelling swelling venous cord
and/or pyrexia