Date:

Time:
Location:
Prescribed
freq of
observation:

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

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

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

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
50 50
40 40
actual actual

170 170

160 160
150 150
140 140
130 130
120 120
BP cuff BP cuff
size:110 size:110
100 100
90 90
80 80
70 70
60 60
actual 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 actual

Staff or carer concerns Staff or

(staff=S,Carer=C,None=N) carer
concerns
(staff=S,Ca
rer=C,Non
e=N)
PEWS 6 PEWS
Initials Initials
Time of Time of
medical medical
review if review if
score score
elevated elevated

Pain Pain
Blood Blood
Glucose Glucose

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

 Name…………………………………

DOB……………………………………

CHI…………………………………….

Affix patient ID label

PAEDIATRIC EARLY WARNING SCORE(PEWS)

>12 MONTHS

(To be used from 12 years and above)

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

PEWS should be calculated every time observations Chart Number…………………….

are recorded. Date……………………………………

How to calculate score :

 Records observations at intervals as prescribed

 Record observations in black pen with a dot
 Score as per the colour key Concerns include,but are not restricted to;
0 1 3
 Add total points score ●gut feeling
 Record total score in PEWS box at bottom of chart
 Score should be taken as below ●looks unwell

●apnoea
PEWS Level of Action to be taken
escalations ●airway threat
Regardless of PEWS always escalate if concerned about about a patient’s condition
0 0 ●increased work of breathing,
1-2 1
3-4 or any in red 2 ●significant↑in 0₂ requirement
zone
●Poor perfusion/blue/mottled/cool peripheries

●seizures

●confusion/irritability/altered behavior

●hypoglycaemia

●high pain score despite appropriate analgesia

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