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

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

PEWS
score
Vital sign Time (24 hour): Time (24 hour): First Names: . . ..........................................................
3
40 40 D ate of Bir th: ......... / . . ...... / . . ....... Sex: . . ....................
3
35 35
Respiratory rate 2 PL ACE PATIENT ID HERE
30 30
(breaths/min) 1
25 25
0
20 20
0
PAEDIATRIC VITAL SIGNS CHART: ≥ 12 YEARS
Add >50 write value
in box 15 15
1
10 10
2
5 PET
5
Severe 3 Severe Medical Staff Modification to Early Warning Score (PEWS) Triggers
Respiratory Moderate 2 Moderate
Any modification to the PEWS must be made by a Consultant or Registrar and regularly
distress Mild 1 Mild
reviewed by the primary team. Ignore any modification that is not signed & dated.
Nil 0 Nil
≥ 15 > 50% 3 ≥ 15 > 50% Accepted Values & Date Doctors name,
Vital Sign
11-14 40-50% 2 11-14 40-50% Adjusted PEWS & time designation, contact details
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 :
89-92 1 89-92 / /
SpO2
:
write value in box 85-88 2 85-88
/ /
< 85 3 < 85
:
2
150 150 / /
Blood Pressure 2 Not for CPR Not for PET
145 145 :
0
(mmHg) 140 140 All limitations must be documented in the patient’s clinical record.
0
135 135
0
130
125
0
130
125
Mandatory Early Warning Score Escalation Pathway
0 Total PEWS Action
120 120
0 • Inform nurse in charge
115 115
0 • Optimise appropriate treatment as prescribed
110 110
105
0
105
PEWS 1-3 • Manage anxiety/pain
0 or any vital sign in yellow zone
100 100 • Observations at least 4 hourly or more frequently if required
0 • Review oxygen requirement
95 95
0
90 90 PEWS 4-5
1 or any vital sign in orange zone • Notify nurse in charge
85 2 85
Score systolic • HO Review within
80 3 80 Acute illness or unstable 60 minutes • Calculate full PEWS score
ONLY 75 3 75 chronic disease
• Optimise treatment
70 70 • Notify nurse in charge
PET • Plan to be formulated and
3 • Registrar review documented including timeframe
Heart rate 160 160 within 15 minutes
150 3 and criteria for review and
(beats/min) 150 PEWS 6-7 • Paediatric & PAR team
140 3 140 frequency of vital signs
or any vital sign in red zone referral #6785
130 2 130 • Recalculate PEWS after interventions
2 Likely to deteriorate rapidly • If patient is is about • Consider ICU referral
120 120
110 1 to trigger a PET call,
110
X 100 0 100 please contact SMO
90 0 90 before dialing 777
80 0 80 • DIAL 777
70 70 • STATE ‘PAEDIATRIC MEDICAL EMERGENCY’
60
0 PEWS 8+ • Vital signs Q15mins
If heart rate
1 60 or any vital sign in blue zone
>180 or <50 50 3 50 • Document plan which includes timeframe and criteria for review
write value in box 40 Immediately life threatening
3 40 • Recalculate PEWS after interventions
critical illness • CONTACT PRIMARY CARE TEAM
39.5 39.5 • Consider transfer to ICU
39 39
38.5 38.5
Temperature CALL A PAEDIATRIC MEDICAL EMERGENCY REQUEST URGENT REVIEW IF:
38 38
(oC) IMMEDIATELY IF: Apnoea
37.5 37.5
Respiratory or cardiac arrest is imminent Unexpected seizure
37 37
X Any observations in PET Zone If score has increased by >4 in last hour
36.5 36.5
Major Bleeding Nurse concerned about patient
36 36
Airway threat
35.5 35.5
Level of Alert 0 Alert FACES PAIN SCALE: Children > 5 years old
Consciousness Voice 1 Voice 0 1 2 3 4 5 6 7 8 9 10
Resources courtesy of Canterbury DHB

Pain 3 Pain
Unresponsive PET Unresponsive No pain Pain
Pain score 0 to 10 0 to 10
Capital Docs ID 1.101905
Issued October 2014
Review March 2015

TOTAL PEWS TOTAL PEWS Each patient will have blood pressure done on admission,
and once per shift if stable or as clinically indicated.
Initials Initials
 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 ≥ 12 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