Event Record for PEWS score ≥6

Date Time PEWS Nurse Initials & NMBI Alert

Hospital Logo Addressograph
Addressograph
Paediatric Observation Chart
Ward
0-3 Months Consultant Ward
Consultant
Escalation Guide
PEWS does not replace an emergency call Assessment of Respiratory Effort
Score Minimum Observations Minimum Alert Minimum Response Mild Moderate Severe
Airway • Stridor on exertion/crying • Mild stridor at rest • Stridor at rest
1 4 hourly Any trigger should prompt increase in
Nurse in Charge Behaviour • Normal • Some/intermittent irritability • Increased irritability and/or lethargy
2 2 - 4 hourly observation frequency as clinically appropriate • Looks exhausted
and feeding • Talks
T in sentences • Difficultly talking/crying
3* 1 hourly Nurse in Charge review • Difficultly feeding or eating • Unable to talk or cry
Nurse in Charge + Doctor on call • Unable to feed or eat
4-5 30 minutes Urgent medical review • Respiratory rate in pink zone
Respiratory • Mildly increased • Respiratory rate
Nurse in Charge + Doctor on call rate in blue zone • Increased or markedly reduced
6 Continuous Urgent SENIOR medical review respiratory rate as the child tires
+ Senior Doctor + Consultant
Accessory • Mild intercostal and • Moderate intercostal and • Marked intercostal, suprasternal
™ Continuous URGENT PEWS CALL Immediate local response team muscle use suprasternal recession suprasternal recession and sternal recession
• Nasal flaring
* Pink score in any parameter merits review
Oxygen • No oxygen • Mild hypoxemia • Hypoxemia may not be
PEWS does not replace clinical concern requirement corrected by oxygen corrected by oxygen
• Increasing oxygen requirement

ISBAR
• Gasping, grunting
Identify Situation Background Assessment Recommendation
Other
• Extreme pallor, cyanosis
Communication Tool • Apnoea

Medical Escalation Suspension

Date / Time Next Medical Doctor
Suspension Conditions Review Signature/Print name /MCRN

Start Date:

Start Time:

End Date:

End Time:

Start Date:

Start Time:

End Date:

End Time:

Start Date:

Start Time:

End Date:

End Time:

Paediatric Sepsis 6

Mochua Print & Design | www.mochuaprint.ie

• IV or IO access and take blood samples
Recognition TAKE 3 • Urine output measurement
2 or more of the following < 60 Mins.
• Early SENIOR input
• Core temperature <36°C or >38.5°C
• Inappropriate tachypnoea
• Inappropriate tachycardia
Suspected or Within 60 minutes
• Reduced peripheral perfusion proven sepsis • High flow oxygen
• Altered mental status GIVE 3 • IV/IO fluids & consider early inotropic support
• Consider co-morbidities < 60 Mins.
• Broad spectrum IV/IO antimicrobials

Version N3 | 2016
 PEWS Score Key
0-3 Months Chart Date D D / M M / Y Y
0 1 2 3
Gestational age: Corrected: Y/N
Date / Time Clinical Parameters New Acceptable Range Next Medical Review Doctor
Signature/Print name /MCRN

Addressograph

Ward

Parameter
Amendment
For Chronic Conditions
Consultant
Core Year Date 12/12 Core
Parameters Parameters
Time 18:45

Frequency of observations 40

Clinician / Family Concern

Concern Score 0 Concern
80 80
70 70
Respiratory 60 60
Rate 50 50
AB (breaths per minute)
40 40
AIRWAY Assess for
30 30
& BREATHING 60 seconds
20 20
15 15

RR Number 44
RR Score 0 RR Score
Severe Severe
Moderate Moderate
Respiratory Mild Mild
Effort Normal Normal
RE Score 0 RE Score
Mode of O2 delivery Mode RA Mode
Room air (RA) Oxygen
Nasal Cannula (NC) Pressure Pressure
Face mask (FM) Therapy >2L >2L
Tracheostomy (T) /0LQV
”/ ”/
HHFNC (H)
CPAP (C) / BiPAP (B) O2 T Score 0 O2 T Score
• 98 •
 
SpO2
  
” ”
SpO2 Score 0 SpO2 Score
190 190
180 180
170 170
160 160
150 150
C 140 140
CIRCULATION 130 130
If HR scores 1 or more Heart Rate 120 120
consider central CRT (beats per minute)
110 110
and BP and refer to Assess for
100 100
Sepsis 6 Protocol 60 seconds
90 90
80 80
*HR <60 with no signs of 70 70
life - begin CPR and
call the emergency team
60 60

HR Number 124
HR Score 0 HR Score
Central Capillary >2 >2
Refill Time (seconds) ” ”
CRT Score 0 CRT Score
120 120
110 110
Blood Pressure
(mmHg) 100 100
Score systolic BP 90 90
80 80
Cuff Size: 70 70
________ 60 60
50 50
45 45

BP Number 65
BP Score 0 BP Score
PK - pink M - mottled
P - pale C - cyanosed Skin Colour PK Colour
6FRUH¶·LIQRWDVVHVVHG Alert A
and put a vertical line Voice V
through column AVPU
D Pain P
DISABILITY Unresponsive U
If not Alert, consider GCS AVPU Score 0 AVPU Score
• •
E Temperature  
ʝ  
EXPOSURE
Consider sepsis if Record  
temperature <360&RU!0C as graph
 
Notify doctor if urine output
is <1mL/Kg/hr ” ”

Total PEWS score 0 Total PEWS

Reassess within (Mins.) Reassess within
Pain scale in use (): Pain Score
FLACC
Faces
Numeric
Nurse/NMBI