Date Time PEWS Nurse Initials & NMBI Alert. Airway Behaviour and feeding. Accessory muscle use. Oxygen. Other

Transcription

1 Score Date / Time Minimum Observations 1 4 hourly hourly Hospital Logo Paediatric Observation Chart 12+ Years Maximum Duration Nurse in Charge Escalation Guide Minimum Alert PEWS does not replace an emergency call * Pink score in any parameter merits review Medical Escalation Agreement Following clinical assessment, if appropriate, state clinical impression, permitted parameters & calling criteria. Document clearly in clinical notes. Minimum Response Any trigger should prompt increase in observation frequency as clinically appropriate 3* 1 hourly Nurse in Charge review minutes Urgent medical review 6 Continuous Urgent SENIOR medical review + Senior Doctor +/- 7 Continuous URGENT PEWS CALL Immediate local response team ISBAR Communication Tool PEWS does not replace clinical concern Identify Situation Background Assessment Recommendation Senior Doctor Airway Behaviour and feeding rate Accessory muscle use Other Event Record for PEWS score 6 Date Time PEWS Nurse Initials & NMBI Alert Assessment of Effort rate Stridor on exertion/crying Talks in sentences ly increased intercostal and No oxygen requirement stridor at rest Some/intermittent irritability Difficultly talking/crying Difficultly feeding or eating rate in blue zone rate intercostal and Nasal flaring hypoxemia Increasing oxygen requirement Stridor at rest Increased irritability and/or lethargy Looks exhausted Unable to talk or cry Unable to feed or eat rate in pink zone Increased or markedly reduced respiratory rate as the child tires Marked intercostal, suprasternal and sternal recession Hypoxemia may not be Gasping, grunting Extreme pallor, cyanosis Apnoea Paediatric Sepsis 6 Recognition 2 or more of the following temperature <36 C or >38.5 C Inappropriate tachypnoea Inappropriate tachycardia Reduced peripheral perfusion Altered mental status Consider co-morbidities Suspected or proven sepsis TAKE 3 < 6 Mins. GIVE 3 < 6 Mins. IV or IO access and take blood samples Urine output measurement Early SENIOR input Within 6 minutes High flow oxygen IV/IO fluids & consider early inotropic support Broad spectrum IV/IO antimicrobials Mochua Print & Design Version N

2 12+ Years PEWS Score Key Chart Date DD/ MM/ YY Date / Time Clinical New Acceptable Range Next Medical Review Senior Doctor Parameter Amendment For Chronic Conditions Year Date Time (24hr) 12/12 18:45 Frequency of observations 4 AB AIRWAY & BREATHING Clinician / Family Concern Concern Score Rate (breaths per minute) 6 seconds Concern of O2 delivery Room air (RA) Nasal Cannula (NC) Face mask (FM) Tracheostomy (T) HHFNC (H) CPAP (C) / BiPAP (B) C CIRCULATION If HR scores 1 or more consider central CRT and BP and refer to Sepsis 6 Protocol *HR <6 with no signs of life - begin CPR and call the emergency team RR Number rate Effort Therapy (L/Mins.) SpO2 (%) Heart Rate (beats per minute) 6 seconds L L 9-93% RA 98 rate L L 9-93% Central Capillary Refill Time (seconds) HR Number 9 CRT Score CRT Score Blood (mmhg) Score systolic BP Cuff Size: PK - pink P - pale D DISABILITY If not Alert, consider GCS BP Number (systolic/diastolic) 1 72 BP Score BP Score M - mottled C - cyanosed Score - if not assessed and put a vertical line through column AVPU Skin Colour Alert Voice Pain Unresponsive PK Colour A V P U EEXPOSURE Consider sepsis if temperature <36 C or >38.5 C Notify doctor if urine output is <.5mL/Kg/hr Temperature ( ) Record as graph Pain scale in use ( ): Total PEWS score Pain Score Reassess within (Mins.) Total PEWS Reassess within FLACC Faces Nurse/NMBI Numeric

3 Score Date / Time Minimum Observations 1 4 hourly hourly Hospital Logo Paediatric Observation Chart 5-11 Years Maximum Duration Nurse in Charge Escalation Guide Minimum Alert PEWS does not replace an emergency call * Pink score in any parameter merits review Medical Escalation Agreement Following clinical assessment, if appropriate, state clinical impression, permitted parameters & calling criteria. Document clearly in clinical notes. Minimum Response Any trigger should prompt increase in observation frequency as clinically appropriate 3* 1 hourly Nurse in Charge review minutes Urgent medical review 6 Continuous Urgent SENIOR medical review + Senior Doctor +/- 7 Continuous URGENT PEWS CALL Immediate local response team ISBAR Communication Tool PEWS does not replace clinical concern Identify Situation Background Assessment Recommendation Senior Doctor Airway Behaviour and feeding rate Accessory muscle use Other Event Record for PEWS score 6 Date Time PEWS Nurse Initials & NMBI Alert Assessment of Effort rate Stridor on exertion/crying Talks in sentences ly increased intercostal and No oxygen requirement stridor at rest Some/intermittent irritability Difficultly talking/crying Difficultly feeding or eating rate in blue zone rate intercostal and Nasal flaring hypoxemia Increasing oxygen requirement Stridor at rest Increased irritability and/or lethargy Looks exhausted Unable to talk or cry Unable to feed or eat rate in pink zone Increased or markedly reduced respiratory rate as the child tires Marked intercostal, suprasternal and sternal recession Hypoxemia may not be Gasping, grunting Extreme pallor, cyanosis Apnoea Paediatric Sepsis 6 Recognition 2 or more of the following temperature <36 C or >38.5 C Inappropriate tachypnoea Inappropriate tachycardia Reduced peripheral perfusion Altered mental status Consider co-morbidities Suspected or proven sepsis TAKE 3 < 6 Mins. GIVE 3 < 6 Mins. IV or IO access and take blood samples Urine output measurement Early SENIOR input Within 6 minutes High flow oxygen IV/IO fluids & consider early inotropic support Broad spectrum IV/IO antimicrobials Mochua Print & Design Version N

4 5-11 Years PEWS Score Key Chart Date DD/ MM/ YY Date / Time Clinical New Acceptable Range Next Medical Review Senior Doctor Parameter Amendment For Chronic Conditions Year Date Time 12/12 18:45 Frequency of observations 4 AB AIRWAY & BREATHING Clinician / Family Concern Concern Score Rate (breaths per minute) 6 seconds Concern of O2 delivery Room air (RA) Nasal Cannula (NC) Face mask (FM) Tracheostomy (T) HHFNC (H) CPAP (C) / BiPAP (B) C CIRCULATION If HR scores 1 or more consider central CRT and BP and refer to Sepsis 6 Protocol *HR <6 with no signs of life - begin CPR and call the emergency team RR Number rate Effort Therapy (L/Mins.) SpO2 (%) Heart Rate (beats per minute) 6 seconds 9-93% L L L L RA 98 rate 9-93% Central Capillary Refill Time (seconds) HR Number 96 CRT Score CRT Score Blood (mmhg) Score systolic BP Cuff Size: PK - pink P - pale D DISABILITY If not Alert, consider GCS BP Number (systolic/diastolic) 68 BP Score BP Score Skin Colour PK Colour A AVPU M - mottled C - cyanosed Score - if not assessed and put a vertical line through column Alert Voice Pain Unresponsive V P U EEXPOSURE Consider sepsis if temperature <36 C or >38.5 C Notify doctor if urine output is <1mL/Kg/hr Temperature ( ) Record as graph Pain scale in use ( ): Total PEWS score Pain Score Reassess within (Mins.) Total PEWS Reassess within FLACC Faces Nurse/NMBI Numeric

5 Score Date / Time Minimum Observations 1 4 hourly hourly Hospital Logo Paediatric Observation Chart 1-4 Years Maximum Duration Nurse in Charge Escalation Guide Minimum Alert PEWS does not replace an emergency call * Pink score in any parameter merits review Medical Escalation Agreement Following clinical assessment, if appropriate, state clinical impression, permitted parameters & calling criteria. Document clearly in clinical notes. Minimum Response Any trigger should prompt increase in observation frequency as clinically appropriate 3* 1 hourly Nurse in Charge review minutes Urgent medical review 6 Continuous Urgent SENIOR medical review + Senior Doctor +/- 7 Continuous URGENT PEWS CALL Immediate local response team ISBAR Communication Tool PEWS does not replace clinical concern Identify Situation Background Assessment Recommendation Senior Doctor Airway Behaviour and feeding rate Accessory muscle use Other Assessment of Effort rate Stridor on exertion/crying Talks in sentences ly increased intercostal and No oxygen requirement Event Record for PEWS score 6 Date Time PEWS Nurse Initials & NMBI Alert stridor at rest Some/intermittent irritability Difficultly talking/crying Difficultly feeding or eating rate in blue zone rate intercostal and Nasal flaring hypoxemia Increasing oxygen requirement Stridor at rest Increased irritability and/or lethargy Looks exhausted Unable to talk or cry Unable to feed or eat rate in pink zone Increased or markedly reduced respiratory rate as the child tires Marked intercostal, suprasternal and sternal recession Hypoxemia may not be Gasping, grunting Extreme pallor, cyanosis Apnoea Paediatric Sepsis 6 Recognition 2 or more of the following temperature <36 C or >38.5 C Inappropriate tachypnoea Inappropriate tachycardia Reduced peripheral perfusion Altered mental status Consider co-morbidities Suspected or proven sepsis TAKE 3 < 6 Mins. GIVE 3 < 6 Mins. IV or IO access and take blood samples Urine output measurement Early SENIOR input Within 6 minutes High flow oxygen IV/IO fluids & consider early inotropic support Broad spectrum IV/IO antimicrobials Mochua Print & Design Version N

6 1-4 Years PEWS Score Key Chart Date DD/ MM/ YY Date / Time Clinical New Acceptable Range Next Medical Review Senior Doctor Parameter Amendment For Chronic Conditions Year Date Time 12/12 18:45 Frequency of observations 4 AB AIRWAY & BREATHING Clinician / Family Concern Concern Score Rate (breaths per minute) 6 seconds Concern of O2 delivery Room air (RA) Nasal Cannula (NC) Face mask (FM) Tracheostomy (T) HHFNC (H) CPAP (C) / BiPAP (B) C CIRCULATION If HR scores 1 or more consider central CRT and BP and refer to Sepsis 6 Protocol *HR <6 with no signs of life - begin CPR and call the emergency team Effort Therapy (L/Mins.) SpO2 (%) Heart Rate (beats per minute) 6 seconds RR Number rate rate L L L L % 9-93% SpO 2 Score RA Central Capillary Refill Time (seconds) HR Number 1 CRT Score CRT Score Blood (mmhg) Score systolic BP Cuff Size: PK - pink P - pale D DISABILITY BP Number (systolic/diastolic) 1 65 BP Score BP Score M - mottled C - cyanosed Skin Colour PK Colour Score - if not assessed and put a vertical line through column If not Alert, consider GCS AVPU Alert Voice Pain Unresponsive A V P U EEXPOSURE Consider sepsis if temperature <36 C or >38.5 C Notify doctor if urine output is <1mL/Kg/hr Temperature ( ) Record as graph Pain scale in use ( ): Total PEWS score Pain Score Reassess within (Mins.) Total PEWS Reassess within FLACC Faces Numeric Nurse/NMBI

7 Score Date / Time Minimum Observations 1 4 hourly hourly Hospital Logo Paediatric Observation Chart 4-11 Months Maximum Duration Nurse in Charge Escalation Guide Minimum Alert PEWS does not replace an emergency call * Pink score in any parameter merits review Medical Escalation Agreement Following clinical assessment, if appropriate, state clinical impression, permitted parameters & calling criteria. Document clearly in clinical notes. Minimum Response Any trigger should prompt increase in observation frequency as clinically appropriate 3* 1 hourly Nurse in Charge review minutes Urgent medical review 6 Continuous Urgent SENIOR medical review + Senior Doctor +/- 7 Continuous URGENT PEWS CALL Immediate local response team ISBAR Communication Tool PEWS does not replace clinical concern Identify Situation Background Assessment Recommendation Senior Doctor Airway Behaviour and feeding rate Accessory muscle use Other Event Record for PEWS score 6 Date Time PEWS Nurse Initials & NMBI Alert Assessment of Effort rate Stridor on exertion/crying Talks in sentences ly increased intercostal and No oxygen requirement stridor at rest Some/intermittent irritability Difficultly talking/crying Difficultly feeding or eating rate in blue zone rate intercostal and Nasal flaring hypoxemia Increasing oxygen requirement Stridor at rest Increased irritability and/or lethargy Looks exhausted Unable to talk or cry Unable to feed or eat rate in pink zone Increased or markedly reduced respiratory rate as the child tires Marked intercostal, suprasternal and sternal recession Hypoxemia may not be Gasping, grunting Extreme pallor, cyanosis Apnoea Paediatric Sepsis 6 Recognition 2 or more of the following temperature <36 C or >38.5 C Inappropriate tachypnoea Inappropriate tachycardia Reduced peripheral perfusion Altered mental status Consider co-morbidities Suspected or proven sepsis TAKE 3 < 6 Mins. GIVE 3 < 6 Mins. IV or IO access and take blood samples Urine output measurement Early SENIOR input Within 6 minutes High flow oxygen IV/IO fluids & consider early inotropic support Broad spectrum IV/IO antimicrobials Mochua Print & Design Version N

8 4-11 Months PEWS Score Key Chart Date DD/ MM/ YY Date / Time Clinical New Acceptable Range Next Medical Review Senior Doctor Parameter Amendment For Chronic Conditions Year Date Time 12/12 18:45 Frequency of observations 4 AB AIRWAY & BREATHING Clinician / Family Concern Concern Score Rate (breaths per minute) 6 seconds Concern of O2 delivery Room air (RA) Nasal Cannula (NC) Face mask (FM) Tracheostomy (T) HHFNC (H) CPAP (C) / BiPAP (B) C CIRCULATION If HR scores 1 or more consider central CRT and BP and refer to Sepsis 6 Protocol *HR <6 with no signs of life - begin CPR and call the emergency team RR Number rate Effort Therapy (L/Mins.) SpO2 (%) Heart Rate (beats per minute) 6 seconds rate L L L L % 9-93% SpO 2 Score RA HR Number 119 Central Capillary Refill Time (seconds) CRT Score CRT Score Blood (mmhg) Score systolic BP Cuff Size: PK - pink P - pale D DISABILITY If not Alert, consider GCS M - mottled C - cyanosed Score - if not assessed and put a vertical line through column BP Number (systolic/diastolic) 9 68 AVPU BP Score BP Score Skin Colour PK Colour Alert Voice Pain Unresponsive A V P U EEXPOSURE Consider sepsis if temperature <36 C or >38.5 C Notify doctor if urine output is <1mL/Kg/hr Pain scale in use ( ): FLACC Temperature ( ) Record as graph Total PEWS score Pain Score Reassess within (Mins.) Total PEWS Reassess within Faces Numeric Nurse/NMBI

9 Score Date / Time Minimum Observations 1 4 hourly hourly Hospital Logo Paediatric Observation Chart -3 Months Maximum Duration Nurse in Charge Escalation Guide Minimum Alert PEWS does not replace an emergency call * Pink score in any parameter merits review Medical Escalation Agreement Following clinical assessment, if appropriate, state clinical impression, permitted parameters & calling criteria. Document clearly in clinical notes. Minimum Response Any trigger should prompt increase in observation frequency as clinically appropriate 3* 1 hourly Nurse in Charge review minutes Urgent medical review 6 Continuous Urgent SENIOR medical review + Senior Doctor +/- 7 Continuous URGENT PEWS CALL Immediate local response team ISBAR Communication Tool PEWS does not replace clinical concern Identify Situation Background Assessment Recommendation Senior Doctor Airway Behaviour and feeding rate Accessory muscle use Other Event Record for PEWS score 6 Date Time PEWS Nurse Initials & NMBI Alert Assessment of Effort rate Stridor on exertion/crying Talks in sentences ly increased intercostal and No oxygen requirement stridor at rest Some/intermittent irritability Difficultly talking/crying Difficultly feeding or eating rate in blue zone rate intercostal and Nasal flaring hypoxemia Increasing oxygen requirement Stridor at rest Increased irritability and/or lethargy Looks exhausted Unable to talk or cry Unable to feed or eat rate in pink zone Increased or markedly reduced respiratory rate as the child tires Marked intercostal, suprasternal and sternal recession Hypoxemia may not be Gasping, grunting Extreme pallor, cyanosis Apnoea Paediatric Sepsis 6 Recognition 2 or more of the following temperature <36 C or >38.5 C Inappropriate tachypnoea Inappropriate tachycardia Reduced peripheral perfusion Altered mental status Consider co-morbidities Suspected or proven sepsis TAKE 3 < 6 Mins. GIVE 3 < 6 Mins. IV or IO access and take blood samples Urine output measurement Early SENIOR input Within 6 minutes High flow oxygen IV/IO fluids & consider early inotropic support Broad spectrum IV/IO antimicrobials Mochua Print & Design Version N

10 -3 Months PEWS Score Key Date / Time Clinical New Acceptable Range Next Medical Review Senior Doctor Gestational age: Corrected: Y/N Chart Date DD/ MM/ YY Parameter Amendment For Chronic Conditions Year Date Time 12/12 18:45 Frequency of observations 4 Clinician / Family Concern Concern Score Concern AB AIRWAY & BREATHING Rate (breaths per minute) 6 seconds of O2 delivery Room air (RA) Nasal Cannula (NC) Face mask (FM) Tracheostomy (T) HHFNC (H) CPAP (C) / BiPAP (B) Effort Therapy (L/Mins.) SpO2 (%) RR Number rate 44 RA rate L L L L % 9-93% SpO 2 Score C CIRCULATION If HR scores 1 or more consider central CRT and BP and refer to Sepsis 6 Protocol *HR <6 with no signs of life - begin CPR and call the emergency team Heart Rate (beats per minute) 6 seconds Central Capillary Refill Time (seconds) HR Number 124 CRT Score CRT Score Blood (mmhg) Score systolic BP Cuff Size: PK - pink P - pale D DISABILITY If not Alert, consider GCS BP Number (systolic/diastolic) BP Score BP Score M - mottled C - cyanosed Skin Colour PK Colour Score - if not assessed and put a vertical line through column AVPU Alert Voice Pain Unresponsive A V P U EEXPOSURE Consider sepsis if temperature <36 C or >38.5 C Notify doctor if urine output is <1mL/Kg/hr Temperature ( ) Record as graph Pain scale in use ( ): FLACC Total PEWS score Pain Score Reassess within (Mins.) Total PEWS Reassess within Faces Numeric Nurse/NMBI