PEAD EWS.xlsx

	A	B	C	D	E	F	H	K	O	R	V	W	AE
1												PATIETN IDENTIFICATION LABEL
2
3							PEDIATRICS EARLY WARNING SIGNS (0-3Months)
4							PEDIATRICS EARLY WARNING SIGNS (0-3Months)
5
6	DATE OF ADMISSION:							AGE:			WEIGHT:
7	PEWS KEY				DATE					SCORE			DATE
8	0	1	2	3	TIME					SCORE			TIME
9	A+B Respiratory Rate breaths/min				≥80								≥80
10					71-80								71-80
11					61-70								61-70
12					51-60								51-60
13					31-50								31-50
14					21-30								21-30
15					16-20								16-20
16					≤15								≤15
17
18	Respiratory Efforts				Severe								Severe
19					Moderate								Moderate
20					Mild								Mild
21					Normal								Normal
22
23	Oxygen Therapy Device: Room Air(RA), Nasal Cannula (NC), Face Mask (FM), HFNC (H)				Pressure								Pressure
24					>2L								>2L
25					≤2L								≤2L
26					Room Air(RA)								Room Air(RA)
27					Device								Device
28
29	Oxygen Saturation SpO2				≥94%								≥94%
30					90-93%								90-93%
31					86-89%								86-89%
32					≤85%								≤85%
33
34	C CIRCULATION *HR <60 with no signs of life- begin CPR and Call emergency				≥191								≥191
35					181-190								181-190
36					171-180								171-180
37					161-170								161-170
38					151-160								151-160
39					141-150								141-150
40					131-140								131-140
41					121-130								121-130
42					111-120								111-120
43					101-110								101-110
44					91-100								91-100
45					81-90								81-90
46					71-80								71-80
47					61-70								61-70
48					≤60								≤60
49
50	BLOOD PRESSURE (mmHg) Score Systolic BP				>120								>120
51					111-120								111-120
52					101-110								101-110
53					91-100								91-100
54					81-90								81-90
55					71-80								71-80
56					61-70								61-70
57	Skin Colour Pink (P), Mottled (M), Pale (P), Cynosed ( C)				51-60								51-60
58					46-50								46-50
59					≤45								≤45
60					Skin Colour								Skin Colour
61	Central Capillary Refill Time (Sec)				>2								>2
62	Central Capillary Refill Time (Sec)				≤2								≤2
63
64	D DISABILITY (AVPU)				Alert								Alert
65					Voice								Voice
66					Pain								Pain
67					Unresponsive								Unresponsive
68
69	E EXPOSURE Temperature				≥40°								≥40°
70					39°								39°
71					38°								38°
72					37°								37°
73					36°								36°
74					s								<35°
75
76	PEWS Score
77
78	Blood Sugar
79	Pain Score
80	Urine Output Monitoring
81	Monitoring Frequency
82	Escalation of Care Y/N
83	Initials
84	PEWS ACTION PLAN
85	SCORE					FREQUENCY OF MONITORING			LOCATION			CLINICAL RESPONSE
86	0-1					4 Hourly			General Bed			Continue Monitoring , Any trigger should prompt increase in observation frequency as clinically appropriate.
87	2					2 Hourly			General Bed			Increase Monitoring Frequency, Inform Nurse Incharge
88	3					1 Hourly			High Dependency Bed			Requires urgent Medical Review, Inform Nurse Incharge Pediatric Registrar/MRP and Nursing Supervisor
89	≥4					Close Observetion With Contenious Monitoring			High Dependency Bed/Intensive Care Unit			Requires Urgent Medical Review, Inform Nurse Incharge Pediatric Registrar/MRP and Nursing Supervisor
90	Assessment Of Respiratory Efforts
91						Mild			Moderate			Severe
92	Air Way					Stridor on exertion/Crying			Mild Stridor at rest			Stridor at rest
93	Behaviour And Feeding					* Normal * Talks In Sentences			* Some/Intermittent irritablity * Diffculty Talking/Crying * Difficulty Feeding or Eating			* Increased Irritablity and/or lethargy * Looks Exhausted * Unable to talk or Cry * Unable to feed or eat
94	Respiratory Rate					* Mildly Increased			Respiratory Rate In Blue Zone			* Respiratory Rate in Pink Zone *Increased or markedly reduced respiratory rate as child tries
95	Accessory Muscle Use					* Mild Intercoastal and Suprasternal Recession			* Moderate Intercoastal and Suprasternal Recession * Nasal Flaring			Marked Intercostal, Suprasternal and Sternal Recession.
96	Oxygen					No Oxygen Requirement			* Mild Hypoxemia corrected by Oxygen * Increasing Oxygen Requirement			Hypoxemia may not be Corrected by oxygen
97	Other											* Gasping, Grunting * Extreme Palour, Cyanosis *Apnoea
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