Exam

Pediatric Early Warning Score

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Pediatric Early Warning Score, PEWS Score

  • Criteria
  1. Behavior
    1. Score 3
      1. Lethargic or
      2. Cofused or
      3. Reduced pain response
    2. Score 2
      1. Irritable or agitated and not consolable
    3. Score 1
      1. Sleeping or
      2. Irritable but consolable
    4. Score 0
      1. Playing or
      2. Appropriate activity for the patient
  2. Cardiovascular
    1. Score 3
      1. Grey appearance or
      2. Capillary Refill Time 5 seconds or longer or
      3. Tachycardia with Heart Rate 30 beats above normal for age
      4. Bradycardia for age
    2. Score 2
      1. Capillary Refill Time 4 seconds or less
      2. Tachycardia with Heart Rate 20 beats above normal for age
    3. Score 1
      1. Pale or
      2. Capillary Refill Time 3 seconds or less
    4. Score 0
      1. Skin Pink or
      2. Capillary Refill Time 1-2 seconds
  3. Respiratory
    1. Score 3
      1. Respiratory Rate 5 breaths per minute below normal range or
      2. Supplemental Oxygen of FIO2 50% or higher to maintain adequate oxygenation
    2. Score 2
      1. Respiratory Rate 20 breaths per minute above normal range or
      2. Accessory muscle use (neck retractions, intercostal retractions, abdominal breathing) or
      3. Supplemental Oxygen of FIO2 40-49% or 3 LPM or more to maintain adequate oxygenation
    3. Score 1
      1. Respiratory Rate 10 breaths per minute above normal range or
      2. Accessory muscle use (neck retractions, intercostal retractions, abdominal breathing) or
      3. Supplemental Oxygen of FIO2 24-40% or 2 LPM or more to maintain adequate oxygenation
    4. Score 0:
      1. Respiratory Rate normal for age
      2. No retractions
  4. Modifiers
    1. Score 2:
      1. Frequent interventions (e.g. frequent suctioning, repositioning, Supplemental Oxygen changes) or
      2. Multiple IV attempts
  • Interpretation
  1. Calculate total score
    1. Add score from each category (behavior, cardiovascular, respiratory and modifier)
  2. Parental concern regardless of score
    1. Rapid response evaluation
  3. Total score 7 or more
    1. Assess every 30 minutes
  4. Total score 6
    1. Assess every 1 hour
  5. Total score 5
    1. Assess every 1-2 hours
  6. Total score 4 or less
    1. Assess every 4 hours