1. Ashley Lynch, BSN, RN, CMSRN
Pediatric Early Warning Score Assessment Tool
at Beaufort Memorial Hospital
Ashley Lynch, BSN, RN, CMSRN

2. Behavior Score 0 Score 1 Score 2 Score 3 Playing Alert Appropriate
At Baseline
Sleepy
Fussy but Consolable
Irritable or Inconsolable
Lethargic
Confused
Reduced Response to Pain

3. Cardiovascular Score 0 Score 1 Score 2 Score 3 Pink
Capillary refill 1-2 seconds
Pale
Capillary refill 3 seconds
Grey
Capillary refill 4 seconds
Tachycardia 20 BPM above normal rate
Mottled
Capillary refill 5 seconds or above
Tachycardia 30 BPM above normal rate
Bradycardia

4. Respiratory Score 0 Score 1 Score 2 Score 3 Within normal parameters
Rate greater than 10 BPM above normal
Accessory muscle use
30% + FIO2
3+ L/min. O2
Rate greater than 20 above normal
Retractions
40% + FIO2
6+ L/min. O2
O2 saturation 5% below baseline
Below normal rate
Grunting
50% + FIO2
8+ L/min. o2
O2 Saturation greater than 5% below baseline

5. What to do next? Score 0-2 Reassess as scheduled & PRN Score 3
Reassess at least Q4 hours & PRN
Score 4
Notify CRN
CRN assess and calculate PEWS
Call RT to bedside PRN
Q1 hour Vital Signs until baseline
Q1 hour assessment until baseline
Notify MD
Consider PRR
Score >4 or
3 in any Category
Q 15 minute Vital Signs
Q 15 minute assessments
Activate PRR
Notify MD
Notify RT
Provide intervention per Protocol
Consider transfer to higher level of care
Reassess PEWS following intervention

6. Did the PEWS positively impact your practice?

7. Did the PEWS Lead to Earlier Physician Contact or Initiation of PRRT?

8. References
Monaghan, A. (2005). Detecting and managing deterioration in children. Paediatric Care, 17(1), doi: /paed c964