Download 1 to 4 years

MRN
• Blood Glucose Level 2 – 3 mmol/L
• Concern by family member
CIRCULATION
• Reduced urine output or anuria (< 1mL/kg/hr)
Blood Pressure (mmHg)
• Concern by you or any staff member
• Senior Medical Officer or Nurse review within
30 minutes.
• Observations recorded at least 30 minutely for
the first hour and then hourly thereafter.
• Prioritise care if deteriorating.
Consider:
• Need for continuous monitoring.
• Whether changes in temperature reflects
deterioration in your patient
• Consider whether there is an adverse trend in
other observation
Increase Frequency of Observations
GCS
DISABILITY
130215
NH606611
• Repeat and increase the frequency of
observations as indicated by your patients
conditions
Right
Pupil
Left
Pupil
pH
Bilirubin
Blood
Urobilinogen
Leukocytes
Protein
Ketones
Glucose
MSU/CSU/SPA
Rapid Response
Page 1 of 6
YES
NO
MODIFIED PAEDIATRIC GLASGOW
COMA SCALE
EYES OPEN
Spontaneously
To speech
To pain
None
4
3
2
1
(Check unit policy)
Nitrite
Temperature (oC)
Specific Gravity
EXPOSURE
Respiratory Rate
(breaths per minute)
Size
Reaction
Size
Reaction
Initials
Initials
FEMALE
M.O.
2 - 5 yrs
Appropriate
Words
Inappropriate
Cries but consolable
Words
Persistent cries /
screams
Cries /
Screams
Grunts
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Orientated
5
Confused
4
Inappropriate
Words
Incomprehensible
Sounds
None
Date
Time
41
40.5
40
39.5
39
38.5
38
37.5
37
36.5
36
35.5
35
34.5
34
Severe (7-10)
Moderate (4-6)
Mild (1-3)
No pain
Ini als
>5yrs
Smiles, coos
LOCATION
41
40.5
40
39.5
39
38.5
38
37.5
37
36.5
36
35.5
35
34.5
34
BEST VERBAL RESPONSE
<2yrs
Yes
Date
Time
Time:
≥ 3 Seconds
<3 Seconds
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
EYES
VERBAL
MOTOR
TOTAL SCORE
Size
Reaction
Size
Reaction
Clinical Review
URINALYSIS
Date:
TIME
INTRAVENOUS
FLUIDS 1
Severe (7-10)
Moderate (4-6)
Mild (1-3)
No pain
Ini als
FLUID BALANCE CHART
INTAKE
INTRAVENOUS
FLUIDS 2
OUTPUT
ORAL &
NG
PROG. IVC
TIME
TOTAL site
URINE
VOMIT
STOOL
OTHER
PROG.
TOTAL
3
2
1
BEST MOTOR RESPONSE
<1yr
>1yr
Spontaneous
Obeys commands
6
Localises to pain
5
Flexion - withdrawal
4
Flexion - abnormal
3
Extension
2
None
1
KEY
Pupil Scale (mm)
1
2
+
Reactive
SL
Sluggish
-
Non
Reactive
C
Closed
Eyes
T
ETT
3
4
5
BGL
EYES
VERBAL
MOTOR
TOTAL SCORE
WEIGHT:
Fluid Restriction: N/A
Volume:
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
SpO2(%)
(any amount
of O2)
≥ 3 Seconds
<3 Seconds
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
Blood Glucose Level
BLUE ZONE RESPONSE
• Initiate appropriate clinical care
ALL OBSERVATIONS MUST BE GRAPHED
6
GCS
• Greater than expected fluid loss
D.O.B. _______ / _______ / _______
LOCATION
Heart Rate
(beats per minute)
• Poor peripheral circulation (e.g. mottled/pallor)
M.O.
MALE
ADDRESS
100
95
90
85
80
75
<70
L/min or %
Device
220
210
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
220
210
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
GIVEN NAME
FEMALE
ADDRESS
Systolic Blood
Pressure is the trigger
• Increasing oxygen requirement
D.O.B. _______ / _______ / _______
Date
Time
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
Severe
Moderate
Mild
Normal
100
95
90
85
80
75
<70
L/min or %
Device
Heart Rate
(beats per minute)
Additional YELLOW ZONE
Criteria
• New, increasing or uncontrolled pain
Respiratory Rate
(breaths per minute)
Oxygen
• Senior Medical Officer or Nurse review within
10 minutes.
• Observations recorded at least 15 minutely.
• Must have continuous monitoring.
MALE
Blood Pressure (mmHg) > <
• Serious concern by you or any staff
member
Date
Time
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
Severe
Moderate
Mild
Normal
Altered Calling Criteria
DO
• Serious concern by family member
• Altered mental state: Agitation, combative,
inconsolable.
Respiratory
Distress
SpO2(%)
(any amount
of O2)
BINDING MARGIN - NO WRITING
• Lactate ≥ 4mmol/L
Capillary
Refill
• Blood Glucose Level < 2mmol/L or
symptomatic
><
• Floppy
AIRWAY / BREATHING
SMR110003
• New or prolonged seizures activity
Systolic Blood
Pressure is the trigger
¶SMRÊ+Î#KÄ
Cardiac or respiratory arrest
Circulatory collapse
Patient unresponsive
New onset of stridor
• Sudden decrease in Level of Consciousness
(a drop of 2 or more points in GCS)
PAEDIATRIC EMERGENCY
DEPARTMENT OBSERVATION
CHART
1 - 4 YEARS
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Additional RED ZONE
Criteria
• Significant Bleeding
M.O.
LOCATION
ALL OBSERVATIONS MUST BE GRAPHED
GIVEN NAME
FEMALE
ADDRESS
Altered Calling Criteria
• 3 or more simultaneous ‘Yellow Zone’
observations
Holes Punched as per AS2828.1: 2012
D.O.B. _______ / _______ / _______
PAEDIATRIC EMERGENCY
DEPARTMENT OBSERVATION
CHART
1 - 4 YEARS
• Deterioration not reversed within 1 hour of
Clinical Review
MALE
MRN
FAMILY NAME
ALLERGY / ALERTS:
Pain Score
GIVEN NAME
MRN
FAMILY NAME
NO
TP
RI
NT
FAMILY NAME
7
Right
Pupil
Left
Pupil
8
Totals
Page 2 of 6
mLs
Totals
mLs
Page 3 of 6
MRN
FAMILY NAME
GIVEN NAME
MALE
PAEDIATRIC EMERGENCY
DEPARTMENT OBSERVATION
CHART
1 - 4 YEARS
M.O.
ADDRESS
LOCATION
Altered Calling Criteria
Behaviour & Feeding
SEVERE
• Stridor on exertion
• Stridor at rest
• Partial airway obstruction
• New onset of stridor
• Imminent airway obstruction
• Some / Intermittent irritability
• Difficulty talking or crying
• Difficulty feeding or eating
• Agitated / confused
• Drowsy
• Unable to talk or cry
• Unable to feed or eat
• Respiratory rate in the Red Zone
• Decreasing (exhaustion)
Accessory Muscle Use
• None / minimal
• Moderate recession
• Tracheal tug
• Nasal flaring
• Severe recession
• Gasping
• Grunting
• Extreme pallor
• Cyanosis
• Absent breath sounds / silent chest
TIME:
hh:mm
dd/MM/yy
hh:mm
xx-xx
< or > xx
Red Zone
Yellow Zone
Red Zone
Yellow Zone
Red Zone
Yellow Zone
Red Zone
Apnoeic Episodes
• None
• Abnormal pauses in breathing
• Apnoeic episodes
Oxygen
• No oxygen requirement
• Mild hypoxaemia, corrected by oxygen
• Increasing oxygen requirement
• Hypoxaemia, may not be
corrected by oxygen
Medical Officer Name (BLOCK letters)
P. SMITH
Medical Officer Signature
P. SMITH
ADMISSION CHECK
PAIN SCORE - SELF ASSESSMENT
Name Band:
Hurts Whole Lot
Hurts Worst
N/A
Allergy Band: Yes
Weight (Kg):
PRESENTING PROBLEM:
PROTOCOL COMMENCED:
IMMUNISATIONS UTD:
1. Person responsible:
Notified : Yes
2. Person responsible:
Notified : Yes
Yes
No
Phone No:
No
Relationship:
Cannot be contacted
Relationship:
Cannot be contacted
Phone No:
No
Valuables returned to the person responsible:
2
4
6
8
10
PAIN SCORE - FLACC PAIN SCALE (BEHAVIOURAL)
Score 0
No Particular
expression or smile
FACE
CRY
N/A
Specific language:__________________________________________________
Date:
Time:
INJURY / NEGLECT RISK ASSESSMENT / SCREEN
Score 2
Frequent to constant frown,
clenched jaw, quivering chin
1.
Inappropriate delay in presentation?
No
Yes
2.
Injury not explained? Injury not consistent with the stated cause? Child disclosed abuse?
No
Yes
Kicking, or
Legs drawn up
3.
Injury not consistent with this child’s development?
No
Yes
4.
Recurrent injuries or ingestions?
No
Yes
5.
Behaviour of parents / carers inappropriate?
No
Yes
6.
Are there any signs of neglect and / or a failure to follow medical advice?
No
Yes
Lying quietly normal
position - moves easily
Squirming
Shifting back / forth / tense
Arched Rigid or
jerking
Moans or Whimpers
Occasional Complaints
Crying Steadily
Screams or Sobs
Frequent Complaints
Content
Relaxed
Reassured by occasional
touching, hugging or talking
to distractible
Difficult to console or
comfort
This score chart is used for the non-verbal child - adding the scores of each of the five points together from 1 - 10
Page 4 of 6
ED Staff Name:
ED Staff Designation:
ED Staff Signature:
Date:
Time:
Page 5 of 6
D.O.B. _______ / _______ / _______
FEMALE
M.O.
ADDRESS
LOCATION
Altered Calling Criteria
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
ALL OBSERVATIONS MUST BE GRAPHED
MEDICAL ADMISSION AT TIME OF ACCEPTANCE OF CARE
PROVISIONAL DIAGNOSIS:
Attending Medical Officer’s name:
Delegate’s name (if applicable):
Accepted care of patient
Date:
Time:
Clinical plan explained to patient /carer
Clinical plan documented in progress notes
Yes
Yes
Admission completed by:
ED Medical Officer name:
ED Medical Officer signature:
PAEDIATRIC DEPARTURE CHECKLIST – ED TO WARD / OTHER FACILITY
NURSING
MEDICAL
Verified that all documentation is complete
• Admission/Transfer forms/eMR
Yes
• Medications charted
Yes
• Analgesia charted
Yes
• IV fluids charted
Yes
• Fluid balance up to date
• Progress notes up to date
• Risk assessments completed
Diet: Eat & Drink
Nil By Mouth
IVT
Medical handover given
Yes
Outstanding results and actions handed over:
N/A
N/A
N/A
2.
3.
NG
Infection status (incl. recent contact):
Precautions / Isolation required
No
1.
4.
Yes
Specify: Contact precautions / Respiratory
5.
Parents / Guardian aware of transfer
Yes
Patient belongings sent to ward
Yes
N/A
Medication sent to ward
Yes
N/A
Medical Officer accepting care name:
ED Medical Officer providing Handover
Name:
Sign:
Date:
Time:
Ward accepting care:
Ward Nurse Accepting care:
ED Nurse Transferring name:
ED Nurse transferring sign:
PAEDIATRIC DEPARTURE CHECKLIST – ED TO USUAL PLACE OF RESIDENCE
Cannula / ID band removed
Yes
Discharge in care of parents/guardian
Yes
Discharge / referral letter
Yes
Education / Fact sheet
Yes
Discharge prescription
Yes
Clothes / belongings
Yes
AUTHORISATION FOR PAEDIATRIC DEPARTURE FROM ED
Observations within the last hour
Yes
Is the patient ‘Between the Flags’
Yes
No
Alterations to calling criteria documented
Yes
No
Frequency for observations documented
Yes
No
SENIOR ED NURSE
Authorised as safe for departure
If YES to any answer, CONSULT AND ACTIVATE LOCAL CHILD PROTECTION RESPONSE / PROCEDURE
Refer to the MANDATORY REPORTER GUIDE
Referral made to:
CONSOLABILITY
PAEDIATRIC EMERGENCY
DEPARTMENT OBSERVATION
CHART
1 - 4 YEARS
MALE
If not, clinical reason and plan is documented and signed
SMR110.003
Uneasy, Restless, Tense
No Cry
(Awake or Asleep)
Yes
Nurse (BLOCK LETTERS):
Normal position or
Relaxed
GIVEN NAME
¶SMRÊ+Î#KÄ
ACTIVITY
Occasional grimace or frown
No
No
MRN
FAMILY NAME
SMR110003
LEGS
Score 1
Interpreter required:
Yes
DO
0
Comment:
PAEDIATRIC EMERGENCY DEPARTMENT
OBSERVATION CHART 1 - 4 YEARS
Hurts Even More
dd/MM/yy
Yellow Zone
• Respiratory rate in the Yellow Zone
Hurts Little More
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
DATE:
Next review due
Date & Time
• Mildly increased
Hurts Little Bit
LOCATION
Any alterations MUST be signed by a Senior Emergency Department Medical Officer
Document rationale for altering CALLING CRITERIA in the patient’s health care record
MODERATE
Respiratory Distress
No Hurt
M.O.
ALTERATIONS TO CALLING CRITERIA
MILD
• Normal
• Talks in sentences
FEMALE
ADDRESS
ALL OBSERVATIONS MUST BE GRAPHED
ASSESSMENT OF RESPIRATORY DISTRESS
Airway
D.O.B. _______ / _______ / _______
Altered Calling Criteria
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
ALL OBSERVATIONS MUST BE GRAPHED
MALE
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
NO
TP
RI
NT
D.O.B. _______ / _______ / _______
GIVEN NAME
FEMALE
EXAMPLE
XAMPL
PAEDIATRIC EMERGENCY
DEPARTMENT OBSERVATION
CHART
1 - 4 YEARS
MRN
FAMILY NAME
Yes
MEDICAL AUTHORISATION
Authorised as safe for departure
Name (BLOCK LETTERS):
Name (BLOCK LETTERS):
Signature:
Signature:
Date:
Time:
Date:
Yes
Time:
Page 6 of 6