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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