INSTRUCTIONS FOR USE OF PROVINCIAL PEDIATRIC PATIENT

FLOWSHEET

PURPOSE
The purpose of this document is to provide clear standardized instruction for use of the Pediatric Early
Warning Systems (PEWS) patient flowsheet.
ABBREVIATIONS
Use only abbreviations that are included in the legend on the document and do not use any abbreviations
or symbols that are on the “DO NOT USE” list (e.g. @, <, >)
Abbreviations used in this document:
Bi-level Positive Airway
BiPAP Pressure L Left N No RLL Right Lower Lobe
°C Degrees Celsius LLL Left Lower Lobe N/A Not Applicable RLQ Right Lower Quadrant
cm Centimeter(s) LLQ Left Lower Quadrant NG Nasogastric RML Right Middle Lobe
Continuous Positive
CPAP Airway Pressure LUL Left Upper Lobe NJ Nasojejunal RUL Right Upper Lobe
EVD External Ventricular Drain LUQ Left Upper Quadrant NN Nurses’ Notes RUQ Right Upper Quadrant
GT Gastrostomy Tube M Mask NP Nasal Prongs Y Yes
Mean Arterial Vacuum Assisted
HFNP High Flow Nasal Prongs MAP Pressure q__h Every ___ hours VAC Closure
JT Jejunostomy tube mL Milliliters R Right
Most Responsible
kg Kilograms MRP Practitioner RA Room Air
Note: In Fraser Health follow the Clinical Abbreviations Catalogue available through the Clinical
Policy Office.

FRONT SIDE OF DOCUMENT

PATIENT IDENTIFICATION
Addressograph or label flowsheet in top right corner
GRAPHIC SECTION
1. Date: RECORD date at top Left of page ensuring day, month and year are included (e.g. 12 SEP 2012
or SEP 12, 2012) spelling out the month using first 3 letters
2. INITIAL in the space provided below the time. Ensure that full signature has been recorded on the
signature identification record located in the patient’s chart and/or on reverse side of flowsheet.
3. Time: RECORD the actual time of the assessment or intervention in the assigned space running across
the top of the page. Use 24 hour clock format e.g. 0030
4. RESPIRATORY SECTION:
a. RECORD respiration rate using a ● symbol. PLEASE NOTE: draw a line to connect each
subsequent rate symbol to create a visual trend
b. RECORD oxygen saturations percentage
c. RECORD any supplemental O2 concentration delivered in litres per minute in appropriate spaces
d. RECORD supplemental O2 mode of delivery (Room Air [RA], Nasal Prongs [NP], Mask [M], Blow By
[BB], High Flow Nasal Prongs [HFNP]).

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PLEASE NOTE: The use of oxygen delivery via the blow by method is not recommended, as it is
difficult to determine the exact percentage of oxygen and the actual dose received by the patient. If
blow by method is used please document in the nurses notes and provide clinical rationale.
RECORD using  symbol to indicate level of respiratory distress per CTAS manual 2013 (p.42)
definitions:
Severe: Excessive work of breathing, cyanosis; lethargy, confusion, inability to recognize caregiver,
decreased response to pain; single word or no speech; tachycardia or bradycardia; tachypnea or
bradypnea; apnea irregular respirations; exaggerated retractions, nasal flaring, grunting; absent or
decreased breath sounds; upper airway obstruction (dysphagia, drooling, muffled voice, labored
respiration’s and stridor); unprotected airway (weak to absent cough or gag reflex); poor muscle
tone.
Moderate: Increased work of breathing, restlessness, anxiety, or combativeness; tachypnea;
hyperpnea; mild increased use of accessory muscles, retractions, flaring, speaking phrases or
clipped sentences, stridor, but airway protected, prolonged expiratory phase.
Mild: Dyspnea; tachypnea; shortness of breath on exertion; no obvious increased work if breathing;
able to speak in sentences; stridor without obvious airway obstruction; mild shortness of breath on
exertion; frequent cough.
e. CALCULATE RESPIRATORY CATEGORY PEWS
SCORE:
Document assessment findings on the flowsheet for:
respiratory rate, supplemental oxygen concentration
delivery and respiratory distress. The Respiratory PEWS
score is assigned based on the most severe score in the
category. The maximum score a patient can receive for
the respiratory category is 3. Always score using the
highest number in each category.

See red circled example

f. RECORD PEWS score for respiratory category in the
appropriate box
PLEASE NOTE: When caring for patients with Asthma a PRAM
score will be calculated and recorded on the flowsheet in the ROUTINE NURSING CARE section.

5. CARDIOVASCULAR SECTION:

a. RECORD apical heart rate using  symbol. PLEASE NOTE: draw use a line to connect each
subsequent rate symbol to create a visual trend
b. RECORD blood pressure (BP) using  symbol (BP is not included in the score).

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Note: Indicate limb used for BP measurement (if other than arm), and patient position using the
following symbols:

Lying Sitting Standing

c. RECORD mean arterial pressure (MAP). Note: calculate MAP use the following equation:
MAP = Systolic Pressure + (2 X Diastolic Pressure)
3
d. RECORD capillary refill time in seconds (by pressing lightly on a peripheral site such as a nail)
e. INDICATE skin colour using a symbol in the appropriate box.
f. CALCULATE CARDIOVASCULAR CATEGORY PEWS SCORE (refer to 4. e instructions)
g. RECORD PEWS score for the cardiovascular section in the appropriate box

6. BEHAVIOUR SECTION:
a. INDICATE assessed patient behaviour using a symbol in the appropriate box
Behaviour is scored exactly as observed. If you are unsure about what is expected, please review
the patient’s behaviour with their family/caregiver and/or a more experienced health care provider
PLAYING/APPRORIATE- is the patient behaving as expected based on the current circumstances
and their child's developmental level
SLEEPING- is the patient sleeping?
IRRITABLE- is the patient inconsolable, restless, or agitated?
LETHARGIC/CONFUSED- does the patient have an altered mental status? Are they confused,
disoriented, or presenting with severe drowsiness?
REDUCED RESPONSE TO PAIN- does the patient have an altered mental status? Do they
respond only to pain?
b. CALCULATE BEHAVIOUR CATEGORY PEWS SCORE (refer to 4. e instructions)
c. RECORD PEWS score for the behaviour section in the appropriate box
7. OTHER PEWS INDICATORS:
a. INDICATE if the patient has unexpected persistent vomiting following surgery using a symbol in
the corresponding box
Postoperative nausea and vomiting (PONV) is defined as any nausea, retching, or vomiting occurring during
the first 24–48 hours after surgery in inpatients. PONV is common complication for pediatric patients, and is
often expected. Persistent Vomiting refers to >2 times per hour of more than expected episodes of emesis. If
you are unsure about what is expected, please review with a more experienced health care provider (Hohne,
2014; Pierre & Whelan, 2013).
b. INDICATE if the patient is using an bronchodilator every 15 minutes using a symbol in the
corresponding box

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8. TOTAL PEDIATRIC EARLY WARNING SYSTEM (PEWS) SCORE:

a. To obtain a total PEWS score, ADD the category scores together (respiratory + cardiovascular +
behaviour + vomiting + bronchodilator = maximum achievable score of 13).
b. CALCULATE and RECORD total PEWS score with every set of vital signs. PLEASE NOTE if
PEWS score is zero please record 0
9. TEMPERATURE:
a. RECORD temperature using  symbol. Indicate route: oral (O), axilla (A), rectal (R), temporal (T)
and esophageal (E). PLEASE NOTE: draw use a line to connect each subsequent rate symbol to
create a visual trend.
b. SCREEN for Sepsis Pediatric Sepsis Screening Tool, if PEWS score increases by 2 or core
patient temperature is greater than 38.5°C or less than 36°C.
RECORD using a  symbol to INDICATE the sepsis screen was completed. DOCUMENT in the
nursing notes, used in your agency, the criteria identified on the sepsis screen tool:
0 - No risk factors identified
A – Signs of infection
B – SIRS (systemic inflammatory response)
C – Organ dysfunction

10. SITUATIONAL AWARENESS FACTORS:

a. With each set of vital signs ASSESS patient for situational awareness factors. Place a symbol for
the situational awareness factors that apply to the patient.
i. Patient/Family/Caregiver Concern: a concern voiced about a change in the patient's
status or condition (e.g. concern has the potential to impact immediate patient safety, family
states the patients is worsening or they are not behaving as they normally would).
ii. Unusual Therapy: includes staff unfamiliar with ward or department (e.g. float nurses or
break coverage), therapy or process (e.g. high risk infusion, new medication or protocol for
patient or nurse).
iii. Watcher Patient: a patient that you or a team member identified as requiring increased
observations (e.g. unexpected responses to treatments, child different from “normal”,
aggressive patient, “certified” patient, over/under hydration, pain, edema, “gut” feeling).
iv. Communication Breakdown: describes clinical situations when there is lack of clarity
about treatment, plan, responsibilities, conversation outcomes and language barriers.
v. PEWS Score 2 or higher: PEWS score greater than or equal to 2 should trigger increased
awareness and action.

11. If escalation process is activated, RECORD NN in the corresponding time slots. FOLLOW escalation
aid prompts to access supports:
a. 0 – 1: continue to monitor;

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b. 2 or any one of the 5 situational awareness factors: Review with a more experienced
health care provider. Escalate if further consultation required or resources do not allow.
Continue to monitor as per orders/protocols.
c. 3: Increase frequency of assessments and documentation as per plan from consultation
d. 4 and/or score increases by 2 after interventions: Notify MRP or delegate. Consider
pediatrician consult if deteriorating fast. MRP or delegate to communicate a plan of care.
Increase assessments. Reassess adequacy of resources and escalate to meet deficits.
e. 5 – 13 or score of 3 in any one category: Immediate assessment by MRP or delegate
(and pediatrician if available). MRP or delegate to communicate a plan of care. Increase
nursing care with increasing interventions as per plan. Consider or internal or external
transfer to higher level of care.

12. DOCUMENT in the nursing notes used in your agency escalation actions taken and responses in
greater detail as needed.
NEUROLOGICAL
1. ASSESS Neurovital signs once a shift unless ordered more frequently or clinically indicated.
2. Pupils: RECORD pupil size using guide located on the bottom left corner of form. RECORD pupillary
response using the following letters to indicate B = Brisk, S = Sluggish, and/or F = Fixed under the
corresponding time column.
3. Glasgow Coma Scale (GCS): RECORD using  symbol to indicate the score for eye, verbal and
motor response under the time column when the assessment was completed.
4. RECORD total score for GCS in the total score box.
5. Muscle Strength: RECORD numeric score in appropriate box for each limb under corresponding time
column.
6. Color, Sensation and Warmth of Extremities: RECORD using symbol to indicate Normal or NN to
indicate that there is further documentation in the Nursing Notes section of the health record.
7. Bladder Function: RECORD using  symbol to indicate Normal or NN to indicate that there is further
documentation in the Nursing Notes section of the health record.
ROUTINE NURSING CARE
1. Time: RECORD the actual time of the assessment or intervention in the assigned space running across
the top of the page. Use 24 hour clock format e.g. 0030

2. RECORD the pain score, tool used and location of pain under the time column when pain was
assessed. Pain score will be recorded as a numeric value. Name of tool and location of pain to be
written in space provided. If more space is required document NN and record observations in the
nurses notes. Pain is to be assessed every 4 hours and PRN. If patient is on a continuous opioid
infusion, epidural analgesia or PCA, refer to your agency specific documentation guidelines.

3. RECORD the patient’s level of arousal score every hour if awake and if the patient is receiving

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continuous opioid infusion or patient controlled continuous analgesia (PCA) infusion or when sleeping
and respirations are below norm for patient’s age.

4. RECORD Enteral/Gastric Tube site to source check using a symbol to indicate the time it was
completed. Document this hourly or per your agency guidelines. Use NN to indicate that there is
further documentation in the Nursing Notes section of the health record.

5. RECORD using a  symbol to indicate the IV site to source checks, including rate & solution, was
completed. This  also indicates that the IV Touch, Look, & Compare check was completed. Document
this hourly or per your agency guidelines. Use NN to indicate further documentation in the Nursing
Notes section of the health record.

6. RECORD using a  symbol to indicate a patient safety check was completed in the space provided.
Document this hourly or per your agency guidelines. Please use this for patients that do not have an
IV.

7. RECORD PRAM Score if used in your agency once a shift and prn for those patients with reactive
airway disease/asthma receiving therapy under appropriate time column when assessed.

8. RECORD using a  symbol to indicate you have checked the phototherapy module and eye shield
placement. Document this hourly or per your agency guidelines.

9. RECORD using a  symbol for routine nursing care under the time it was provided.

10. RECORD using a  symbol to indicate the time the oximeter probe site was changed (q4h & PRN)
REVERSE SIDE OF DOCUMENT
INTAKE AND OUTPUT
The purpose of this section is to keep an accurate account of all intake and output for the patient.
1. RECORD all parenteral, enteral, and oral intake. DESCRIBE each type of intake on a separate line
including any additives.
2. RECORD the time at the top of the column and RECORD the volume infused during that hour below.
Note: If any infusion, medication or oral intake is complete at any time other than on the hour it is
included in that hour’s intake.
3. CALCULATE the total volume of intake for hourly and if required, cumulative volumes. Cumulative
volumes can be indicated by writing the hourly total over the cumulative total. (Refer to output example
below).
4. CIRCLE the total volume infused at the completion of any infusion if the infusion completes before the
end of the shift as a reminder to add this volume to the total for shift.
5. CALCULATE all total volumes infused during the shift to obtain a final 12-hour total. RECORD this
amount at the end of the last column and circle.

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6. RECORD all types of output including urine, stool, blood loss, emesis and drainage. DESCRIBE each
type of output on a separate line.
7. RECORD under the appropriate hour the volume of any type of output. Note: If output occurs at any
time other than on the hour it is included in that hour’s intake.
8. RECORD Bristol stool score (type 1 – 7) for all stool output under appropriate time column.
9. CALCULATE the total volume of output for hourly and if required, cumulative volumes. Cumulative
volumes can be indicated by writing the hourly total over the cumulative total. (Refer to example below).
10. E.g.:

05 08

urine 120 100

120 220

11. CALCULATE all total volumes of output recorded during shift to obtain a 12-hour total; RECORD this
amount at the end of the last column and circle.
12. SUBTRACT intake from output to obtain a 12-hour fluid balance; RECORD this as either a positive (+)
or negative (-) amount in the appropriate box.
13. CALCULATE your 24 hour fluid balance by adding the two 12-hour balances together. For example: if
the 0700-1900 hr balance is +300 mL and the 1900-0700 hr balance is -200 mL the 24 hour fluid
balance would be +300 mL + -200 mL = +100mL.
14. CALCULATE the maintenance fluid requirement for the patient in mL/hr and record it here. NOTE:
Calculate at the start of each shift. For example: if the patients weight is 6 kg the calculated
maintenance would be 25 mL/hr (6x100= 600/24= 25).
15. CALCULATE the actual total fluid the patient received in mL/kg/hr and record it here. This is to be
done as part of the 12-hour balance.
16. CALCULATE urine output in milliliters per kilogram per hour (mL/kg/hr).
17. RECORD in the space provided any measurements taken such as abdominal girth, head
circumference, height
18. RECORD admission weight, previous 24 hr weight, current weight and previous 24-hour fluid balance in
the spaces provided. Two spaces have been provided for current weight for documentation of BID
weights when ordered.
19. RECORD any intravenous access initiated using space provided. Include signature of initiator.
INITIAL ASSESSMENT – DAY/NIGHT
1. RECORD time and initials of health care provider in spaces provided.
2. RECORD initial patient assessment for day or night shift using a  symbol to indicate assessment
findings ticking the appropriate descriptors; filling in the blank spaces provided to indicate details of
assessment findings. Strike a line through any assessment data to indicate that it does not apply.
Using a  symbol indicate See Nursing Notes if additional assessment findings need to be recorded in
the narrative nursing notes.

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3. RECORD using a  symbol to indicate a mental health status exam was complete, if used in your
agency.
4. COMPLETE peripheral pulse assessment using  to record assessment findings.
5. COMPLETE quality checks and scores by using  to indicate completion and/or record the actual score
in space provided.
6. RECORD using a  symbol to indicate any PERSONAL SAFETY PRECAUTIONS identified- when identified
communicate findings with the MRP for further evaluation. Develop a Plan of Care with Observation Level as
required.
7. RECORD in the nursing notes used in your agency any assessment findings or changes noted during
shift in greater detail. Record time of entry and use variance charting including data, action and
response (DAR) or problem, intervention, evaluation (PIE) formats.
8. RECORD full signature and initials in space provided.
DOCUMENT CREATION / REVIEW
Adapted from BC Children’s Hospital by Child Health BC
Create Date: December 31, 2013
Revision Date: September 22, 2016

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REFERNCES

American Heart Association. (2012). Pediatric emergency assessment, recognition, and stabilization
(PEARS), provider manual. South Deerfield, MA: Author.

BC Children's Hospital. (2013, December 31). Instructions for use of BCCH inpatient flowsheet. Retrieved
from
http://bccwhcms.medworxx.com/Site_Published/bcc/document_render.aspx?documentRender.IdTyp
e=32&documentRender.GenericField=1&documentRender.Id=12739

Brady, P.W. et al. (2013). Improving situational awareness to reduce unrecognized clinical deterioration
and serious safety events. Pediatrics, 131(1), e298-e308.

Canadian Association of Emergency Physicians. (2013, November). Canadian triage and acuity scale
(CTAS) participant manual (version 2.5b).

Heart & Stroke Foundation of Canada. (2011). Pediatric advanced life support provider manual. Ottawa,
ON: Author.

Hohne, C. (2014). Postoperative nausea and vomiting in pediatric anesthesia. Current Opinion in
Anesthesiology, 27(3), 303-308.

Monaghan, A. (2005). Detecting and managing deterioration in children. Paediatric Nursing, 17(1), 32–35.

National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and.
Adolescents. (2004). The fourth report on the diagnosis, evaluation, and treatment of high blood
pressure in children and adolescents. Pediatrics, 114 (Issue 2 Suppl), 555-576.

Pierre, S., & Whelan, R. (2013). Nausea and vomiting after surgery. Continuing
Education in Anaesthesia, Critical Care & Pain, 13(1), 28-32.

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