Standard Paediatric Observation Chart 1 To 4 Years
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1
2MRN
MRN
FAMILY NAME
FAMILY NAME
GIVEN NAME
GIVEN NAME
MALE
FEMALE
MALE
FEMALE
1-4 Years
1 4 Y Y Y
1 4 Y Y ea a rs
1-4 Years
1 4 Y Y Y
1 4 Y Y ea a rs
D.O.B. _______ / _______ / _______
_______ / _______
______ / _____
M.O.
M.O.
M.O.
D.O.B. _______ / _______ / _______
______ / _______
____ / _______
M.O.
M.O.
M.O.
Facility: _________________________
Facility: _________________________
ADDRESS
ADDRESS
STANDARD PAEDIATRIC
STANDARD PAEDIATRIC
OBSERVATION CHART (SPOC)
OBSERVATION CHART (SPOC)
1-4 Years
LOCATION
LOCATION
1-4 Years
Altered Calling Criteria
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Date
Date
Time
Time
Alert
Alert
80
80
Verbal
Verbal
75
75
Pain
Pain
70
70
Unresponsive
Unresponsive
65
65
Enter appropriate letter. A= Alert, V= Rousable only by voice (consider GCS). P= Rousable only by central pain (conduct GCS). U=Unresponsive
60
60
Severe (7-10)
Severe (7-10)
55
55
50
50
Moderate (4-6)
Moderate (4-6)
Mild (1-3)
Mild (1-3)
45
45
40
40
Nil
Nil
35
35
41
41
30
30
40.5
40.5
25
25
40
40
39.5
39.5
20
20
39
39
15
15
38.5
38.5
10
10
38
38
5
5
37.5
37.5
37
37
Severe
Severe
36.5
36.5
36
36
Mod
Moderate
35.5
35.5
Mild
Mild
35
35
Normal
34.5
34.5
Normal
34
34
100
100
BGL
BGL
95
95
90
90
Weight
Weight
85
85
80
80
Initi als
75
75
<70
<70
Probe
Probe
CONSIDER EARLIER ESCALATION OF PATIENTS WITH
ADDITIONAL CRITERIA
Change
Change
L/min
L/min
Chronic or complex conditions
or %
or %
FOR ESCALATION
Post-operative
Device
Device
Pre-Existing cardiac or respiratory conditions
220
220
ON BACK PAGE
210
210
Opioid Infusions
200
200
190
190
180
180
170
170
ASSESSMENT OF RESPIRATORY DISTRESS
160
160
150
150
140
140
MILD
MODERATE
SEVERE
130
130
120
120
Airway
• Stridor on exertion
• Stridor at rest
• New onset of stridor
110
110
• Partial airway obstruction
• Imminent airway obstruction
100
100
90
90
80
80
Behaviour & Feeding
• Normal
• Some / Intermittent irritability
• Agitated /Confused
70
70
• Talks in sentences
• Diffi culty talking or crying
• Drowsy
60
60
• Diffi culty feeding or eating
• Unable to talk or cry
>3 Seconds
>3 Seconds
• Unable to feed or eat
<3 Seconds
<3 Seconds
Respiratory Rate
• Mildly increased
• Respiratory rate in the yellow zone
• Respiratory rate in the red zone
• Decreasing (exhaustion)
150
150
140
140
Accessory Muscle
• None /Minimal
• Moderate recession
• Severe recession
130
130
Use
• Tracheal tug
• Gasping
120
120
110
110
• Nasal fl aring
• Grunting
100
100
• Extreme pallor
90
90
• Cyanosis
80
80
• Absent breath sounds
70
70
60
60
50
50
Apnoeic Episodes
• None
• Abnormal pauses in breathing
• Apnoeic episodes
40
40
30
30
20
20
Oxygen
• No oxygen requirement
• Mild Hypoxaemia, corrected by oxygen
• Hypoxaemia, may not be
10
10
• Increasing oxygen requirement
corrected by oxygen
Initi als
Increase Frequency of Observations
Clinical Review
Rapid Response
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STANDARD PAEDIATRIC OBSERVATION CHART 1 TO 4 YEARS SMR110.017.indd 1
STANDARD PAEDIATRIC OBSERVATION CHART 1 TO 4 YEARS SMR110.017.indd 1
4/11/2010 10:49:47 AM
4/11/2010 10:49:47 AM
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