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PEDIATRIC EARLY WARNING SCORE



12+ TH



Tanggal Jam



Frek.observasi



AB



35



RR Hitung 60'



30 25 20



AIRWAY &



15



BREATHING



10



RR SKOR BERAT Resp



Effort



SEDANG RI NGAN NORMAL SKOR ALAT



R A: R o o m Air NC : Nas al C anule F M : F ace M a s k



Terapi O2



>2L ≤2L



T: Tra cheo s t o my C P AP ©/ B iP AP (B )



TEKANAN



L/min



SKOR ≥94% 90-93%



SpO2



88-89% ≤85% SKOR



C



150 140



HR Hi tung



60'



CIRCULATION



130 120 110



Jika skor HR ≥ 1



100



cek TD &CRT



90



sentral kmd



80



lanjut ke



70



protokol sepsis



60 50



HR 2 ≤2 SKOR 160 150 140



TD



130 120 110 100



SISTOLIK



90 80 70



TD (S/D) SKOR



PK:Pink M:Mott led P:Pale C:Cyanosis



WAR NA KULIT



D



Disability



SPONTAN SUARA



AVPU



NYERI RESPON -



E Exposure



SKOR ≥40.0



Tax



38.0



Ji ka s uhu 38.5= s e ps i s



36.0



Jk UO