Paediatric Nurse Print Sign Child Accompanied by Name

Paediatric Nurse (Print & Sign)…………. . . Child Accompanied by Name Relationship to child Parental Responsibility Yes / No Family structure in addition to above Parent / Guardian’s Names (If different to above) Siblings: Names and DOB Who is looking after them at present time? Who lives in the home with the child? Social Worker Involvement with Family: Yes / No Name: Safeguarding Flag: Yes / No Safeguarding team informed of attendance: Yes / No Social services informed: Yes / No PLF completed : Yes / No MASH completed: Yes / CAN referral: Yes / No / Declined DSH Pathway completed : Yes / No Dog Bite Mandatory Information No CSE Concerns: Yes / No; Toolkit started Yes / No Where did the incident take place? What breed is the dog (if breed not know, describe appearance)? Who owns the dog? If unknown where did the attack take place? Does the owner of the dog have children? Yes □ No □ Have the Police been informed? Yes □ No □ Incident Number: …………………. . If Yes, what action is going to be taken? What treatment has been required? What further treatment will be required? Alleged Assault Mandatory Information Where did the incident take place? Assailant(s)? Unknown (male/female) / Relative / Partner / Multiple Name & relationship if assailant known Names and DOB of any children present OR any children of assailant/perpetrator Have the Police been informed? Yes □ No □ Incident Number: …………………. . If Yes, what action is going to be taken? Any previous assaults by perpetrator? Motive for attack? Gang activity / Theft / Bullying / Racial / Sexual / Physical Abuse / Domestic Violence/ Other: …………………. Exit Observations Time: RR Pulse BP Signed: Temp SP 02 Print Name: BM GCS / AVPU Pain score / 10 PEWS Destination: …………. . Time Discharged: ………………. Transferred by…………………. .

NGH ED Paediatric First Assessment Form Allergies, intolerances and other e. g. diet (this section must be completed before prescribing/ administering, except in exceptional circumstances No known drug allergy Medication (or other): Date…………… Time……. . . Wt…. ……. . Kg Name……………………………. DOB…………… Age……………. Hospital Number……………………. . School: ………………………. . GP: …………………………. . Contact No…………………………. Nurse (Print & Sign)………………… Reaction: Presenting Complaint: ………………. . . . Airway Patent B RR Compromised % O 2 Sats C HR D A V P U / GCS E Temp °C Insp O 2 BM E V M Neurovascular Observations: Pulse PEWS MILD MODERATE SEVERE 0 1 -3 4 -6 7 -10 Peak Flow >5 yrs Asthma BP required on all Illness , Head Injury and Major Trauma BP NO PAIN Pain Score…… / 10 Time: …… CRT Analgesia Prehospital Total Type / Dose Pupils: R Declined analgesia L Rash? No BLANCHING NON-BLANCHING Colour Warm Sensation Time Reassess: / 10 Time: Intervention ≥ 3 OR Could the child have Sepsis OR Serious Concern? Sepsis Screen - Possible infection at any site with any 2 of: Core Temperature <36 or >38. 5 YES Inappropriate Tachypnoea, Tachycardia or bradycardia for age (PEWS = 1 for HR or RR) Name: ………… Altered mental status (inc. sleepiness/irritability/lethargy/floppiness) NO Reduced peripheral perfusion/cap refill >2 secs/reduced urine output Sepsis present Y Sepsis / N CALL SENIOR DOCTOR → Start Sepsis 6 and Screen for Severe Sepsis/Septic Shock/Red Flag Any Abnormal Obs →Start PEWS Chart → Repeat Time: ……… Triage / Actions: (maximum 60 minutes) Immunisations UTD Yes / no Prescriptions Date Time Pain Score Medicine (Approved Name) Dose Route Prescriber’s Signature Given By Time Given V 4 July 2017