Observations and sepsis flags Flashcards
Normal heart rate - < 1 year old
110 - 160 bpm
Normal heart rate - 1 -2 year old
100 - 140 bpm
Normal heart rate - 2 - 5 year old
95 - 130
Normal heart rate - 5 - 12 year old
80 - 120
Normal heart rate - >12 year old
80 - 100
Normal systolic BP - <1 year old
70-90
Normal systolic BP - 1 - 2 year old
80-95
Normal systolic BP - 2 - 5 year old
80-100
Normal systolic BP - 5 - 12 year old
90-110
Normal systolic BP - >12 year old
100-120
Normal respiratory rate - <1 year old
30 - 40
Normal respiratory rate - 1 - 2 year old
25 - 35
Normal respiratory rate - 2 - 5 year old
25 - 30
Normal respiratory rate - 5 - 12 year old
20 - 25
Normal respiratory rate - >12 year old
15 - 20
<5 Sepsis risk
Colour - low risk
Normal colour
<5 Sepsis risk
Colour - intermediate risk
Pallor noted by parent
<5 Sepsis risk
Colour - high risk
Pale
Mottled/ashen
Blue
<5 Sepsis risk
Activity - low risk
Responds normally
Smiles
Awakens quickly
Not crying/normal cry
<5 Sepsis risk
Activity - intermediate risk
Abnormal response
No smile
Prolonged stimulation to wake
Decreased activity
<5 Sepsis risk
Activity - high risk
No social cue response
Looks ill to healthcare
Does not stay awake
Cry: weak/high-pitched/continuous
<5 Sepsis risk
Circulation - low risk
Normal skin/eyes
Moist mucous membranes
<5 Sepsis risk
Circulation - intermediate risk
Tachycardia
CRT >=3s
Dry mucous membranes
Poor feeding in infant
Reduced urine output
<5 Sepsis -
High risk: Circulation
Reduced skin turgor