an accurate health history and a thorough physical examination. respiratory assessment's are done as part of a comprehensive physical examination or as a focused examination. the judgment in determining whether all or part of the history and physical examination is often completed based on a chief complaint of the patient. respiratory can be measured by rate, rhythm, characteristics of breathing, and supplemental oxygen use. different characteristics of breathing are lung sounds, retractions, accessory muscle use, tracheal tug, etc. pews uses highly visible and easily monitored characteristics are used, such as retractions, that way there is little variation based on in interpretation. retractions are a sucking in of the skin around the bones of the chest and illustrate the additional use of muscle to breath, indicated the increased work needed to breath. similarly, the more supplemental oxygen needed, the less the lungs are providing adequate oxygenation. all of these symptoms indicate respiratory failure, a condition where there is inadequate oxygenation to the body's tissues and organs or inadequate removal of carbon monoxide from the body by the lungs. left untreated, it is life-threatening. neurological behavior is typically measured by playing, sleeping, irritable, and confused or reduced response to pain. this is due to the fact it is an age-based assessment and pediatric patients have some form of "playing" as their age appropriate norm. whether it be gurgling and cooing, coloring, or video games, it is age-specific behavior to a younger population. irritability in children is often a cue that something is wrong, especially in those unable to communicate verbally due to age or disorder. other scales simply use level of consciousness as they're neurological assessment, instead of behavior. scoring nursing interventions associated with different pews scores.numbers or color are used in scoring of pews. the numbers represent the total score added from the domains (pictured in the above table of monaghan's design) and the colors are easily understandable "cautions" recognized by most people to help facilitate urgency and in some care settings, communication with patients correlated with numeric scores. 0-2: a score of 0-2 indicates no change in a child's status and regular rounding is acceptable. the plan of care will be continued as is. 3-4: indicates that a child's care is worsening, but they do not need immediate assistance. the plan of care may change or continued close monitoring will be initiated. 5: the child's status is deteriorating and a change in the plan of care is needed to improve outcomes. this is an urgent situation that requires close monitoring and the involvement of other disciplines. 6+: there are severe consequences if quick intervention is not established, including possible permanent damage or death. a child with a pews score of 6+ will mostly be transferred to a picu to receive the level of critical care they need to improve outcomes with a staff trained to do so. application in practice when implemented, pews has had statistically significant impact on multiple units and the care of children. it can identify children admitted to the ed who require admission to the picu, as well as, help staff assessment of their needs and accurate interventions. it has helped identify more than 75% of code blues within one hour of warning and has the ability to assess more than ten hours earlier the need to adapt a care plan to avoid rapid response. bedside pews, an adopted method for bedside care, can help staff identify when a child is at risk for decline and/or rapidly deteriorating. also, it has proven to improve staff communication and patient safety. limitations one limitation in the use of pews is that there is not a standard model in practice. doctors and nurses have access to too many variations of how to use the pews assessment tool and there is no defined standard. there is over 30 different variations of the assessment tool available to the medical staff to help diagnose pews. pews provides an easy, objective way to measure a deviation from normal, however, with variation in model, the score is not completely transferable. another limitation is since this is relatively new, there is little research done on the implementation of pews and the effectiveness of its usage. citations (epstein and brill, 2005, p.987) (epstein and brill, 2005, p.988) "early warning systems: scorecards that save lives". www.ihi.org. retrieved 2017-10-12. (jensen, aagaard, olesen, and kirkegaard, 2017, p.2) (monaghan, 2005, p.33) (monaghan, 2005, p.35) (agrawal, 2009, p.2) (honckenberry and wilson, 2015) (agrawal, 2009, p.1) (murray, williams, pignatarao, and volpe, 2015, p.166; fuijkschot et al., 2015, p.15) (murray, williams, pignataro, and volpe, 2015, p.171) (murray, williams, pignataro, and volpe, 2015, p.171; jensen, aagaard, olesen, and kirkegaard, 2017, p.2) (murray, williams, pignataro, and volpe, 2015, p.168-170) (baruteau et al., 2016, p.151) (baruteau et al., 2016, p.152) (murray, williams, pignataro, and volpe, 2015, p.170) (jensen, aagaard, olesen, and kirkegaard, 2017, p.3) (arke et al., 2010, p.e767)