Pediatric Patient Assessment Triangle Medic12

• ..........................^
• ........................./..\ work of breathing
• ......................./.....\
• .....apperance /........\
• ..................../______\
• ....................circulation

• 1. How severe is this child's illness or injuy or injury?
• 2. What is most likely the physiologic abnormality?
• 3. How quickly do I need to act?

• Tone
• Interactions
• Consolability
• Look/Gaze
• Speech/Cry

• INCREASE, NORMAL, DECREASED
• Observation of motor activity...
• Is this child moving vigorously?
• Is he resisting our exam?
• Can he sit or walk?
• Is he limp in parents arms?

• NORMALLY ACTIVE & ALERT, LISTLESS, LETHARGIC, UNRESPONSIVE
• Normal child interacts w/ her enviroment.
• How responsive is this child?
• Can you draw her attention?
• Will she reach for an offered toy or turn towards sound?
• Does she answer when spoken too?

• CONSOLABLE, INCONSOLABLE
• There are many reasons a child may be agitated...
• Can the child be consoled?

• Does the child fix on a face?
• Does he track movements?
• (Kids will make eye contact w/ parents.)
• Lack of contact or a blank stare = sick child

• Is there a stronng cry or only whimpler?
• Does he speak clearly or w/ slurred speech?
• Does he make sense or seem confused?
• Speaking w/ whole sentences or only a few words?
• Is child SOB?
• (Unless pt is obviously critical gather info fr a distance whe child is calm & not agitated)

work of breathing

• 1. abnormal airway sounds
• 2. retractions
• 3. nasal flaring
• (any 1 of these alone indicates respiratory problem but several together indicative of more severe respiratory compromise)

• 1. stridor
• 2. snoring

• high pitched whistling heard on inspirationor inspiration & expiration
• (indicative of upper airway obstruction)

low pitched sound caused by decrease of tone in structures of the upper airway causing partial airway obstruction

• 1. altered LOC
• 2. infection
• 3. foreign body aspiration
• 4. neck trauma

• 1. grunting
• 2. wheezing

short low pitched sound heard during exhalation against closed vocal cords. this is a reflex action to increase lung expansion & max out gas exchange in the face of hypoxia.

This is a sign of severe respiratory distress & cause should be identified & treated ASAP.

high or low pitched whistling or sighing sound heard most often during expiration

• 1. pneumonia
• 2. pulmonary contusion
• 3. pulmonary edema
• 4. asthma

indicative of severe upper airway obstruction. pt struggling to maintain patent airway.

maximizes use of accessory muscles

• recruiting of accessory muscle pwr to support ventilation
• * may be present beneath, between or above ribs, above clavicles or beneath sternum
• * easier to see in child than adult

tip off to moderate to severe hypoxia

respiratory distress - may require interventions but evaluate 1st

approaching or in respiratory failure. requires immediate intervention.

pt fatiqued & at risk for arrest. assist ventilation IMMEDIATLEY

• 1. if cardiac output less than metabolic demands peripheral vessel constriction results
• 2. blood shunted from skin & circulation to vital organs is increased

• 1. pallor
• 2. mottling
• 3. cyanosis

• pale skin & mucus membranes
• (early sign of compensated shock)

• irregular or patchy discoloration of skin
• (sign of poor skin perfusion)

• bluish discoloration or skin & mucus membranes
• (late finding or respiratory failure or shock. NEVER wait for cyanosis for treatment)

• 1. A&O child w/ peripheral cyanosis may simply be cold
• 2. abnormal appearance & circulation to skin may mean your pt is shocky

• Always Needed:
• - assess baby's response to birth
• - keep baby warm, position, clear airway, stimulate to breathe by drying, & give O2 (as necessary)
• Needed Less Frequently:
• - establish effective ventilation, bag and mask, endotracheal intubation
• Rarely Needed:
• - provide chest compressions
• - administer medications