Pediatric assessment triangle: Difference between revisions
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*Look for pallor, mottling, or cyanosis | *Look for pallor, mottling, or cyanosis | ||
*Check capillary refill | *Check capillary refill | ||
*Look for tears, wet diaper | |||
==Management== | ==Management== | ||
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==External Links== | ==External Links== | ||
*[https://www.ernursecentral.com/post/rapid-pediatric-assessment-the-pediatric-assessment-triangle] | |||
==References== | ==References== | ||
Revision as of 08:22, 8 January 2023
Background
- Tool used to succinctly evaluate and form a general impression (sick/not sick) of a pediatric patient
- Consists of three domains: Appearance, Breathing, and Circulation
Evaluation
Appearance
- Muscle tone
- Irritability/consolability
- Gaze (tracking, eye contact, vacant stare)
- Age-appropriate speech
Breathing
In addition to respiratory rate this includes assessing for:
- Grunting or noisy breathing
- Use of accessory muscles of respiration
- Intercostal or supraclavicular retractions
- Belly breathing
- Nasal flaring
Circulation
- Look for pallor, mottling, or cyanosis
- Check capillary refill
- Look for tears, wet diaper
Management
Children with an abnormality noted in any aspect of the pediatric assessment triangle require resuscitation
- Breathing difficulty with normal appearance and circulation usually implies respiratory distress
- Child is in distress but still adequately oxygenating to maintain distal perfusion and mental status
- Breathing difficulty with abnormal appearance and/or circulation usually implies respiratory failure
- Child's oxygenation is no longer sufficient to support distal perfusion and/or mental status
- Poor appearance and circulation usually implies shock