Pediatric Patient Assessment Triangle Medic12
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Pediatric Patient Assessment Triangle
- ........................./..\ work of breathing
- .....apperance /........\
Goal of PAT is to answer what 3 questions?
- 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?
- 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)
Signs of increased WOB include...
- 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)
Upper airway abnormalities produce what sounds?
- 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
causes of foreign body airway obstruction (FBAO) in upper airway include...
- 1. altered LOC
- 2. infection
- 3. foreign body aspiration
- 4. neck trauma
Lower airway abnormalities produce the following sounds...
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
causes of lower airway abnormalities include...
- 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
normal appearance (alert & active)
increased WOB (retractions / nasal flaring)
respiratory distress - may require interventions but evaluate 1st
normal appearance (not alert or active)
increased WOB (retractions / nasal flaring)
approaching or in respiratory failure. requires immediate intervention.
pt fatiqued & at risk for arrest. assist ventilation IMMEDIATLEY
circulation to skin
- 1. if cardiac output less than metabolic demands peripheral vessel constriction results
- 2. blood shunted from skin & circulation to vital organs is increased
signs of inadequate skin circulation includes...
- 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)
tips when evaluating circulation
- 1. A&O child w/ peripheral cyanosis may simply be cold
- 2. abnormal appearance & circulation to skin may mean your pt is shocky
Newborn Inverted Assessment Triangle
- 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
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