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Pediatric Assessment Triangle (PAT) (Nursing)

by Paula Ruedebusch

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    00:01 This is the pediatric assessment triangle.

    00:03 It's a rapid assessment technique and objective tool that clinicians can use to aid in their respiratory assessment.

    00:09 There are 3 components in the pediatric assessment triangle, and we will touch on all of these.

    00:14 They include the appearance of the child, the work of breathing, and the circulation to their skin.

    00:19 The clinician can determine in 30 seconds or less how sick a child may be regarding their respiratory status.

    00:25 The clinician can use this tool throughout their management of a pediatric patient to see if they're improving or worsening during their shift.

    00:33 The acronym, TICLS, pronounce "tickles" is sometimes used by emergency medical providers to remember the components of the appearance item.

    00:43 Regarding the child's appearance, the nurse will assess the patient for their tone.

    00:48 Does the child look limp or rigid? Is the child laying listlessly on the exam table or are they actively running around the room? Normal tone includes flexion.

    00:58 Infants like to be in this flexed position.

    01:01 They should strongly resist attempts to straighten their limbs.

    01:06 There are variations on the theme for the "I." It can stand for either interactiveness, or level of irritability.

    01:12 Normally, a child is able to interact with their caregivers and the staff, based on age-appropriate milestones.

    01:18 Abnormally, a child would not interact or engage with caregivers or their surrounding activities.

    01:24 The "C" stands for consolability.

    01:27 Normally, a child is able to be comforted by its usual caregivers and the child is usually acting like themselves in regard to environmental stimuli.

    01:35 Abnormally, you would see a child who just cannot be consoled or comforted by their usual caregivers, and parents will tell you this.

    01:42 They will say their child is unusually fussy and cannot be consoled.

    01:46 Abnormally, too, the child would not respond normally to their environmental stimuli, like preferred toys, and they just wouldn't be acting like themselves.

    01:54 The "L" stands for the look or gaze.

    01:57 Normally, a child, depending on their age, should be able to make and maintain eye contact.

    02:03 Abnormally, your child would have a vacant stare and a lack of eye on eye contact, and the child has a, sort of, checked out look.

    02:10 They may not recognize their normal caregivers and they may just look out of it.

    02:15 The final component of the appearance section is the speech or cry.

    02:19 Normally, a child will be able to use age-appropriate verbal communications.

    02:24 And when speech and crying are normal, this indicates that the child has a nice, open, patent airway.

    02:31 Abnormally, the child would not be using their age-appropriate communications, or their speech or cry may be absent.

    02:38 This raises the concern for an occluded airway or an altered mental status.

    02:43 The next component of the pediatric assessment triangle is the work of breathing.

    02:48 The first part involves looking for nasal flaring, which is a compensatory symptom that increases the upper airway diameter through the nose, to decrease the resistance of the airflow and the work of breathing.

    02:59 Here, you see normal nostrils, normal size.

    03:02 On the right, this patient's displaying nasal flaring, and this is going to maximize their airflow through their nose while they breathe.

    03:09 Next, you can see the work of breathing by looking for retractions.

    03:13 Retractions are a sign that someone is working hard to breathe.

    03:16 Normally, when you take a breath, the diaphragm and the muscles around the ribs create a vacuum that pulls the air into your lungs.

    03:23 If a person is having trouble breathing, these extra accessory muscles and the muscles between the ribs will kick in to help.

    03:29 These are the retraction sites.

    03:31 When a patient has severe retractions, you're going to see these in the suprasternal area.

    03:37 When a patient has less severe retractions, they fall in the moderate category.

    03:41 They're going to have these in the supraclavicular region, so above the clavicle, or in the intercostal area between the ribs.

    03:48 When a patient's just starting with retractions, they're going to be in the sub-sternal area or in the subcostal area.

    03:54 So it's important to look at the patient's chest.

    03:57 You always lift up the pediatric patient's shirt or completely remove their shirt to assess for retractions.

    04:03 You can assess the work of breathing by looking for posturing.

    04:06 Look at your patient.

    04:07 How are they sitting? Are they propped in an abnormal position that's helping them breathe, such as a tripod position? What is their position of comfort? Do they have trouble breathing if you lay them flat on their back? If so, the head of the bed should be raised as needed.

    04:22 Next, evaluate the breath sounds.

    04:25 Are there any abnormal sounds like wheezing, crackles, rales, stridor, or coughing? Last, you'll check the circulation of the skin.

    04:34 Circulation, as measured by skin color and capillary refill, is a great indicator of perfusion in children.

    04:41 Capillary refill time is defined as the time it takes for the color to return to an external capillary bed after pressure is applied to cause blanching.

    04:50 This can be done at the distal tips of the fingers.

    04:52 You're also going to assess for pallor.

    04:54 Pallor is associated with early signs of hypoxia and occurs as a result of the peripheral vasoconstriction.

    05:01 The skin will look pale.

    05:03 And you might ask the parents, "Does your child always have this skin tone?" and that's a good way to ask if maybe they're pale.

    05:10 The skin can also look mottled and this is another sign of compromised perfusion.

    05:15 It indicates abnormal capillary tone, and it has a speckled, lacy look.

    05:20 The child may also show cyanosis, and this is a blue discoloration of the skin due to low oxygen levels in the blood.

    05:27 The peripheral blood vessels are going to vasoconstrict, and this is going to decrease the hemoglobin and cause a bluish hue of the skin or the mucous membranes.

    05:35 Cyanosis is most easily seen around the mouth, in the oral mucosa.

    05:40 This is called perioral cyanosis.

    05:44 You use this to assess if your patient is experiencing early signs of shock.

    05:48 They will start with poor perfusion and that is the sign of your patient decompensating.


    About the Lecture

    The lecture Pediatric Assessment Triangle (PAT) (Nursing) by Paula Ruedebusch is from the course Respiratory Disorders – Pediatric Nursing.


    Included Quiz Questions

    1. Limp muscle tone
    2. Inability to be consoled
    3. Vacant stare
    4. Flexed muscle tone
    5. Strong cry
    1. Nasal flaring
    2. Retractions
    3. Grunting
    4. Posturing
    1. Pallor
    2. Mottling
    3. Cyanosis
    4. Delayed capillary refill
    5. Erythema

    Author of lecture Pediatric Assessment Triangle (PAT) (Nursing)

     Paula Ruedebusch

    Paula Ruedebusch


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