This is the pediatric assessment triangle.
It's a rapid assessment
technique and objective tool
that clinicians can use to aid
in their respiratory assessment.
There are 3 components in the
pediatric assessment triangle,
and we will touch on all of these.
They include the appearance of the
child, the work of breathing,
and the circulation to their skin.
The clinician can determine
in 30 seconds or less
how sick a child may be regarding
their respiratory status.
The clinician can use this tool throughout
their management of a pediatric patient
to see if they're improving or
worsening during their shift.
The acronym, TICLS, pronounce "tickles"
is sometimes used by
emergency medical providers
to remember the components
of the appearance item.
Regarding the child's appearance, the nurse
will assess the patient for their tone.
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.
Infants like to be in this flexed position.
They should strongly resist
attempts to straighten their limbs.
There are variations on the theme for the "I."
It can stand for either interactiveness,
or level of irritability.
Normally, a child is able to interact
with their caregivers and the staff,
based on age-appropriate milestones.
Abnormally, a child would not interact
or engage with caregivers or
their surrounding activities.
The "C" stands for consolability.
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.
Abnormally, you would see a child
who just cannot be consoled
or comforted by their usual caregivers,
and parents will tell you this.
They will say their child is unusually
fussy and cannot be consoled.
Abnormally, too, the child would not respond
normally to their environmental stimuli,
like preferred toys, and they just
wouldn't be acting like themselves.
The "L" stands for the look or gaze.
Normally, a child, depending on their age,
should be able to make
and maintain eye contact.
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.
They may not recognize their normal
caregivers and they may just look out of it.
The final component of the appearance
section is the speech or cry.
Normally, a child will be able to use
age-appropriate verbal communications.
And when speech and crying are normal,
this indicates that the child has
a nice, open, patent airway.
Abnormally, the child would not be using
their age-appropriate communications,
or their speech or cry may be absent.
This raises the concern for an occluded
airway or an altered mental status.
The next component of the
pediatric assessment triangle
is the work of breathing.
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.
Here, you see normal nostrils, normal size.
On the right, this patient's
displaying nasal flaring,
and this is going to maximize their airflow
through their nose while they breathe.
Next, you can see the work of
breathing by looking for retractions.
Retractions are a sign that someone
is working hard to breathe.
Normally, when you take a breath,
the diaphragm and the
muscles around the ribs
create a vacuum that pulls
the air into your lungs.
If a person is having trouble breathing,
these extra accessory muscles
and the muscles between the
ribs will kick in to help.
These are the retraction sites.
When a patient has severe retractions,
you're going to see these
in the suprasternal area.
When a patient has less severe retractions,
they fall in the moderate category.
They're going to have these in
the supraclavicular region,
so above the clavicle, or in the
intercostal area between the ribs.
When a patient's just
starting with retractions,
they're going to be in the sub-sternal
area or in the subcostal area.
So it's important to look
at the patient's chest.
You always lift up the
pediatric patient's shirt
or completely remove their shirt
to assess for retractions.
You can assess the work of breathing
by looking for posturing.
Look at your patient.
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.
Next, evaluate the breath sounds.
Are there any abnormal sounds like wheezing,
crackles, rales, stridor, or coughing?
Last, you'll check the
circulation of the skin.
Circulation, as measured by skin
color and capillary refill,
is a great indicator of
perfusion in children.
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.
This can be done at the
distal tips of the fingers.
You're also going to assess for pallor.
Pallor is associated with
early signs of hypoxia
and occurs as a result of the
The skin will look pale.
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.
The skin can also look mottled and this is
another sign of compromised perfusion.
It indicates abnormal capillary tone,
and it has a speckled, lacy look.
The child may also show cyanosis,
and this is a blue discoloration of the
skin due to low oxygen levels in the blood.
The peripheral blood vessels
are going to vasoconstrict,
and this is going to decrease
and cause a bluish hue of the
skin or the mucous membranes.
Cyanosis is most easily seen around
the mouth, in the oral mucosa.
This is called perioral cyanosis.
You use this to assess if your patient
is experiencing early signs of shock.
They will start with poor perfusion
and that is the sign of your