Paediatric Assessment

Question 1

Paediatric Assessment Triangle

Answer 1

Rapid (30-sec) hands-off assessment:
1. Appearance (CLITS)
- Consolability
- Look/glaze
- Interactiveness
- Tone
- Speech/cry
2. Work of breathing (PAM)
- Position - tripod, sniffing.
- Abnormal breath sounds
- Movement - NF, HB, UOAM, recessions, chest expansion/diaphragm, see-saw.
3. Circulation - colour & temp.

Question 2

Vital signs - NEONATE (<28 days)

Answer 2

Weight - 3.5kg
SBP - 60-95
HR - 120-185
RR - 25-60
SpO2 - 91-95
PaO2 - 50-80

Question 3

Vital Signs - INFANT (<12 months)

Answer 3

Weight - 6-8kg
SBP - 60-105
HR - 110-180
RR - 25-60

Question 4

Vital Signs - TODDLER (1-3 yrs)

Answer 4

Weight - 10-12
SBP - 70-105
HR - 95-180
RR - 20-45
SpO2 > 94

Question 5

Vital Signs - YOUNG CHILD (4-8 yrs)

Answer 5

Weight - 15-25
SBP - 75-115
HR - 70-150
RR - 16-30
SpO2 > 94

Question 6

Vital Signs - OLDER CHILD (10-12 yrs)

Answer 6

Weight - 30-40
SBP - 85-120
HR - 60-120
RR - 15-25
SpO2> 94

Question 7

Vital Signs - ADOLESCENT (14+ yrs)

Answer 7

Weight - 50+
SBP - 90-135
HR - 60-115
RR - 14-25
SpO2 > 94

Question 8

AIRWAY

Answer 8

1. Secure - self-protect or artificial?
2. Patent - able to speak, partial or complete obstruction.

Question 9

BREATHING

Answer 9

1. Respirations - rate, depth (bilateral), pattern.
2. Effort/WOB - noises, positioning, NF/HB, UOAM, recessions/retractions, abdomen.
3. Oxygenation - SpO2 and O2 delivery.
4. Skin (central/peripheral) - colour, temp, moisture.
5. Audible and adventitious breath sounds - wheezing, stridor, grunting.

Question 10

CIRCULATION

Answer 10

1. Heart - rate, rhythm, abnormal sounds.
2. Blood pressure (TERMINAL SIGN)
3. Pulses - central vs peripheral, rate, strength/volume.
4. Skin - colour, temp, moisture, turgor, oedema.
5. CRT
6. Oral mucosa - colour, moisture.
7. U/O and other volume losses (V/D, bleeding, drainage)
8. Infant - anterior fontanelle
9. Specimens - blood or urine

Question 11

DISABILITY

Answer 11

1. LOC - AVPU
2. mGCS score
3. Suspected brain injury - PERRLA, abnormal posturing.
4. Infant - newborn reflexes, fontanel.
5. Seizure activity
6. BGL
7. Pain.
8. Deficit - disability, implant/device, aids.

Question 12

EXPOSURE

Answer 12

1. Temperature
2. Skin - rash, bruising, wounds, bites/stings.
3. Injury

Question 13

FAMILY

Answer 13

1. Parent/caregiver concern
2. CALD or ATSI status
3. Cultural and/or religious considerations
4. Social supports
5. Health literacy

Question 14

Weight calc

Answer 14

1-5 years = 2 x (age + 5)
5+ years = 4 x age