Peds Assesment Flashcards
What is the peds assessment triangle?
Sick or not sick classifier
-Appearance
-work of breathing
-circulation to skin
What does appearance pertain to
Reflects adequacy of ventilation, oxygenation, brain perfusion, body homeostasis and CNS function
What is TICLS used for
Appearance
Tone
Interactiveness
Consolability
Look / gaze
Speech / cry
Work of breathing
Often a better assessment of oxygenation and ventilation status than auscultation or RR
Reflects the child’s attempt to compensate for abnormalities in oxygenation, ventilation
Hands-off assessment includes listening for abnormal airway sounds and looking for signs of increased breathing effort
What indicates an upper away obstruction
Snoring, muffles or hoarse voice, stridor.
Can be a result of croup, upper airway infections, bleeding or edema
What is indicative of a lower airway obstruction
Grunting or wheezing
What is grunting
Form of auto PEEP
-heard at the end of exhalation
Moderate to severe hypoxia
Pneumonia and pulmonary edema
What is wheezing
Occurs on exhalation
Can occur on inhalation and exhalation
What is the sniffing position
Child is trying to align the axes of the airways to improve patency and increase air flow
Often reflects a severe upper airway obstruction
What are retractions
The recruitment of accessory muscles of respiration to provide more muscle power to move air into the lungs in the face of airway or lung disease
What is head bobbing
Form of retractions seen only in infants
Use of neck muscles to help breathing during severe hypoxia
Neck extends during inhalation; head falls forward during exhalation
What is nasal flaring
Exaggerated opening of the nostrils during laboured inspiration
What threee characteristics are considered when observing circulation
-Pallor
-Mottling
-Cyanosis
After assessing PAT, if the pt is deemed unstable
-Assess ABC’s
-Treat life threats
-transport immediately
How to assess breathing
-RR
-Breath sounds
-Pulse oximetry
