Which initial assessment made by the triage nurse suggest that a child requires immediate intervention?

Acknowledging the above pediatric red flags and utilizing the PAT as a guide, how would you categorize the three different children in the triage scenarios below? 

Scenarios for Knowledge Integration 

A three-year-old with a history of reactive airway disease presents to triage with complaints of coughing for two days. She is awake, alert, and smiling at her mother. She has mild tracheal tugging, no audible adventitious airway noises, and a respiratory rate of twenty-four. Her lips are pink, as are her fingertips, and her mucous membranes are also pink and moist.  

A second child is a 10-month-old without known past medical history. The child had a fall from standing, struck his head on the edge of a coffee table, sustained a 1cm vertical laceration to the mid-forehead 1–hour prior to arrival, and had no loss of consciousness; He is awake and alert with coordinated movements of extremities, no dysconjugate gaze, crying in triage, but consolable with mother. He is breathing at a normal rate and depth when calm, with no outward signs of bleeding, and has pink and warm skin.  

The final child is a 3-month-old with a history of term–birth which is still in his car seat. The mother reports he has had difficulty feeding for over a month now, including irritability, sweating, and increased work of breathing. In the last 48 hours, she has noticed that he is more fussy than usual and will not take a bottle; also, she has noticed noisy breathing at rest and some swelling to his hands and feet. As the triage nurse, during your across–the–room assessment, you notice that the infant is awake, occasionally crying, but it sounds weak. You note grunting noises with respirations and a respiratory rate of 70. It is noted as is circumoral and periorbital pallor that turns dusky with crying.

Which child is sick, sicker, and sickest?  

Recalling that the child without significant alteration in any one category of the PAT can have their focused assessment deferred [sick], an alteration in one category indicates a need for emergent focused assessment [sicker], and an alteration in two or more of the three categories indicates the need for resuscitation [sickest]. 

Rationale 

The child from scenario 1 has a normal general appearance, a normal rate of respirations for age but tracheal tugging [an indication of increased work of breathing] and normal circulation to their skin.  

The second child has a normal general appearance, normal work of breathing, and normal circulation to his skin with bleeding controlled from the head injury.  

The final child has an alteration in his general appearance: weak cry, alteration in his work of breathing: grunting respirations, rapid respiratory rate, and alteration in circulation to his skin: circumoral and periorbital duskiness when agitated and pallor at rest.  

Based on these findings, the second child is sick, the first is sicker, and the third is the sickest.  

1. Was there any variation in your categorization of the patients?
2. Could the PAT be applied to the adult population as well? 

Age-Specific Developmental Milestones  

Consideration of age-specific developmental milestones for pediatric patients is another important skill for a triage nurse, as it assists with optimizing the physical assessment. 

In the young infant, ensuring their comfort, and using minimal stimulation allows for auscultation of accurate heart tones and breath sounds. This may require allowing the child to remain in the car seat and quietly and gently altering clothing to allow for visualization of the chest wall. Engaging caregiver’s assistance is also advantageous as it offers some element of control for the concerned caregiver while allowing for the best possible exam. You may find that allowing the infant to feed- if medically advisable- will also offer comfort for both caregiver and infant.  

In an older infant who can sit unsupported, you can have them sit on the exam table or stretcher; however, you may find increased cooperation if they are left in their caregiver’s arms. Limitation of invasive pieces of the exam should be left until the end to avoid agitation; most older infants find items such as pulse oximetry monitoring devices and blood pressure cuffs to be upsetting, so offering distractions with age-appropriate toys can be helpful.  

Toddlers and preschool-aged children learn through play and by doing. Therefore, it is ideal to approach them with an inquisitive and playful perspective if the condition allows [1]. They should be allowed choices in positioning for the exam as well as other limited options, but they must allow the patient to feel some sort of control over the situation; engaging the caregiver to participate is also beneficial.  

For school-age and adolescent children, their participation will depend largely on the circumstances preceding their presentation to the ED. Independence and privacy are of large importance to both groups and should be considered by the triage nurse whenever possible. To build trust with the pediatric patient it is important to allow them to sit or stand in the position of comfort, undress in privacy, and ensure the most palatable level of caregiver involvement. 

1. Considering the milestones reviewed above, moving forward, how might you alter your practice of triaging specific age groups?  

2. Toddlers can be especially challenging; do you have distraction techniques that you‘ve utilized that have been successful? 

3. If not, is there a way to institute a distraction box for these patients in your facility? 

Care of Special Pediatric Populations  

The final area we will cover in this course for triage nurses is special pediatric patient populations. Whether you are part of a large, university-associated hospital with a multitude of pediatric resources or a small community-based ED with limited pediatric subspecialists, knowledge of practices specific to special populations will improve the quality of care delivered and improve the experience for the child and their family. 

As medicine and technology continues to advance, children with more severe and complex conditions are beginning to live longer; however, the need for greater medical and technological intervention continues to grow. As a triage nurse, it is imperative to acknowledging this need and to be aware of a few key points when these special pediatric populations present to the ED.  

First, and foremost, the caregivers for these children are the experts on their condition and the care they require. For this reason, if the acuity of the presenting problem allows, obtaining a thorough medical history as it pertains to the history of present illness is critical to determining the correct interventions. Many families are now seeking medical care with a prepared illness plan from their treatment team. For example, children with alteration in metabolic functioning will often present with a “recipe” of sorts that will identify the intravenous solutions to replete their deficiencies. Ensuring this information accompanies the child back for treatment is essential to optimizing the child’s care plan.  

DM Type I with DKA  

A common ED visit reason in pediatrics is new-onset Type I Diabetes, often presenting with diabetic ketoacidosis [DKA]. Recognition of this in triage can expedite and streamline the care a child will receive. 

Presenting symptoms often include:  

• Polydipsia 
• Polyuria  
• Weight loss 
• Vomiting 
• Fast breathing with Kussmaul Respirations  
• Fruity odor in breath 

The triage nurse should identify the child who presents with these symptoms as serious, requiring expedited care.  

Evaluation of the child’s neurologic state of functioning and obtaining blood glucose as soon as possible should be a critical first step in treating these patients.  These symptoms are the human body’s attempt to regulate the hyperglycemia and ketosis occurring as the body breaks down fat. DKA is a medical emergency and requires accurate recognition and quick actions on the part of the first-line care provider- and in this case, usually the triage nurse.  

The Septic Neonate 

The septic neonate is another pediatric population that requires immediate identification and rapid treatment. For this reason, the triage nurse should be able to identify a neonate at risk for and presenting with the hallmark symptoms of sepsis. 

Presenting symptoms often include:  

• Feeding difficulties 
• Increased sleepiness  
• Fever [occasionally] 

In other cases, the infant may be hypothermic, which should cause the triage nurse to be suspicious of sepsis and initiate your facility’s pediatric sepsis pathway. The time window for administering antibiotics can have grave consequences for the septic neonate, so triage is a critical piece of expediting care.  

Fever and Neutropenia 

Fever and neutropenia in the pediatric patient are common presenting problems that require expedited care. As more children are able receive their hematological and oncological treatments as outpatients, the number who require ED visits for treatment-induced neutropenia that develop fevers have increased. 

Most caregivers will know to mention their child’s underlying diagnosis, but important pieces for the triage nurse to gather include: 

• Time of fever onset 
• Last treatment date 
• CBC results if known.  

Like the septic neonate, the time window for administering antibiotics is critical and should be recognized and coordinated at the point of triage.  

Ingestions  

Accidental or intentional ingestions are another frequent chief complaint for the pediatric patient population in the ED. Key details to assist with determining the need for immediate interventions include:  

• the time of ingestion 
• any contact with the poison control center and their recommendations,  
• any attempted treatments prior to arrival [especially if vomiting was induced as this could indicate concern for aspiration, retraumatization to esophagus and airway if substance is caustic] 
• ingredients of the product or the number of the medication in a bottle prior to ingestion and the dosage of the contents  

Your facility providing a reference list of the most dangerous substances as well as allowing access to your designated poison control center are essential resources for a triage nurse. This is important to mention as the recommendations are constantly changing. For example, household bleach is rarely toxic as the FDA has regulated its alkalinity; however, industrial bleach has higher concentrations, and thus, remains very caustic. Distinguishing the details of the ingestant is imperative to accurate care.  

Hydrocarbons are another dangerous household products. These are products such as liquid lamp oil, furniture polishes, lighter fluid, and aerosol propellants [1]. Unfortunately, these products are usually marketed in enticing colors and often catch the eye of children. The unintentional ingestion of a hydrocarbon causes gastrointestinal distress and severe respiratory impairment if aspirated. Following, if untreated, it can often lead to chemical pneumonitis and the viscosity of the liquid leads to significant lung injury. The biggest risk is that if the child coughs or vomits during or following ingestion, this can lead to a critical illness. If a child is suspected of having ingested a hydrocarbon and continues to have a cough or throat clearing, they require immediate care, including a chest radiograph.  

Autism Spectrum Disorder [ASD] 

As triage nurses, our focus must be to perform accurate and rapid assessments as well as proper categorization of illness acuity.  

When it comes to the care of the pediatric patient with ASD, understanding the stimuli that are most noxious, attempting to alleviate fears, and remaining calm and comforting must be first line treatment. The caregivers of the child and will be your guide to the history of the patient, and potentially, your interpreter depending on the capabilities of the child. Requesting the caregiver’s advice on the best means of performing assessments and how to achieve the child‘s cooperation will lead to a better experience. It may also be useful to assemble a “sensory box“ filled with items such as weighted blankets, light spinners, vibrating rings and other items that can be found through online resources. 

1. Consider the highest acuity pediatric populations you have seen in your practice. Incorporating the above teaching points, is there anything you might alter in your care after this review?  

2. Are there protocols in place to expedite the care of fragile pediatric patient populations? 

Conclusion  

Triage nurses are the gatekeepers and resource allocators of the ED, so it is of the utmost importance that they are well-informed of the various aspects of assessment tools, care plans for special pediatric populations, and much more; it will ensure the highest possible level of care to the greatest number of patients. Pediatric patients and their families deserve a healthcare provider who is well versed, comfortable with, and confident in their abilities to adequately recognize and appropriately categorize a wide variety of pediatric ill and injured patients. 

References + Disclaimer

1. Hohenhaus, MA, RN, CEN, FAEN, S. M. [2012]. Prioritization: Focused Assessment, Triage, and Decision Making. In Emergency Nursing Pediatric Course, Provider Manual, Fourth Edition [pp. 54-61]. Emergency Nurses Association. 
2. Mersch, MD, FAAP, J. [2020, 11 5]. Pediatric Vital Signs Ranges and Charts. EMedicine Health. Retrieved April 5, 2021, from //www.emedicinehealth.com/pediatric_vital_signs/article_em.htm.  
3. Patrick, MD, FAEMS, C. [2020, October 27]. The Pediatric General Assessment Triangle. EMS Neonatal Pediatrics. Retrieved April 1, 2021, from //www.ems1.com/ems-products/neonatal-pediatric/articles/the-pediatric-general-assessment-triangle-KE8VtMVnpbpRIJgh/ 

Use of Course Content. The courses provided by NCC are based on industry knowledge and input from professional nurses, experts, practitioners, and other individuals and institutions. The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NCC. The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare. The information provided in this course is general in nature and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Knowledge, procedures or insight gained from the Student in the course of taking classes provided by NCC may be used at the Student’s discretion during their course of work or otherwise in a professional capacity. The Student understands and agrees that NCC shall not be held liable for any acts, errors, advice or omissions provided by the Student based on knowledge or advice acquired by NCC. The Student is solely responsible for his/her own actions, even if information and/or education was acquired from a NCC course pertaining to that action or actions. By clicking “complete” you are agreeing to these terms of use.

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