The Paediatric Assessment Triangle is a rapid assessment tool that allows healthcare providers to quickly evaluate a paediatric patient’s overall condition. Comprising three key components – Appearance, Work of Breathing, and Circulation to the Skin – the Paediatric Assessment Triangle provides critical insights into a child’s well-being and helps identify potential life-threatening conditions.
Paediatric Assessment Triangle Components
Appearance
The Appearance component focuses on observing the child’s general appearance, behaviour and interaction with the environment. It provides valuable insights into the child’s mental status, level of distress and potential signs of serious illness.
Key elements indicated below can also be referred to the TICLS mnemonic:
- Tone
- Interactiveness
- Consolability
- Look/Gaze
- Speech/Cry
Differences in appearance for a well or unwell child:
| Well | Unwell | |
|---|---|---|
| Tone | Active, reaching, moving, strong grip | Still, floppy, quiet |
| Interactiveness | Interested int he environment, looking, smiling | Not interested in their surroundings |
| Consolability | Easily comforted/consoled | Inconsolable |
| Look/Gaze | Looks at parents/caregivers or items of interest | Staring, not engaging in eye contact |
| Speech/Cry | Cries | Moaning, grunting or quiet |
When assessing appearance, healthcare providers consider the following key indicators:
- Level of Consciousness: Evaluate the child’s level of consciousness, ranging from alert and responsive to drowsy or unresponsive. Assessing consciousness helps identify any neurological issues or potential altered mental status that may require immediate attention.
- Behavioural Assessment: Observe the child’s behaviour, including their interaction with their surroundings, response to stimuli and engagement with caregivers. Look for any abnormal behaviour such as irritability, lethargy, or agitation, as it may indicate underlying distress or illness.
- Interaction with Caregivers: Assess how the child interacts with their caregivers. Observe their ability to make eye contact, respond to their name and engage in appropriate social interactions. Lack of responsiveness or poor interaction may suggest a decline in mental status or neurological impairment.
- Signs of Distress: Look for signs of distress, such as facial grimacing, clenched fists, or guarding specific body parts. These signs can indicate pain, discomfort, or localised injury, requiring further evaluation and management.
- Colour of Mucous Membranes: Assess the colour of the child’s mucous membranes, such as the lips and oral cavity. Pale or cyanotic mucous membranes may suggest inadequate oxygenation or perfusion, warranting immediate attention.
- Skin Appearance: Examine the child’s skin for any abnormal findings, such as pallor, jaundice, or rashes. Unusual skin findings may provide clues to underlying conditions, infections or allergic reactions.
- Hydration Status: Evaluate the child’s hydration status by assessing factors like skin turgor, dryness of mucous membranes and the presence of tears. Poor hydration can indicate potential fluid imbalances that may require intervention.
Work of Breathing
The Work of Breathing component evaluates the child’s respiratory effort, rate, and quality. It provides crucial information about the child’s respiratory status and helps identify any signs of respiratory distress.
Key elements include:
- Abnormal breath sounds
- Abnormal positioning
- Retrations
- Nasal flaring
When assessing the work of breathing, healthcare providers consider the following key indicators:
- Respiratory Rate: Assess the child’s respiratory rate, which refers to the number of breaths per minute. Abnormal respiratory rates, such as rapid breathing (tachypnea) or slow breathing (bradypnea), may indicate underlying respiratory compromise or distress.
- Use of Accessory Muscles: Observe if the child is using additional muscles, such as neck muscles or intercostal muscles to assist with breathing. Increased reliance on accessory muscles suggests increased respiratory effort and potential respiratory compromise.
- Nasal Flaring: Look for flaring of the child’s nostrils during breathing. Nasal flaring is a sign of increased work of breathing and can indicate airway obstruction or respiratory distress.
- Retractions: Assess for retractions, which are inward movements of the chest wall during inspiration. Retractions in areas such as the intercostal spaces, above the clavicles, or below the rib cage indicate increased respiratory effort and potential respiratory distress.
- Abnormal Breath Sounds: Listen for any abnormal breath sounds, such as wheezing, crackles, or stridor. These sounds can provide insights into underlying respiratory conditions and help guide appropriate interventions.
- Grunting: Pay attention to any grunting sounds made by the child during expiration. Grunting is a protective mechanism the body uses to increase lung volume and improve oxygenation but can also indicate respiratory distress.
- Symmetry of Chest Movement: Observe the symmetry of chest movement during respiration. Asymmetrical chest movement, with one side showing reduced expansion, may suggest underlying lung pathology or pneumothorax.
Circulation to the Skin
The Circulation to the Skin component involves assessing the child’s skin colour, temperature and perfusion. It provides valuable information about the child’s cardiovascular status, blood circulation, and potential hypoperfusion.
Key elements include:
When assessing circulation to the skin, healthcare providers consider the following key indicators:
- Skin Colour: Observe the child’s skin colour and note any abnormalities. Pallor, which is paleness of the skin, may indicate decreased blood flow or anaemia. Cyanosis, a bluish discolouration of the skin, can suggest inadequate oxygenation. Jaundice, a yellowish tint of the skin, may indicate liver dysfunction or excessive breakdown of red blood cells.
- Temperature: Assess the child’s skin temperature by gently touching the skin with the back of your hand. Abnormal skin temperatures, such as cool or cold skin, may indicate poor perfusion or hypothermia. Warm or hot skin can be a sign of fever or hyperthermia.
- Capillary Refill Time: Perform a capillary refill test by pressing on the child’s fingertip or nail bed and then releasing the pressure. The time it takes for the colour to return to the area reflects the capillary refill time. Prolonged capillary refill time may suggest poor peripheral perfusion and inadequate blood flow.
- Skin Moisture: Evaluate the moisture level of the child’s skin. Excessive dryness or cool clamminess can indicate poor circulation and potential shock. Normal or slightly moist skin is generally a positive finding.
- Skin Mottling: Look for the presence of skin mottling, which appears as a patchy, bluish discolouration of the skin. Mottling can be a sign of poor peripheral perfusion and may indicate a serious underlying condition.
- Oedema: Assess for any swelling or oedema in the child’s extremities or other areas of the body. Oedema can suggest fluid imbalances, circulatory issues, or underlying systemic conditions.