CPEN Exam

Triage is where pediatric emergency nursing judgment is tested most directly. The CPEN exam rewards a nurse who recognizes the sick child quickly from across the room, applies the Emergency Severity Index (ESI) the way the handbook intends, screens for hidden risks such as suicide, communicable disease and missed immunizations, and knows how pediatric needs change when the department shifts into decontamination or mass casualty mode.

This chapter covers the first seconds of triage: the Pediatric Assessment Triangle (PAT), how to interpret each side, and how the general impression drives the decision to stop triage and start resuscitation.

Children compensate well and then decompensate fast. Touching, undressing or separating a frightened child often changes heart rate, respiratory rate and work of breathing, which hides the very signs you need. For that reason the pediatric emergency approach starts with a hands-off look, done in 30 to 60 seconds, before any equipment touches the child.

The PAT is that look. It needs no stethoscope, no monitor and no cooperation. It answers one question: is this child sick, and if so, what kind of sick? It does not give a diagnosis. It sorts the child into a physiologic category that tells you how urgently to act and which interventions come first.

Appearance reflects the adequacy of oxygenation, ventilation, brain perfusion and central nervous system function. It is the most important side. The mnemonic TICLS guides it: Tone (moving vigorously or limp), Interactiveness (reaching for toys, tracking the caregiver, or uninterested), Consolability (calms with the caregiver or inconsolable), Look or gaze (makes eye contact or stares blankly), and Speech or cry (strong cry and age-appropriate speech or a weak, muffled, hoarse cry).

Work of breathing reflects oxygenation and ventilation effort. Look and listen for abnormal airway sounds (stridor, grunting, snoring, hoarseness, wheeze audible without a stethoscope), abnormal positioning (sniffing position, tripod position, refusal to lie down), retractions (suprasternal, intercostal, subcostal), nasal flaring and head bobbing in infants.

Circulation to skin reflects cardiac output and perfusion of core organs. Because the body shunts blood away from the skin early in shock, skin signs appear before blood pressure falls. Look for pallor, mottling and cyanosis. Central cyanosis is a late and ominous sign.

Pediatric Assessment Triangle: Components and Abnormal Findings

The pattern of abnormal sides points to a physiologic state. Learn these combinations, because exam stems often describe only what the nurse sees from the doorway and ask for the general impression or the priority action.

General Impressions From the PAT

Clinical Scenario: A mother carries a 10-month-old to the triage window. From across the room the infant is pale and mottled, lies quietly against her shoulder without looking around, and breathes fast but without retractions. Appearance and circulation are abnormal while work of breathing is near normal, which suggests hypotensive shock (often from dehydration or sepsis at this age). The nurse should bypass routine triage, bring the infant to a resuscitation bed, place the infant on a monitor, obtain vascular access, check glucose and alert the team for fluid resuscitation.

The PAT is a hands-off, 30- to 60-second look at appearance, work of breathing and circulation to skin.

Appearance (TICLS) is the most important side and the best single indicator of how sick a child is.

Abnormal appearance plus abnormal work of breathing means respiratory failure; abnormal circulation alone means compensated shock; all three abnormal means cardiopulmonary failure.

An abnormal PAT stops routine triage and moves the child to a resuscitation area.