Pediatric CCRN Exam

This chapter covers the rapid first look (the Pediatric Assessment Triangle), the primary survey, early warning scores, the difference between compensated and decompensated states, and the comprehensive physical and psychosocial assessment that guides care.

The Pediatric Assessment Triangle (PAT) is a hands-off, doorway assessment done in seconds. It uses three components: appearance, work of breathing and circulation to the skin. Together they tell you whether the child is sick or not sick and what kind of problem is most likely.

Memory Aid: Appearance uses "TICLS" (pronounced "tickles"): Tone, Interactiveness, Consolability, Look or gaze, Speech or cry.

After the first look, perform the hands-on primary survey. Treat life threats as you find them; do not finish the survey before acting on an obstructed airway.

The secondary survey adds a focused SAMPLE history (signs and symptoms, allergies, medications, past history, last meal, events) and a head-to-toe examination.

Exam Tip: When a stem describes an obstructed airway or apnea, the best answer addresses airway or breathing even if circulation also looks poor. When the airway and breathing are supported and perfusion is poor, the best answer moves to circulation.

Respiratory distress means increased work of breathing with adequate gas exchange. Respiratory failure means the child can no longer oxygenate or ventilate adequately. Signs of progression include a falling respiratory rate without clinical improvement, decreasing level of consciousness, inadequate chest rise, cyanosis despite oxygen, bradycardia and a rising PaCO2.

Common Trap: Reading a slowing respiratory rate as improvement. In a tired child who is becoming less responsive, a falling rate is fatigue and impending arrest. Assist ventilation.

Compensated shock maintains a normal systolic blood pressure through tachycardia, increased systemic vascular resistance and increased contractility. Decompensated (hypotensive) shock occurs when these mechanisms fail.

Pediatric early warning scores (PEWS) assign points to behavior, cardiovascular and respiratory findings, sometimes with additional points for nurse or family concern or for frequent nebulizer use. A rising score triggers more frequent assessment, provider notification or a rapid response call according to the unit's algorithm. Scores support, but never replace, clinical judgment: a nurse who is worried should escalate even when the score is low.

Escalation tools include the chain of command, SBAR communication (situation, background, assessment, recommendation) and family-activated rapid response, since families often notice subtle changes first.

Bedside Scenario: A 4-year-old on the step-down unit two days after appendectomy has a PEWS that rose from 1 to 4 over three hours. Heart rate is 148, respiratory rate 34, capillary refill 3 seconds and the child is newly irritable and refusing to drink. The temperature is 38.9 C (102 F). The nurse calls the rapid response team using SBAR, states a concern for sepsis from an intra-abdominal source, and anticipates cultures, vascular access and fluid resuscitation. Waiting for the next scheduled vital signs would miss the window for early sepsis treatment.

The comprehensive assessment combines systems review with age-specific techniques. Approach a frightened toddler from least to most invasive: observe and count respirations first, auscultate the chest while the child sits on a parent's lap, and leave the ears, throat and painful areas for last. Include fontanel assessment in infants, liver edge palpation (hepatomegaly suggests right heart failure or fluid overload), pulse comparison between upper and lower extremities, skin integrity under every device, and growth measurement.

Psychosocial assessment identifies developmental stage, coping, family structure, cultural and spiritual needs, and stressors. It shapes how you explain, prepare and comfort.

Common Trap: Explaining a procedure to a preschooler days in advance. Preschoolers do better with brief preparation close to the event; school-age children and adolescents benefit from earlier, more detailed explanation.

• The PAT (appearance, work of breathing, circulation to skin) identifies sick versus not sick in seconds.
• Treat life threats during the ABCDE survey as you find them.
• A slowing respiratory rate with declining responsiveness is fatigue, not improvement.
• Rising early warning scores trigger escalation, but nurse or family worry is enough to call for help.
• Tailor assessment and preparation to developmental stage.