Pediatric emergency medicine trisk 0134 0134
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The mnemonic CIAMPEDS provides a systematic approach to triage history
taking. Information gathered helps the triage nurse determine potential triage
interventions, isolation requirements, special needs, and triage acuity ( Table 6.5
).
Focused Physical and Pain Assessments
Comprehensive physical assessment is not warranted during the triage process as
it prolongs the triage evaluation and delays definitive care. Once a chief
complaint is determined, a focused physical assessment of the affected area(s)
should be completed as abnormal findings often impact patient triage care and
acuity. For instance, a distended, rigid abdomen or a decreased distal pulse in an
injured extremity warrants expedited physician evaluation, and therefore, higher
triage acuity. Pain assessment utilizing validated, developmental appropriate tools
is incorporated into the triage secondary assessment to provide a baseline for the
ED visit, and to assess for necessary triage intervention.
Vital Signs
Vital signs assessment during the triage process can provide key indicators as to
the severity of illness and compensatory status of the pediatric patient. Table 6.6
depicts normal vital sign parameters by age as drawn from current existing
literature. Pediatric vital signs should be assessed utilizing appropriately sized
equipment to ensure accuracy in values. Blood pressure assessment should be
based on nursing judgment as to patient need as it is not a critical factor in acuity
assignment. As fever can impact acuity for numerous pediatric populations
including neonates, immunocompromised and sickle cell patients, temperature
should be evaluated during the triage process. Higher acuity should be considered
in patients with tachycardia without fever, or tachycardia outside expected range
for fever (every degree Celsius rise in temperature should correlate with a 10%
rise in baseline heart rate). Pulse oximetry should be measured on patients who
present with respiratory or cardiac complaints. If one vital sign parameter is
abnormal, it is important to obtain a full set to determine appropriate acuity
assignment.
