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Issues in Paediatric Triage

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  ISSUES IN P EDI TRIC TRI GE Cathy Almond RN, Grad Cert Paeds, Grad Dip Vocational Ed and Training, ENPC Instructor Sydney Childrens Hospital Abstract Recognising the unwell child at triage is a difficult process. Vital signs, particularly in paediatrics, can be an unreliable basis for making a triage decision. Common signs obtained at triage include temperature, heart and respiratory rates, oxygen saturations and blood pressure but the only vital signs that may be considered necessary are the heart and respiratory rates. Triage nurses need to increase utilisation of their excellent observational skills in order to enhance the process of triage. Initial assessment of the child presenting to emergency is via an 'across the room' assessment This, arguably, is the single, most important observational tool that is utilised for children. With experience, it quickly becomes obvious whether the child has a problem with airway, breathing or circulation and whether intervention is necessary. Taking the child's temperature, blood pressure or measuring pulse oximetry are useful adjuncts but given the time and nature of triage, unnecessary. The benefit of taking vital signs at triage can be questioned based on well- documented evidence. Look at the child Instead of relying on vital signs, we need to develop our observational assessment skills. An 'across the room assessment' that occurs when the patient arrives 8 can communicate vital information. This assessment can be considered an observational primary assessment in that airway, breathing, circulation and disability are simultaneously assessed. In doing this, the question of whether the child 'looks well', 'looks unwell' or whether the nurse is uncertain is decided. This will help triage category allocation; if the child looks well, they are at the lower end of the scale. An unwell child is probably a 1 or 2 and uncertainty may indicate the need for further assessment. Airway Airway patency is obvious from looking at the child, taking into account the position necessary to maintain a patent airway. A significant airway problem in a child may be suspected if: - they are unable to vocalise normally eg cry, babble, talk; they cannot swallow saliva or fluids without drooling (babies around 6-9 months normally drool - ask the caregiver if this is normal); - the child has difficulty breathing both asleep and awake. Consider whether the child is sitting upright, being held or able to lie flat. The 'tripod' position describes the child who attempts to maximise air entry by sitting forward, hands on knees with their neck extended. It is often seen with an upper airway obstruction, eg epiglottitis, where the child is struggling to maintain a patent airway. Breathing Assessment of the breathing is ascertained by looking at the child's respiratory rate and pattern. Looking at the chest you can ascertain whether the child's rate is too fast or too slow. It is important to know normal age ranges and therefore recognise abnormal. You will also note signs of respiratory distress, e.g. tracheal tug, intercostal/subcostal recession, nasal flaring. It then becomes obvious the child has an increased respiratory effort; pulse oximetry or a respiratory rate will not change your triage decision. Consider any audible respiratory noises that the child may be making. Wheezing is generally expiratory, indicative of a lower airway obstruction and is commonly associated with asthma, bronchiolitis or foreign body obstruction. A stridor is a low, harsh sound, usually inspiratory and indicative of an upper airway obstruction, eg croup (laryngotracheobronchitis). Grunting occurs because the child attempts to create their own PEEP (positive end expiratory pressure), to prevent alveoli collapsing at the end of expiration. It is a sign of severe respiratory distress observed most frequently in children with pneumonia. These are easily identifiable signs that indicate the child needs priority treatment, without having touched or talked to the child or parents. Circulation Circulation is evaluated by looking firstly at the child's colour. A child with a compromised circulating blood volume may be pale, mottled, flushed, or grey looking. Cyanosis in children is a late sign compared to adults. Children are relatively anaemic by comparison and up to 50% of a child's haemaglobin may be desaturated before cyanosis will be clinically obvious Evaluation of the child's capillary refill, skin temperature and turgot will give a good indication of the adequacy of circulating blood volume. The capillary refill should be less than two seconds; skin turgor can be evaluated by gently pinching the arm or abdomen of the child. The skin should return to a normal state immediately. When the skin is lifted and remains 12 AENJ VOLUME 3 NO 1 APRIL 2000  in that position for a prolonged period it is known as tenting. It is a sign of severe dehydration. Disability When a child arrives at the triage desk, their activity level, response to their environment and level of consciousness is an excellent indicator of their neurological status? The brain is one of the most sensitive organs to hypoxia, hence changes in the child's mental status are a good indication of this. Consider how the child responds to the environment they are in and to their parents/caregivers. Most children in a different environment will be curious; looking around at the people and equipment. In pre-verbal children, listen to their cry and response to comfort measures. Parents can distinguish their child's cry from one of hunger/dirty/in pain or wind; they recognise a normal cry for their child. Children who cry inconsolably or have a high pitched, almost cat like wail are of concern, as are children who do not respond to comfort measures. From around six weeks of age a neonate is able to maintain eye contact and starts to recognise primary caregivers. A child who is disinterested in the environment, does not recognise his caregivers or is difficult to rouse should alert the nurse to an unwell child. Paradoxical irritability is the term used for a child who is quiet and listless, often falling asleep when left alone, and restless and irritable when disturbed. It is an indicator of a neurological problem (eg meningitis). A decreased response to pain in a child of any age is abnormal My child has a fever Fever is a common presenting problem and often creates great anxiety amongst parents. The anxiety is mainly associated with the possibility of a seizure or brain damage. A common perception is that ...infection is bad, infection causes fever, and that therefore fever is bad. '7 Literature suggests that giving paracetamol will not prevent a febrile convulsion. Fever, h9wever, has some beneficial effects. It improves the body's immune response, is associated with an increased survival rate and has been shown tobe a protective mechanism to prolong survival. 5 It is also an indication that an infection exists. Treatment of fever is considered appropriate for patient comfort. Generally children will be irritable and miserable when febrile, and a reduction in temperature can be very comforting. Children have higher oxygen demands than adults due to higher metabolic needs. A child with a pre-existing medical condition (eg asthma, cardiac structural anomaly) may mean the body is less tolerant of the increased metabolic demands that a fever produces. 5 As long as the infection is present, the fever will often remain - regardless of the amount of antipyretic administered. We should consider the education we give parents regarding the recognition and treatment of a fever as perhaps a more important role at triage. Caregivers - and health personnel - need to refocus our concerns. How the child looks is a much better indicator of how well or unwell they are, rather than the height of the fever. We need to explain t O parents that it is the cause of the fever that will determine the child's outcome, not the fever itself. A fever is a symptom of the underlying problem, not the problem. What was the pulse oximetry Pulse oximetry functions by emitting light through the skin via a sensor, with the aim of measuring oxyhaemoglobin; that is, the amount of haemoglobin saturated with oxygen. 1 It is a widely used, non-invasive tool for monitoring oxygen saturation, as an indicator of hypoxia. Pulse oximetry is difficult to obtain in children with even slight motion, where abnormal haemoglobin exists (e.g. carboxyhaemoglobin poisoning), or with poor perfusion. External light sources can result in a false reading, as can nail polish as it interferes with the light transmission. 2 An anaemic child may have normal oxygen saturation because the total haemoglobin present is fully saturated, although this may be insufficient to meet the body's requirements. The hypoxic child can be clinically recognised, as discussed, by looking at the mental status, respiratory status, colour and capillary refill. You haven't done a blood pressure. Children can lose up to 25% of their circulating blood volume before a decrease in blood pressure is evident. 8 A hypovolaemic child is clinically evident. A widening pulse pressure (the difference between the systolic and diastolic pressure) may be an indicator of raised intracranial pressure, however an altered mental state and tachycardia would be earlier signs. Identifying a trend in blood pressure measurement is more significant than one single blood pressure reading. Assessing blood pressure in children is not always easy; the automated sphygmomanometer, which is routinely used in many emergency departments, inflates the cuff well above expected normal systolic blood pressure for children and can be painful. Excessive movement will affect the accuracy of the reading, and few young children will remain still long enough for this to be completed. The cuff should cover at least two- thirds of the child's upper arm or leg; a variety of sizes are not always readily available at triage. The time taken to attend to this and the clinical significance means it is unlikely to alter your triage decision, therefore is an unnecessary initial intervention. AENJ VOLUME 3 NO. | APRIL 2000 3  The essential vital signs It may prove useful to obtain some baseline vital signs in a child at rest, ie, when the child is settled. As cardiac output increases to meet the body's increased oxygen demands, an elevated heart and respiratory rates are early signs of compromise in a child. This elevation may be due to a variety of causes, but it is important that it is recognised, k resting pulse and respiratory rate is a good indicator of how well or unwell the child is. Fear, anxiety, shock, hypoxia, hypovolaemia, crying or fever will all cause an elevation of a child's heart and respiratory rates which should be acknowledged at triage when observations are recorded. It is important not to attribute, however, an elevation in vital signs because the child is crying. Always attempt to obtain resting vital signs at some stage. Development There is very little time at triage to develop a rapport with children. Having an understanding of basic growth and development will enhance knowledge of expected normal behaviour and therefore simplify the triage process. Neonates' posture is predominantly one of flexion; they lie with arms and legs slightly drawn up and into their body. They are able to maintain eye contact from around six weeks of age. Infants from around 7-9 months develop an awareness of their caregivers as significant others and may become distressed at being separated from them. Toddlers, although desiring independence, have a strong awareness of 'stranger danger' and will often protest strongly and loudly at the absence of their main caregiver. Preschoolers are curious about their environment. School age children will often put on a brave face for their peers. Adolescents desire independence and privacy. From this basic overview, it is easy to understand why knowledge of normal development can guide triage assessment. This understanding will make it easier to recognise normal and abnormal behaviour. Conclusion Nurses attend to vital signs in paediatrics because they are afraid of 'missing something'. Those new to triage require objective reassurance that they allocated the appropriate triage category. I believe we need to change our thinking and update triage training programs. We need to rely less on machines and more on observation. A sick child is often observable. Placing a hand on the child's head is sufficient to tell whether the child is hot or not. Vital signs are not infallible indicators. '4 The triage process - from the initial assessment to the triage decision - should take no longer than five minutes. 9 The time taken to gain a child's trust and co-operation means ascertaining baseline vital signs within this time frame can be 4 AENJ VOLUME 3 NO 1 APRIL 2000 difficult. We need to consider whether attending vital signs will change the triage decision. An unwell child is clinically evident based on observation, therefore blood pressure, pulse oximetry and temperature are useful adjuncts but not essential components of paediatric triage. References 1. Cowan, T 1997 'Pulse oximeters' in Professional Nurse 12(10) pp744-750 2. Durren, M 1992 'Clinical Notebook Getting the most from pulse oximetry' in Journal of Emergency Nursing 18(4) pp 340-342 3. Henker, R 1999 'Evidence-based practice: fever-related interventions' in American Journal of Critical Care 8 (1) pp 481-487 4. Keddington, R.K. 1998 A triage vital sign policy for a children's hospital emergency deparunent in Journal of Emergency Nursing 24 pg 189-192 5. Letizia M and Janusek L 1994 'The self-defense mechanism of fever' in MedSurg Nursing 3(5) pp 373-377 6. Nelson D 1998 'Pediatric Update Emergency treatment of fever phobia' in Journal of Emergency Nursing 24(4) pp 83 84 7. Shan, F 1995 'Paracetamol: use in children' in Australian Prescriber 18(2) pp 33-34 8. Soud TE Rogers JS 1998 Manual of Pediatric Emergency Nursing Mosby, St Louis 9. Travers, D 1999 'Triage: how long does it take? How long should it take? in Journal of Emergency Nursing 25(3) pp 238-240 10. Walsh, P 1996 'Febrile convulsions' in The Aus~alian Paediatric Review 6(3) pp 1-2 EXTRICATION COLLARS~ WHEN ARE THEY REMOVED Pat arnwell RN, BA, Grad Cert Research, ICU Neuro Cert, TNCC, ENPC and CATN Instructor Westmead Hospital The use of extrication collars for injured patients has limited the incidence of further injury due to insufficient stabilisation of the cervical spine. Extrication collars are removed when the neck is cleared of injury or definitive treatment is commenced. The problem I have identified is that clearing the cervical spine may be delayed many hours due to various factors and the hard collar stays on causing the patient increasing discomfit and possible pressure areas. This survey asks you, as nurses, to identify a benchmark time for the replacement of the extrication collar with a treatment type, irrespective of the presence or absence of injury. The trauma guidelines tend to suggest 24 hours; the patient would seem to suggest a much shorter time. Responses to the survey can be emailed to the Association at enainc@ozemail com au or posted to the Association address (PO Box 141 Toongabbie, 2146) marked attention Pat. The results will be published in the Journal at a later date. Thank you for considering the survey: our patients thank you for your advocacy.
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