Queensland Paediatric Emergency Care
Nursing Skill Sheets
Rapid Assessment: Paediatric Assessment Triangle
A rapid assessment can be utilised to quickly and efficiently assess an unwell child to determine if immediate
intervention is required. A commonly used rapid assessment tool is the American Academy of Paediatrics –
Paediatric Assessment Triangle.
Paediatric Assessment Triangle
The presence of any of the below may indicate that the child’s is very ill or that their clinical condition is deteriorating.
Bronchiolitis signs and symptoms
Appearance Breathing
• AVPU: Does the child require • Airway compromise
stimulation to garner a response? • Respirations: absent, decreased,
• Flat, poor/rigid muscle tone moderate or severe respiratory
• Not interacting with parents distress
• Absent or abnormal cry • Noisy breathing: grunting, gasping
• Non-blanching rash or stridor
Circulation
• Pale, cold peripheries, mottled skin,
cyanosis
• Prolonged central capillary refill time
• Fever in those under the age of 3
months
• Actively bleeding
ALERT
Infants and children can deteriorate rapidly, early intervention is imperative. Seek prompt medical assessment
in a child who meets any of the above criteria. Commence cardio-pulmonary resuscitation in any infant or child
found to have absent respirations.
CHQ-NSS-51027 Rapid Assesment v1.0
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Developed by the State-wide Emergency Care of Children Working Group, February 2022
Children’s Health Queensland Hospital and Health Service
For further information:
CHQ Nursing Standard: Clinical Assessment of the paediatric patient (Rapid Assessment/Primary & Secondary Assessment/
Vital Signs) (QH only)
References:
This Queensland Paediatric Emergency Nursing Skill Sheet was developed by the Emergency Care of Children working group
(funded by the Queensland Emergency Department Strategic Advisory Panel) with the help of the following resources:
Children’s Health Queensland Hospital and Health Service. (2017b, June 21). Clinical Assessment of the Paediatric Patient –
Rapid Assessment / Primary and Secondary Survey / Vital Signs. Queensland Health Intranet. https://qheps.health.qld.gov.
au/__data/assets/pdf_file/0019/724240/ns_00241.pdf
Horeczko, T., Enriquez, B., McGrath, N., Gausche-Hill, M., & Lewis, R. (2013). The Pediatric Assessment Triangle: Accuracy of Its
Application by Nurses in the Triage of Children. Journal Of Emergency Nursing, 39(2), 182-189. doi: 10.1016/j.jen.2011.12.020
Nursing Skill Sheet Legal Disclaimer
The information contained in the Queensland Paediatric Emergency Care nursing • Advising consumers of their choices in an environment that is culturally
skill sheets are intended for use by nursing staff for information purposes only. appropriate and which enables comfortable and confidential discussion.
The information has been prepared using a multidisciplinary approach with reference This includes the use of interpreter services where necessary.
to the best information and evidence available at the time of preparation. No assurance • Ensuring informed consent is obtained prior to delivering care.
is given that the information is entirely complete, current, or accurate in every respect. • Meeting all legislative requirements and professional standards.
The nursing skill sheets are not a substitute for clinical judgement, knowledge and • Applying standard precautions, and additional precautions as necessary,
expertise, or medical advice. Variation from the nursing skill sheets, taking into account when delivering care.
individual circumstances may be appropriate. This does not address all elements • Documenting all care in accordance with mandatory and local
of standard practice and accepts that individual clinicians are responsible for the requirements.
following: Children’s Health Queensland disclaims, to the maximum extent permitted by
• Providing care within the context of locally available resources, expertise, law, all responsibility and all liability (including without limitation, liability in
and scope of practice. negligence) for all expenses, losses, damages and costs incurred for any reason
• Supporting consumer rights and informed decision making in partnership associated with the use of this nursing skill sheet, including the materials within or
with healthcare practitioners including the right to decline intervention referred to throughout this document being in any way inaccurate, out of context,
or ongoing management. incomplete or unavailable.
CHQ-NSS-51027 Rapid Assesment v1.0
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Developed by the State-wide Emergency Care of Children Working Group, February 2022
