Welcome to the initial assessment pre-course module. One of the most important things you will learn in ENPC or TNCC is a systematic process to guide your care of pediatric or trauma patients. The initial assessment chapter of each provider manual describes the process in detail. You can also reference the performance checklist that will be used in class. We refer to this as the Pediatric Nursing Process, or PNP, and the Trauma Nursing Process, or TNP. This is a template that will be used to present a variety of patient care scenarios. I will talk you through the process first. Then you will watch a video showing how it might look in class. The ENPC and TNCC criteria differ very slightly, but the prioritization sequence for assessment and intervention is the same. If you receive pre-hospital notification about the patient, you have a few minutes to activate the team, prepare the room and any equipment, and don personal protective equipment while considering potential safety threats. Pre-hospital providers have valuable information to share about on-scene findings to better understand the mechanism of injury for trauma patients, setting the expectation for silence and attention to the pre-hospital report upon patient arrival helps ensure this data is not lost. You can listen to the verbal pre-hospital report while looking at the patient. Use your first look at the patient to form a general impression of the patient's condition. Determine if there is any need to reprioritize to see ABC because of uncontrolled hemorrhage or a need for chest compressions. In the pediatric patient, you will use the Pediatric Assessment Triangle to determine if the child is sick, sicker, or sickest. If you did not receive pre-notification of the patient's arrival, you will activate the team, assess for safety risks, and don personal protective equipment before approaching the patient and while forming the general impression. Alertness and airway, breathing and ventilation, circulation and control of hemorrhage, disability, and exposure and environmental control are the A, B, C, D, E of the primary survey. Each letter must be assessed in order, making them double-starred steps of the pediatric or trauma nursing process. Performing these steps out of order can easily result in missing a life-threatening condition. If any abnormalities are noted, the learner intervenes and may need to reassess prior to moving on to the next letter. Interventions may include but are not limited to insertion of an airway, oxygen administration, intravenous line insertion, the consideration of goal-directed therapy for shock, assessment of a blood glucose, and applying a warming method. Pre-hospital transport devices are removed at E. Reassessment of primary survey interventions are considered single-start items. You do not need to wait until a fluid bolus is complete prior to moving to the next assessment, but you need to reassess the effectiveness of the fluid bolus at some point. You will need to confirm endotracheal tube placement immediately. We appreciate that in real life, these assessments take seconds, and interventions may occur simultaneously with multiple team members present. It is feasible that there may come a time when you are the only person available to manage the initial assessment and will need to prioritize in exactly this order. But more importantly, breaking the process down into very specific assessment criteria and interventions which must be stated and performed in order is a proven teaching-learning strategy to make the process second nature for you when managing a real patient. F and G are adjuncts to the primary survey. If the patient is agreeable and family does not interfere with care or pose a threat to the team, now is the time to assign a support person to facilitate family presence. Assessing respiratory effort and the quality of pulses was sufficient to determine the need for life-saving interventions initially. We can now get a full set of vital signs and attach monitoring devices. Consider the need for labs if they were not already drawn when the intravenous line was inserted and a gastric tube to decompress the stomach. Oxygen may be weaned to prevent hyperoxia, and capnography can be used for early identification of decreased respiratory effort or extubation. Addressing pain includes an assessment using an appropriate pain scale and managing pain with non-pharmacologic and pharmacologic measures. Pain assessment is another single-starred step. This must be done before the completion of the scenario, but can be done at any time. Sequence is not as vital as it was for the life-saving primary survey assessments and interventions. The secondary survey is designed to identify all abnormalities. This is accomplished with a thorough history and head-to-toe exams. Critical findings can be missed if this exam does not include the back, so inspect the posterior is an important reminder. Before returning the patient, consider the possibility of a spine or pelvic injury based on the patient assessment. It may be safest to obtain imaging first or use alternate techniques to move the patient, as log rolling can worsen cord injury with an unstable spine or cause hemorrhage with an unstable pelvis. The nurse will now anticipate interventions or diagnostics based on the patient scenario. At this point, the team has likely left the patient's bedside. It is the nurse's responsibility to just keep re-evaluating. The nurse will communicate any concerns with the team and intervene as appropriate to changes in the patient condition. We hope you see how this systematic process will help you turn chaos into order and prioritize when you have a very sick patient in front of you. Don't worry if you cannot see it just yet. Keep studying your provider manual and your instructors will help you apply this process in class to make it more meaningful. Nurse teaching scenarios will be used in class to reinforce this systematic assessment process. We'll now show you an example of what this looks like in real time. Follow along with your pediatric or trauma nursing process reference and PNP or TNP for students. Are you ready for your pediatric nurse process? I am. You have equipment on the table that's available for use during your demonstration? I'll give you your scenario now. A 10-year-old child was just at a friend's birthday party. The caregiver states the child has an odd cough and seems to be breathing faster than usual. I'd activate my team and assign roles. Your co-workers are present to assist with the initial assessment. Is there any specific equipment that you would prepare? I would get a scale in a room, specific pediatric equipment. I would review my dosing guidelines and protocols and don PPE. Your PPE has been donned and no safety threats have been identified. The patient is brought to a room. I do the cross-room assessment using the PAT triangle, looking at my appearance, worker breathing and circulation. The child is sitting straight up but not looking at surroundings. Respirations are fast and shallow with audible stridor and expiratory wheezes. The skin is flushed. Is there any uncontrolled hemorrhage or is my patient unresponsive? There's no uncontrolled external hemorrhage or unresponsiveness and no need to consider reprioritizing to CABC. I would like to assess his alertness using the APU mnemonic. The child is alert but focused on breathing, answers questions with one word answers. Is he able to open his mouth? The child is sitting upright in bed and opens their mouth for assessment when asked. I would assess his airway at this time, looking for fluids such as blood, vomit secretions, any edema, amputation sounds, tongue obstruction and can he vocalize? There is edema noted to the lips, there are no fluids, no loose or missing teeth, stridor is audible, no tongue obstruction, the child can speak one word at a time. I'd get a weight on him. I would anticipate an order for IM epinephrine. The child weighs 32 kilograms per standing scale, 0.32 milligrams of intramuscular epinephrine has been ordered and administered in the vastus lateralis. I would reassess his alertness in airway. The child is less responsive, stridor and expiratory wheezing are less audible, the tongue is becoming edematous. I would anticipate the need for intubation. Your team is preparing for drug-assisted intubation and inserting an intravenous line, please proceed with your assessment. I would assess his breathing, I'd look for any spontaneous breathing, any breath sounds, I would look at a work of breathing, his skin color and his symmetrical chest rise. Breath sounds are very diminished bilaterally, respirations are shallow, irregular and slow. There is no increased work of breathing, skin color is cyanotic. Breathing is spontaneous but shallow and slow, chest rise is symmetrical. I would assist his breathing with the use of a bag mass device. I would also assess the quality of my ventilations. A team member begins assisting ventilations with a bag mass device. Your chest rise is symmetrical with assisted ventilations, breath sounds are very diminished with faint wheezes bilaterally. An intravenous line was inserted and drug-assisted intubation is complete. Please demonstrate and describe your assessment of endotracheal tube placement. I'd use a pediatric CO2 detector. I'd also look for symmetrical chest rise and fall. I would auscultate over the epigastrum and both sides of the chest. Your CO2 detector device is attached. Symmetrical rise and fall of the chest is noted with assisted ventilations. There are no sounds over the epigastrum. Breath sounds are very diminished with faint wheezes bilaterally. There is evidence of exhaled CO2. I'd document the ET tube position and secure it. The ET tube is secured and the number at the level of the teeth is documented. I would continue ventilations. Your ventilations are provided at an appropriate rate by a team member. Another intramuscular dose of epinephrine has been administered and an epinephrine infusion is being prepared per physician order. You may continue with your assessment. I would like to assess his circulation. I'll be looking for cap refill. I'll be palpating for central and peripheral pulses. I'm going to be inspecting and palpating his skin for color, temperature, and moisture. Capillary refill is six seconds. Skin is pale, cool, and dry. Central pulse is rapid and weak. Peripheral pulses are weaker. I'm going to assess the IV for patency. The IV line is patent. I would anticipate the need for a 20 ml per kilo bolus of warm isotonic solution. The patient weighs 32 kilograms. 640 milliliters of warm IV fluid has been administered. I would reassess his circulation. Again, I'm going to be looking for cap refill, his central and peripheral pulses, and I'm going to be inspecting and palpating his skin for color, temperature, and moisture. Capillary refill is four seconds. Skin is pale, cool, and dry. Central pulse is rapid and slightly stronger. Peripheral pulses remain weak. I would anticipate the need for a second IV. Your second line has been inserted. Epinephrine is now being administered by continuous infusion and will be titrated per order. I would anticipate the need for a second 20 ml per kilo bolus of warm isotonic crystalline. A second warmed IV fluid bolus of 640 milliliters has been administered. I would reassess his circulation. Again, I'm going to be looking for cap refill, central and peripheral pulses, and I'm going to be inspecting and palpating his skin for color, temperature, and moisture. His capillary refill is four seconds. Skin is pale, warmer, and dry. Central pulse is rapid and stronger. Peripheral pulses are stronger. The delayed capillary refill may be due to the epinephrine infusion. The team will continue to evaluate IV fluid needs. You can continue with your assessment. I would like to assess the disability by looking at the patient's GCS. Eye opening, one. Verbal response, one. Motor response, one. The GCS is documented as non-testable after drug-assisted intubation. I'm going to assess pupils. Pearl. I would like to obtain a blood sugar. Your glucose is 35 milligrams per deciliter. The physician ordered an appropriate dose of dextrose, and it has been administered. I will reassess my GCS. Eye opening is one, verbal response is one, motor response is one. The GCS is documented as non-testable after drug-assisted intubation. I will expose my patient by removing all clothing, and I'm looking for any obvious signs of injury or illness. The facial flushing and edema are improving. No other obvious signs of illness or injury are noted. I will put a warm blanket over my patient. Your warming method has been applied. I would like a full set of vital signs. Blood pressure 100 over 84, heart rate 132, respiratory rate appropriate on the ventilator, temperature is 97.6, SpO2 is 97 percent, weight is 32 kilograms. I will facilitate family presence. The parents are at the bedside with the liaison. I would like to get my adjuncts. First I'd like to get some labs. Blood samples are sent to the laboratory. We will continue to monitor the blood glucose. I will put my patient on a cardiac monitor. Sinus tachycardia without ectopy. I will place an NG tube. A gastric tube is inserted. I will put my patient on a pulse ox and a continuous capnography. Your pulse oximetry is 97 percent while being ventilated. Entitled CO2 readings are within normal limits. I would assess my pain using an appropriate pain scale. Pain is zero using an appropriate pain scale. I would do a non-pharmacological intervention by keeping a family present for comfort. I would also consider analgesia or sedation for my intubated and ventilated patients. Non-pharmacologic pain measures have been implemented. An appropriate dose of sedation has been ordered and will be titrated. Is there a need to consider transfer to a pediatric capable facility, surgery, or critical care? Yes, there is. I would like to obtain a history using a sample pneumatic. Signs and symptoms, change in breathing and cough after attending a friend's party. No allergies, no medications, no past medical history, immunizations are up to date. Last ate and drank at the party. Last void is unknown. Events leading up to, nothing unusual until after the party. I would like to do my head to toe assessment. Proceed. I will inspect and palpate the head. No abnormalities. Inspect and palpate the face. The endotracheal tube and orogastric tubes are secured. Oral mucous membranes are pink and moist. Facial edema and flushing have resolved. I'm going to inspect and palpate the neck. No abnormalities. I'm going to inspect and palpate the chest. No abnormalities. I'm going to listen for heart sounds and breath sounds. Your heart sounds are normal. Your breath sounds with much improved air exchange and scattered expiratory wheezes. I'm going to inspect the abdomen. No abnormalities. I'm going to listen to all four quadrants. Bowel sounds are present. I'm going to palpate the abdomen. No abnormalities. Inspect and palpate the flanks. No abnormalities. Inspect the pelvis. No abnormalities. The medial and downward pressure on the iliac crest. No instability. Gentle pressure on the syphus punus. No instability. Inspect the perineum. No abnormalities. I would anticipate the need for a Foley catheter. An indwelling urinary catheter is inserted with return of clear yellow urine. I will inspect and palpate all four extremities. No abnormalities. I'm going to inspect the posterior and palpate. No abnormalities. Please summarize the abnormalities you identified during your scenario. The patient presented with respiratory distress had tachypnea, stridor, wheezing, had a swollen tongue, ended up giving two doses of im-epinephrine, and went on an epinephrine drip, had altered mental status, inadequate breathing, went into respiratory failure, ended up getting intubated, patient had poor perfusion, we gave two boluses of isotonic solution, and the patient was hypoglycemic and we ended up treating that with some dextrose. What interventions or diagnostics can you anticipate for this patient? I would anticipate an x-ray to evaluate the placement of the ET tube. Get a pediatric intensivist consult. I'll also look at getting some maintenance fluids with some dextrose started on him. And I would also continue to evaluate his glucose. And what findings will you continue to re-evaluate while the patient is in your care? Well, I would re-evaluate his vital signs, any interventions that we did. I would continue to re-evaluate the primary survey and his pain. And what is definitive care for this patient? He will go to a hospital that can manage and treat intubated pediatric patients. And is there anything you would like to add? No. Thank you.

pediatric patient

respiratory distress

assessment

interventions

pain management

specialized care