Presenting complaint

Ask:

• Who called for help & what was your concerns (if not obvious)?

History of presenting complaint

Objective: To envision & understand concerns events leading to up to the call for help.

Paediatrics patients who speech has not yet developed are often very challenging to assess. Listen to the parents or who called for help history of events particularly understanding their concerns - but remain in control of the assessment, if faced with one of the following situations click on the tab to reveal specific questions on these topics.

Past medical history

Ask:

• Is the child diagnosed with any medical conditions?

Where applicable ask:

• Has this ever happened before?

About the pregnancy

• Was the child born at 40 weeks?
• Any complications during pregnancy?
• Has the child ever be in intensive care?

Document:

• Your questions
• Patient answers
• Clinical findings

Past surgical history

Ask:

• Any surgery or body organs removed?

Document:

• Your questions
• Patient answers
• Clinical findings

Medication

Ask:

• Has any medication been given prior to our arrival, particularly in the last 6 hours?
• Do they take medication on a daily basis?

If yes question:

• Are they taking them as required?
• Any new medication or changes?

Document:

• Your questions
• Patient answers
• Clinical findings

Allergies

Ask:

• Are they allergic to anything?

If yes question:

• What happens?

Document:

• Your questions
• Patient answers
• Clinical findings

Review of systems

On arrival (document only) Any delay from arriving on scene to patient contact Patient location (at home, in the bathroom) How found (Standing / Prone / Supine / Sat upright/ In parents arms)? Distressed or comfortable? Who else is on scene? Any treatment? Who gave consent?

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Pain assessment:

Ask (where applicable):

• Do they look like they are in any pain?

Assess:

• Wongbaker score

Document:

• Your questions
• Patient answers
• Physical & clinical findings

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Head/CNS:

Ask:

• Any loss of consciousness (LOC)?
• Any seizure activity?
• Are they moving their head around as normal?
• Any neck stiffness or reduced movement?

Assess:

• GCS - Click here
• Fontanelle: Flat/Sunken/raised?
• Pupils equal and reactive to light?
• Pupils size?
• Photophobic?
• Look/Gaze normal?
• Interacting with surroundings?
• Able to coordinate/hold objects?
• Palpation on neck

Think:

• Any neurological deficit?

Document:

• Your questions
• Patient answers
• Physical & clinical findings

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Chest/RESP:

Ask:

• Any difficulty in breathing?
• Any resent coughs/colds or sneezing?
• How does the cry or vocal sounds sound?

Assess:

• Airway: self maintaining?
• Resp rate?
• REG/IRR ?
• Un/Laboured?
• Nasal flaring?
• Trachea tug?
• Grunting/ Stridor/Drooling/Croup sounds
• Chest exposed: Intercostal / Sternum recession
• 02 sats on room air?
• Cyanosis?
• Auscultation any unusual sounds (Rhonchi, Wheeze, Pleuritic rub, Crackles (Heart fail) Reduced sounds (Silent chest)?
• Bilaterally air entry sounds?

Think:

• Any airway compromise or respiratory distress?

Document:

• Your questions
• Patient answers
• Physical & clinical findings

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CVS

Ask:

• Any blood loss seen?

Assess:

• Sternum capillary refill < 2 Sec's
• Brachial pulse rate
• Heart Sounds: Normal/murmurs?
• ECG or SP02 HR
• Is it reg or IRR
• Present on ECG: P-QRS-T
• PR/QRS/QT intervals within normal range
• ECG rhythm?
• BP

Think:

• Any CVS compromise or shock?

Document:

• Your questions
• Patient answers
• Physical & clinical findings

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Lymphatic

Ask:

• Any resent infections?
• Treatment with antibiotic?
• Any known raised temp?
• Any new lumps or swellings seen?
• Anyone in the house been ill?
• Are their inoculation are up to date?

Assess:

• Temp?
• Skin temp symmetrically normothermic?
• Any sepsis markers?
• Biological concerns?

Think:

• Any biological/infection concerns?

Document:

• Your questions
• Patient answers
• Physical & clinical findings

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Abdo/GIT:

Ask:

• Are they bottle/breast fed?
• Last fed?
• Feeding habits normal?
• Are they teething?
• Any difficulty in swallowing?
• Any vomiting?
• Abdo normal presentation?
• Last bowel movement?
• Approx how many bowel movements in last 12hrs?
• How would you describe the stools?
• Child approx weight?

For Infants < 12 months: (age in months + 9)/2 = Weight (kg)

For Children aged 1-10 years: 2 x (age in years + 4) = Weight (kg)

Assess:

• Soft
• Guarding
• Distension
• Hardness

Document:

• Your questions
• Patient answers
• Physical & clinical findings

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Endocrine:

Ask:

• Any drastic weight loss/gain?
• How would you describe the child's energy levels (Normal/Lethargic)?

Assess:

• Blood glucose levels

Document:

• Your questions
• Patient answers
• Physical & clinical findings

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Urine:

Ask:

• How many bottles in last 12hrs
• Is the fluid intake normal or reduced?
• How many wet nappies in last 12hrs?
• What colour does the urine look like?
• Any unusual urine smells?
• Pain passing urine?

Assess:

• Eyes are they sunken?
• Fontanelle: Flat/Sunken/raised?
• Clinical signs of dehydration

Document:

• Your questions
• Patient answers
• Physical & clinical findings

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Skin:

Ask:

• How does child look in colour?
• Any nappy rashes?
• Can I touch the child with the back of my hand assessing for any warm area?

Assess:

• Any Pallor / Mottling Hemorrhagic non blanching rash?
• Rash -

Tumbler test +/- ?
Is it warm or cold?
Raised?

• Any signs of injury?
• Any bruising?

Document:

• Your questions
• Patient answers
• Physical & clinical findings

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Musculoskeletal:

Ask:

• What is the child's normal mobility (non-mobile, crawling, starting to walk, walking)?
• Is the child crawl or walk normal?
• Any new reduced range of movements?
• Any resent trauma

Assess:

• Any painful joints?
• Any injuries?

Document:

• Your questions
• Patient answers
• Physical & clinical findings

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Other:

Ask:

• Consolability: Happy / playful?
• Are they displaying any unusual habits e.g. playing with ears/throat?
• Sleeping well?
• Growing & developing well?

Document:

• Your questions
• Patient answers
• Physical & clinical findings

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Conclude with:

Ask:

• I've asked lot's of questions, is there anything else I should be aware of that I haven't asked?

Background

Ask:

• Who does the child live with?
• Dose the child go to play groups?
• Any resent travel outside the UK?
• Are they known to social services?
• When did they last see another Health care professional for example a Dr, Nurse, midwife?

Document:

• Your questions
• Patient answers
• Clinincal findings

Impressions

This is your clinical thoughts of the presenting complaint or any findings

Explain: examples

• Central chest pain, CVS related, ? ACS
• Pyrexia, immue response to ? Resp infection

Document:

• Your impressions

Clinical concerns

Also known as red flags, explain your concerns to the patient and document

• What have you identified/have concerns about?
• Any vitals outside normal range without reason?
• Health status Deteriorating/Stable/Improving/Back to normal
• Click here for Paramedic pathfinder
• Differential diagnosis (DDX)?
• Risk factors?
• NICE guidelines
• Local guidelines
• National Early Warning Score?
• Under 2 years old

Document:

• Findings
• If none found - document - none.

Safeguarding

Think & observe:

• Have you identified any safeguarding concerns?
• Observe living environment?
• Sleeping arrangements?

Document:

• Any findings or concerns
• Who else did you inform?
• If none found write: Safeguarding considered, none found by crew

Plan

Conclude, document & create a plan of action;

NOTE: All children under 2 years old where ambulance has been dispatched it should be is advised ED or Dr a must be involved in Plan

• Reassure
• Treat PC with?
• Reassess
• Discuss on examination/impressions & clinical concerns
• Implement plan

Handover/Pre-alert

What next

Reflect & ask yourself

• What went well?
• What didn't go well (example a question you asked, something you did or something someone else did?)
• What would you better next time?

On to the next patient

CPD Links

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