Recognising the deteriorating child: the paediatric assessment triangle, PEWS and early shock

What it is

Children compensate for a long time and then decline quickly, and their vital signs are hard to read: blood pressure is insensitive, and heart and breathing rates are not specific. Two tools help the nurse. The paediatric assessment triangle (PAT) is a hands-off look at appearance, work of breathing and circulation to the skin that sorts the child into a physiological category in about 30 seconds. Paediatric early warning systems (PEWS) turn repeated observations into a score with set triggers for escalation. Both support, and never replace, clinical judgement and the family's concern.

Reference values

• Heart rate (beats/min): infant 80–140; toddler 80–130; preschool 80–110; school age 70–100.
• Respiratory rate (breaths/min): 1 month to 1 year 26–60; 1–10 years 14–50; 11–18 years 12–22.
• Capillary refill: under 3 seconds is normal.
• PAT physiological categories: stable, respiratory distress, respiratory failure, shock, central nervous system or metabolic dysfunction, cardiopulmonary failure.

What you need

• The PAT (a look and listen from the doorway, no equipment).
• Age-based vital sign ranges and the PEWS chart the service uses, with its escalation steps.
• Oximeter, paediatric cuffs, a watch, and the emergency call system.

How to measure it (and why)

1. Before touching, look at appearance: tone, interaction, consolability, gaze and cry — a floppy, unfocused or inconsolable child is a warning.
2. Look and listen for work of breathing: noises such as stridor or grunting, flaring, retractions, accessory muscle use — effort shows before oxygen falls.
3. Look at skin circulation: pallor, mottling, cyanosis — skin is the first organ the body sacrifices in shock.
4. Name the PAT category (for example, respiratory distress or shock) — it tells you how fast to act and who to call.
5. Then take full vital signs against the age range, and check capillary refill — they add detail to the first look.
6. Score the observations on the PEWS chart at the frequency set by the protocol — trends catch slow deterioration.
7. Ask the parents if the child seems different from usual, and record it — family concern is an accepted trigger.
8. Escalate as the PEWS and your judgement indicate, using a structured handover — a score without a response does not protect the child.
9. Repeat the assessment after every intervention and record the time — improvement or worsening guides the next step.

How to read it

• A child with normal blood pressure can already be in shock: rely on heart rate, skin colour, capillary refill and appearance.
• Respiratory distress with an abnormal appearance means respiratory failure: the child needs urgent help, not only oxygen.
• Systems work only with the whole chain: training, a clear response team and a safety culture where staff and families can raise concern.
• Shock in children can start with skin changes alone, before other signs: a pale or mottled child needs a full check.

Next step: when to call for help

• Abnormal appearance, abnormal circulation, or two sides of the triangle abnormal: call the rapid response or emergency team at once.
• A PEWS value at or above the trigger: escalate exactly as the protocol says, and record the time and who was called.
• Parents or you feel 'something is wrong' even if the score is low: call the nurse in charge or the doctor.
• No breathing or no signs of life: call for help and start paediatric basic life support per protocol.

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Elsewhere in DurgiPedia

• Vital signs in children: how they change with age
• Fever, infection and sepsis: the bedside signs

Connections

← All of nursing

Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Kids really are just small adults: utilizing the pediatric triangle with the classic ABCD approach to assess pediatric patients (Cureus 12(3):e7424) (Cureus (open access, PMC7182162), 2020); The pediatric assessment triangle: accuracy of its application by nurses in the triage of children (Journal of Emergency Nursing) (Journal of Emergency Nursing (author manuscript, PMC4318552), 2013); Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review (BMJ Open 7(3):e014497) (BMJ Open (open access, PMC5353324), 2017); Nursing Skills, 1.3 Vital Signs (Open RN, CC BY 4.0) (Open Resources for Nursing (Open RN) / LibreTexts, 2021).

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