[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Nursing](https://durgical.com/en/nursing/) › [Paediatric nursing](https://durgical.com/en/nursing/areas/pediatric/) › Recognising the deteriorating child: the paediatric assessment triangle, PEWS and early shock

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

- Assessment

A quick look at appearance, breathing and skin, age-based vital signs and an early-warning score help spot the child who is getting worse before a crash.

Updated Nov 13, 2026

## Key points

- PAT: appearance, work of breathing, circulation to the skin; any abnormal side means the child is unstable.
- Appearance is judged by tone, interactiveness, consolability, look or gaze, and speech or cry.
- Abnormal breathing only = respiratory distress; plus abnormal appearance = respiratory failure; abnormal circulation = shock; all three = cardiopulmonary failure.
- Pale, mottled or cyanosed skin can be an early sign of shock: the body diverts blood from the skin to vital organs.
- Capillary refill normally under 3 seconds; a longer time may mean shock. Low blood pressure is an insensitive, late finding.
- PEWS: a track-and-trigger score; staff or family concern is a valid trigger on its own.

## 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)

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

## Test yourself

Think of the answer, then tap the question to see it.

## What are the three sides of the paediatric assessment triangle?

Appearance, work of breathing and circulation to the skin.

## Which PAT pattern suggests shock?

Abnormal circulation to the skin, with appearance normal or abnormal and normal work of breathing.

## Why is a normal blood pressure not reassuring in a sick child?

Children compensate for a long time; blood pressure is insensitive and falls late, just before a sudden decline.

## Can a family's worry trigger escalation in a PEWS system?

Yes. Staff or family concern is an accepted trigger, alongside the score.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/nursing/recognising-the-deteriorating-child-the-paediatric-assessment-triangle-pews-and/)

## Elsewhere in DurgiPedia

- [Vital signs in children: how they change with age](https://durgical.com/en/clinical-exam/vital-signs-in-children-how-they-change-with-age/)
- [Fever, infection and sepsis: the bedside signs](https://durgical.com/en/clinical-exam/fever-infection-and-sepsis-the-bedside-signs/)

## Connections

## Related 2

- [Recognising deterioration and calling the rapid response team](https://durgical.com/en/nursing/recognising-deterioration-and-calling-the-rapid-response-team/)
- [Basic life support from the nursing side](https://durgical.com/en/nursing/basic-life-support-from-the-nursing-side/)

## Related conditions 4

- [Sepsis and septic shock](https://durgical.com/en/conditions/sepsis-and-septic-shock/)
- [Hypovolaemic shock](https://durgical.com/en/conditions/hypovolaemic-shock/)
- [Anaphylaxis](https://durgical.com/en/conditions/anaphylaxis/)
- [Multisystem inflammatory syndrome in children (MIS-C)](https://durgical.com/en/conditions/multisystem-inflammatory-syndrome-in-children/)

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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)](https://pmc.ncbi.nlm.nih.gov/articles/PMC7182162/) (Cureus (open access, PMC7182162), 2020); [The pediatric assessment triangle: accuracy of its application by nurses in the triage of children (Journal of Emergency Nursing)](https://pmc.ncbi.nlm.nih.gov/articles/PMC4318552/) (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)](https://pmc.ncbi.nlm.nih.gov/articles/PMC5353324/) (BMJ Open (open access, PMC5353324), 2017); [Nursing Skills, 1.3 Vital Signs (Open RN, CC BY 4.0)](https://med.libretexts.org/Bookshelves/Nursing/Nursing_Skills_(OpenRN)/01%3A_General_Survey/1.03%3A_Vital_Signs) (Open Resources for Nursing (Open RN) / LibreTexts, 2021).

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Representative model, for educational purposes only.

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/nursing/recognising-the-deteriorating-child-the-paediatric-assessment-triangle-pews-and/