Date: _______________ Patient label Date: _______________ Patient label ❏ Electronic Triage Patient label

CTAS Level

Location in Department Location in Department Location in Department

Pediatric Nursing Assessment Record Pediatric Nursing Assessment Record Pediatric Nursing Assessment Record

Chief Complaint

Time Nursing Documentation Notes Fluid Balance

Intake Output
Arrival Status to ED Presenting Complaint/Relevant History
Time Site Cath size Initials Solution/Blood Amount IV in Oral Time Urine Other

Date: ________________ Time: _________________

Presented to hospital by:

❏ Walked in ❏ Ambulance ❏ Other: ____________
Transferred from:
❏ Scene ❏ Hospital ❏ Other: ____________
Accompanied by:
❏ Self ❏ Family ❏ Other: ____________
Physical Interventions
Weight: _________ kg ❏ Actual ❏ Estimated ❏ C-Spine/Hard collar ❏ Dressing/Sling/Splint ❏ Nurse initiated activities
Height: _ ________ cm Age: ___________ ❏ Other: _______________________________________________________
Pediatric Assessment Triangle Waiting Area CTAS Reassessment
Appearance: Circulation: Reassess Time Patient Location Progress Notes Initials

❏ Looks well ❏ Normal

❏ Unwell ❏ Concerns identified

Work of Breathing: Disability:

❏ Adequate ❏ Alert Sepsis Screening Infection Control Screen
❏ Concerns identified ❏ Verbal ❏ Sepsis screen completed Does the patient have symptoms
❏ Pain suggestive of an infectious process?
Total Total Time completed: _________
❏ Unresponsive ❏ No
Time Medication Dose Route Initials ❏ Yes, precautions initiated: _____________
Medications Allergies
❏ None ❏ Unknown ❏ Pharmanet ❏ Medication history completed ❏ NKDA ❏ Allergies (please document)
List all medications including over-the-counter, vitamins, inhalers, ❏ Allergy band applied
herbal, and any medications that the child may have accessed. Last dose Last time

Lead: ________ Impression: ______________________ Rate: _________ QT: _________ PR: _________ QRS: _________

Past Medical History Immunizations

If less than 6 months: Birth weight __________ kg Born at ____________ weeks gestation ❏ Up-to-date
Discharge Time: _______________ h Admission Time: _______________ h ❏ Previously healthy ❏ Incomplete
❏ Home ❏ Other: _________________________________________ ❏ Unit: ____________________ ❏ Due
Accompanied by: ❏ Self ❏ Family/caregiver ❏ RCMP ❏ BCAS Transfer/Consult Time: _______________ h
❏ Not given
Initial Monitor Strip
❏ Other: ____________________________________ ❏ Unknown
❏ PTN: ________ h ❏ Telehealth/Telepicu ________ h
❏ Discharge instructions provided ❏ Patient info pamphlet provided ❏ Hospital: ____________________________________ ❏ Last tetanus
❏ Verbalized understanding of discharge instructions/medications ❏ Other: ______________________________________
Last Meal Falls Triage RN Signature
Printed Name Signature Initials
❏ Last liquid: _ ___________ h ❏ Falls assessment completed
❏ Last food: _____________ h
❏ NPO
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 Date: _______________ Patient label Date: _______________ Patient label Date: _______________ Patient label

Location in Department Location in Department Location in Department

Pediatric Nursing Assessment Record Pediatric Nursing Assessment Record Pediatric Nursing Assessment Record

Time: _ _____________ Time: _ _____________

Primary Assessment Secondary Assessment Time Nursing Documentation Notes
Initial: ______________ Initial: ______________
Airway Airway Interventions ❏ None Cardiovascular Cardiovascular Interventions ❏ None
❏ Clear ❏ Maintainable ❏ Positioning ❏ Suctioning ❏ Foreign body removed ❏ Airway ❏ Oral ❏ Nasal Heart Sounds: ❏ S1, S2 clear Chest Pain: ❏ Cardiorespiratory Monitor
❏ Not maintainable ❏ Advanced Airway ETT/Supraglottic ______________________________________ Heart Rhythm: ❏ Regular ❏ N/A ❏ ECG: __________ hrs
❏ C-Spine ❏ Discontinued at _____________ hours by ___________________ ❏ Irregular ❏ Yes Location: _____________________

Comments: Comments:

Breathing Gastrointestinal Gastrointestinal Interventions ❏ None

Breathing Interventions ❏ None
Bowel Sounds: ❏ Present ❏ Absent Symptoms: ❏ NG ❏ OG
Air Entry: Sounds: ❏ SpO2 Monitoring
❏ Capnography Abdomen: ❏ Nausea Size: ___________ ❏L ❏R
A - Absent ❏ Stridor ❏ Vomiting
❏ Soft ❏ Rigid
N - Normal L R ❏ Grunting ❏ Oxygen by: ❏ Non-tender on palpation ❏ Hematemesis
- Decreased ❏ Referred upper airway ❏ NP ____________ Lpm ❏ Tender/Pain: __________________ ❏ Diarrhea ❏ Constipation
W - Wheezes ❏ Audible wheeze ❏ Face mask ____________ Lpm ❏ Flat ❏ Distended ❏ LBM: _________________
C - Crackles ❏ Non-rebreather ____________ Lpm ❏ Gastric tube: __________________
Work of Breathing: Cough: ❏ Heated Humidifed High Flow Therapy _________ FiO2 Comments:
❏ Respirations even/Unlaboured ❏ None ❏ BVM at 100%
Genitourinary Genitourinary Interventions ❏ None
❏ Nasal flaring ❏ Tracheal tug ❏ Weak ❏ RT called
❏ Productive ❏ PRAM initiated Urine: ❏ N/A Reproduction: ❏ N/A Catheter type:
❏ Head bobbing ❏ Tripod
❏ Non-productive ❏ Needle Thoracotomy ❏ Pain: _______________________ ❏ LMP: _____________________________ ❏ Foley ❏ Other: _____________________
❏ Indrawing: ___________________
❏ Burning ❏ Sexually active Size: ___________ Time: ___________
❏ Abdominal breathing ❏ Chest tube insertion:
❏ L ❏ R Time: ____________ Size: ____________ ❏ Urgency ❏ Pregnant: ___________ weeks ❏ Urine dip ❏ Mid-stream ❏ Catheter
Chest Movement:
❏ Frequency ❏ Previous pregnancies ❏ Negative ❏ Positive: _____________
❏ Symmetrical ❏ Nonsymmetrical ❏ Other: ___________________________________________ ❏ Hematuria ❏ Discharge ❏ Bleeding
❏ Last void: ____________________ Amount: __________ Duration: __________ ❏ Pregnancy test: ❏ Negative
Comments: ❏ Number of wet diapers ❏ Penile discharge/Pain ❏ Positive
Circulation Circulation Interventions ❏ None in last 24 hours: ________________ ❏ Scrotal pain
Pulses: Central: ❏ Normal ❏ Weak ❏ Bounding ❏ Cardiorespiratory Monitor Comments:
Peripheral: ❏ Normal ❏ Weak ❏ Bounding ❏ IV Initiated (see IV flowsheet) Musculoskeletal Musculoskeletal Interventions ❏ None
Capillary Refill Time: ❏ _______ seconds (normal less than or equal to 2 sec) ❏ IO initiated (see IV flowsheet) ❏ See diagram
R L L R R ❏ Dressings applied to wounds
Skin Colour: ❏ Pink ❏ Pale ❏ Grey/Cyanotic ❏ Grey/Mottled ❏ Jaundice ❏ CPR initiated (see resuscitation record)
❏ Splint: ____________________ ❏ Trauma record
Skin Temperature: ❏ Warm ❏ Cool ❏ Diaphoretic ❏ Dry ❏ Hot # Fracture D Deformity
Comment: ____________________________
Fontanelles: ❏ Closed ❏ Soft/Flat ❏ Depressed ❏ Full ❏ Bulging #C Compound Fracture S Swelling
A Abrasion H Hematoma
Comments: L Laceration AM Amputation
B Burn P Pain
L
Disability Disability Interventions ❏ None C Contusion PI Penetrating Injury
T Traction /// Crush
❏ Blood Glucose: ___________ Time: ___________ ❏ Siderails up E Edema + Bruising
❏ Alert Responds to: ❏ Voice ❏ Pain ❏ Unresponsive ❏ PERRL ❏ Seizure pads on siderails R Rash

Pupil Size: Left: _______ mm ❏ Brisk ❏ Sluggish ❏ None ❏ Falls protocol Psychosocial Psychosocial Interventions ❏ None
Right: _______ mm ❏ Brisk ❏ Sluggish ❏ None ❏ Restraint protocol Behaviour: ❏ Appropriate/Cooperative ❏ Certified
❏ Uncooperative ❏ Threatening to leave against medical advice ❏ Clothing and belongings removed
❏ Photophobia ❏ Headache ❏ Restraint protocol ❏ Social Worker
At Risk to Self/Others: ❏ Suicidal ideation ❏ Homicidal ideation
❏ Plan: ______________________________________ ❏ MCFD ❏ Psychiatry consult
Comments: ❏ Other: _____________________________
Violence and Aggression: ❏ Confusion/Disorientation ❏ Angry/Irritable ❏ Contract to safety
Exposure Exposure Interventions ❏ None ❏ Paranoid/Suspicious ❏ Agitated/Impulsive ❏ Violence and Aggression ALERT
❏ Clothing removed ❏ Warm blanket provided Substance Use: ❏ Substance intoxication/Withdrawal ❏ Heartsmap completed Time: _________

Comments: Comments:

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