Traffic Light System
2
“ TRAFFIC LIGHT SYSTEM “SCREENING FOR CHILDREN (REVISI) Observation Item Green-Low Risk Amber- Intermediate Risk Red-High Risk Colour/Circulation: Inspect : Skin & Mucous membrane Extremity color& temp Pulse Rate & Strength Capillary refill: at palm,soles,forehead or central body Normal colour of skin Lips and tougue=pink No pallor, No mottling No cyanosis Capillary Refill Time (CRT) 1-2 second No significant bleeding Strong peripheral& central pulses with regular rhythm Moist mucous membane Skin & mucous : Pallor reported by Parent/ caretaker Acrocyanosis Obvious bleeding CRT > 3 seconds Heart Rate 20 bpm above normal rates Dry mucous membranes Pale,cyanotic/blue,mottled,or Ashen Obvious significant bleeding Heart Rate 30 bpm above normal range for age or Bradycardia: -HR < 80 in infancy (< 6 months ) -HR <60 in child ( > 6 months ) CRT > 5 seconds Reduced skin turgour(skin doughy or tented) And /or sunken eyes Activity/Appearance: (TICLS) Tone Interactability/ Alertness Consolability Look/Gaze Speech/Cry Tone :Move spontaneously well,good muscle tone Allertness : responds normally to social cues Contents/ smiles,easy Comforted by caretaker Stay awake or awaken quickly Look/Gaze :make eye contact w object/people/trac k visually Strong normal cry Or no crying Speech/Cry: strong&spontaneous , Not be weak or hoarse No responding normally to social cues. Wakes only with prolonged stimulation Decreased activity No smile or brief smiles or alerts Cries off and on No response to social cues,lethargic,irritable, confusion. No response or poor respons to pain or any stimulus Appears ill to a healthcare professional Does not wake or if roused does not stay awake. Weak,high pitched or continous cry with little response No or poor eye contact,dull no alerting Work of Breathing/ Respiratory Assesment point : Visible movement Respiratory effort Sounds Rate Normal respiratory rate (depend on age age group) No abnormal airway sound(gasping,hoar se speech,stidor,grun ting, wheezing) No retraction,or no nasal flaring Nasal flaring Tachypnoe: RR >50 breaths/min for age 6-12 months RR >40 breaths/min, age >12 months RR>30bpm in scholl age Oxygen sat < 95% in air. Respiratory rate below the normal range RR < 20 bpm for child < 2 years RR <10 bpm for child > 2 years (prescholar or scholl age) or Rapid(Tachypnoe) & Deep Respiration: RR > 60 bpm in Infancy(< 6 mth), RR > 50 bpm in toddler (6-24 mth)
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traffic light system in children paediatric
Transcript of Traffic Light System
TRAFFIC LIGHT SYSTEM SCREENING FOR CHILDREN (REVISI)ObservationItemGreen-Low RiskAmber-Intermediate RiskRed-High Risk
Colour/Circulation: Inspect : Skin & Mucous membrane Extremity color& temp Pulse Rate & Strength Capillary refill: at palm,soles,forehead or central body Normal colour of skinLips and tougue=pink No pallor, No mottling No cyanosis Capillary Refill Time (CRT) 1-2 second No significant bleeding Strong peripheral& central pulses with regular rhythm Moist mucous membane
Skin & mucous :Pallor reported by Parent/caretaker Acrocyanosis Obvious bleeding CRT > 3 seconds Heart Rate 20 bpm above normal rates Dry mucous membranes Pale,cyanotic/blue,mottled,or Ashen Obvious significant bleeding Heart Rate 30 bpm above normal rangefor age or Bradycardia: -HR < 80 in infancy (< 6 months )-HR 6 months ) CRT > 5 seconds Reduced skin turgour(skin doughy or tented) And /or sunken eyes
Activity/Appearance:(TICLS) Tone Interactability/Alertness Consolability Look/Gaze Speech/Cry Tone :Move spontaneously well,good muscle tone Allertness : responds normally to social cuesContents/smiles,easyComforted by caretaker Stay awake or awaken quickly Look/Gaze :make eye contact w object/people/track visually Strong normal cry Or no crying Speech/Cry: strong&spontaneous,Not be weak or hoarse No responding normally to social cues. Wakes only with prolonged stimulation Decreased activity No smile or brief smiles or alerts Cries off and on No response to social cues,lethargic,irritable,confusion. No response or poor respons to painor any stimulus Appears ill to a healthcareprofessional Does not wake or if roused does not stay awake. Weak,high pitched or continous cry with little response No or poor eye contact,dull no alerting
Work of Breathing/Respiratory
Assesment point :
Visible movement Respiratory effort Sounds Rate Normal respiratory rate (depend on age age group) No abnormal airway sound(gasping,hoarse speech,stidor,grunting,wheezing) No retraction,or no nasal flaring Nasal flaring Tachypnoe:RR >50 breaths/min for age 6-12 monthsRR >40 breaths/min,age >12 monthsRR>30bpm in scholl age Oxygen sat < 95% in air. Abnormal airway sounds:crackles Respiratory rate below the normal range RR < 20 bpm for child < 2 yearsRR 2 years (prescholar or scholl age)or Rapid(Tachypnoe) & DeepRespiration: RR > 60 bpm in Infancy(< 6 mth), RR > 50 bpm in toddler (6-24 mth)RR > 40 bpm in prescholar(2-5 thn) RR > 30 bpm in scholl age child Moderate or severe chest indrawing. Abnormal airway sound (gasping,stridor,grunting,wheezing)
