Clinical Skills · Paediatric Assessment

A–E Assessment Framework

The A–E guide students usually wish they had sooner: the real framework, explained in wording you can actually think with under pressure.

Children's nursing · Paediatric OSCE prep · The Nurse Lab

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Student note

If the words feel heavy, translate them back to the bedside. Perfusion means how well blood is getting around the body, AVPU is a quick way of saying how awake the child is, and escalation means asking for more senior help early.

Reassess always

After every intervention, go back to A and look again. Do not assume the problem is fixed just because you have done something.

PEWS score

Work out the PEWS each time you assess. The trend matters most, and a rising score should make you more concerned, not less.

Escalate early

Children can compensate for a while and then deteriorate quickly. Do not wait for perfect proof before acting on concern.

Parents know

If a parent says their child is not right, take that seriously. They usually know what is normal for their child better than you do on first meeting.

Airway

Is the airway open and protected?

Look

Visible obstruction
Lip or tongue swelling
Facial trauma
Accessory muscle use
Cyanosis (late sign)

Listen

Stridor (obstruction)
Gurgling (fluid)
Snoring (soft tissue)
Silence (complete block)

Feel

Air at mouth/nose
Chest rise with breaths
Tracheal position

Act

Head tilt chin lift
Jaw thrust if trauma
Suction if secretions
OPA/NPA if tolerated

Red flags

StridorSilenceCyanosisCannot speak/cryDroolingGrunting

Clinical pearl

In children the narrowest part of the airway is the cricoid ring just below the cords, so even mild swelling can make breathing much harder. In anaphylaxis, give IM adrenaline early rather than waiting for every sign to appear.

Breathing

Is breathing okay in speed, depth, and effort?

Rate & pattern

RR compared with normal for age
Depth and rhythm
SpO₂ target 94–98%
Nasal flaring in infants

Inspect

Chest expansion
Symmetrical movement
Accessory muscle use
Intercostal recession
Tracheal position
Head bobbing
Shoulder shrugging
Subcostal recession
See-saw breathing
Grunting

Listen

Air entry both sides
Added sounds (wheeze/creps)
Dullness on percussion
Silent chest (emergency)

Act

O₂ if SpO₂ <94%
Sniffing position
Non-rebreather if needed
Call paediatric team
Prepare for intubation

Red flags

RR outside age normsSpO₂ <94%Tracheal deviationSilent chestGruntingSevere recessionHead bobbingSee-saw breathing

Circulation

Is blood getting around the body well enough?

Pulse & BP

Heart rate against age norms
Blood pressure (low is late)
Pulse strength
Peripheral vs central pulse

Blood reaching the body

CRT <2s centrally
Skin colour and temperature
Mottling pattern
Behaviour change
Nappy output

Monitoring

ECG or cardiac monitor
Blood tests (including gas/lactate)
Urine output ≥1 ml/kg/hr
Fluid balance

Act

IV or IO access
Fluid bolus 10 ml/kg
Reassess after bolus
Repeat bolus if needed
Escalate early

Red flags

HR outside age normsHypotension (late sign)CRT >2sMottled/pale/grey skinNo urine output

Clinical pearl

Children can look as if they are coping, then suddenly get much worse. Do not wait for low blood pressure before escalating. A fluid bolus in children is 10 ml/kg, not the adult 250 ml, and you reassess after every bolus.

Disability

How awake are they, and what is the blood glucose?

Consciousness

AVPU scale
GCS if older child
Response to parents
Eye opening and tone
Posturing (late sign)

Glucose

Blood sugar check is essential
Treat if <4 mmol/L
Recheck after treatment
Consider IV dextrose
Repeat sugar in 15 min

Pupils & soft spot

Size and symmetry
Reaction to light
Bulging can mean raised pressure in the head
Sunken can suggest dehydration
Only check the fontanelle in babies and young infants

Act

Recovery position if unconscious
Treat hypoglycaemia
Seizure management
Reduce stimulation
Neurology if needed

Red flags

Responds only to pain or is unresponsiveNot responding to parentsBM <4 mmol/LBulging fontanelleActive seizure

Exposure

What has been missed? Inspect thoroughly but maintain dignity.

Inspect

Head-to-toe assessment
Rashes and wounds
Non-blanching rash
Bruising pattern
Skin turgor

Temperature

<36°C or >38.5°C = concern
Hypothermia in neonates
Keep child warm
Fever with rash → urgent
Neonatal temp strictly normal

Lines & drains

IV/IO site and flow
Catheter output/colour
Nappy weight if infant
NG tube position
Drain output

Chart review

Medication chart
Weight-based dosing
Allergy status
Fluid balance trend
PEWS trajectory

Red flags

Non-blanching rashTemp <36°C or >38.5°CUnexplained bruisingFloppy/unresponsivePetechiae

After A–E Checklist

Reassess & escalate

Reassess from A after every intervention

Calculate PEWS score and document

Escalate using SBAR — be specific

Document & monitor

Document findings and all actions taken

Increase monitoring frequency if unwell

Review again in 15–30 minutes

Quick self-test

Sources & References

Resuscitation Council UK (2021) — 2021 Resuscitation Guidelines NICE (2016) — Sepsis: recognition, diagnosis and early management (NG51)NICE (2007) — Acutely ill adults in hospital: recognising and responding to deterioration (CG50)NMC (2018) — The Code: Professional standards of practice and behaviour for nurses

Also practice with

Core Quiz — test your recall →OSCE Stations — apply it clinically →

Discussion (0)

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Clinical Skills · Paediatric Assessment

A–E Assessment Framework

The A–E guide students usually wish they had sooner: the real framework, explained in wording you can actually think with under pressure.

Children's nursing · Paediatric OSCE prep · The Nurse Lab

Save for later

Student note

Reassess always

After every intervention, go back to A and look again. Do not assume the problem is fixed just because you have done something.

PEWS score

Work out the PEWS each time you assess. The trend matters most, and a rising score should make you more concerned, not less.

Escalate early

Children can compensate for a while and then deteriorate quickly. Do not wait for perfect proof before acting on concern.

Parents know

If a parent says their child is not right, take that seriously. They usually know what is normal for their child better than you do on first meeting.

Airway

Is the airway open and protected?

Look

Visible obstruction
Lip or tongue swelling
Facial trauma
Accessory muscle use
Cyanosis (late sign)

Listen

Stridor (obstruction)
Gurgling (fluid)
Snoring (soft tissue)
Silence (complete block)

Feel

Air at mouth/nose
Chest rise with breaths
Tracheal position

Act

Head tilt chin lift
Jaw thrust if trauma
Suction if secretions
OPA/NPA if tolerated

Red flags

StridorSilenceCyanosisCannot speak/cryDroolingGrunting

Clinical pearl

Breathing

Is breathing okay in speed, depth, and effort?

Rate & pattern

RR compared with normal for age
Depth and rhythm
SpO₂ target 94–98%
Nasal flaring in infants

Inspect

Chest expansion
Symmetrical movement
Accessory muscle use
Intercostal recession
Tracheal position
Head bobbing
Shoulder shrugging
Subcostal recession
See-saw breathing
Grunting

Listen

Air entry both sides
Added sounds (wheeze/creps)
Dullness on percussion
Silent chest (emergency)

Act

O₂ if SpO₂ <94%
Sniffing position
Non-rebreather if needed
Call paediatric team
Prepare for intubation

Red flags

RR outside age normsSpO₂ <94%Tracheal deviationSilent chestGruntingSevere recessionHead bobbingSee-saw breathing

Circulation

Is blood getting around the body well enough?

Pulse & BP

Heart rate against age norms
Blood pressure (low is late)
Pulse strength
Peripheral vs central pulse

Blood reaching the body

CRT <2s centrally
Skin colour and temperature
Mottling pattern
Behaviour change
Nappy output

Monitoring

ECG or cardiac monitor
Blood tests (including gas/lactate)
Urine output ≥1 ml/kg/hr
Fluid balance

Act

IV or IO access
Fluid bolus 10 ml/kg
Reassess after bolus
Repeat bolus if needed
Escalate early

Red flags

HR outside age normsHypotension (late sign)CRT >2sMottled/pale/grey skinNo urine output

Clinical pearl

Disability

How awake are they, and what is the blood glucose?

Consciousness

AVPU scale
GCS if older child
Response to parents
Eye opening and tone
Posturing (late sign)

Glucose

Blood sugar check is essential
Treat if <4 mmol/L
Recheck after treatment
Consider IV dextrose
Repeat sugar in 15 min

Pupils & soft spot

Size and symmetry
Reaction to light
Bulging can mean raised pressure in the head
Sunken can suggest dehydration
Only check the fontanelle in babies and young infants

Act

Recovery position if unconscious
Treat hypoglycaemia
Seizure management
Reduce stimulation
Neurology if needed

Red flags

Responds only to pain or is unresponsiveNot responding to parentsBM <4 mmol/LBulging fontanelleActive seizure

Exposure

What has been missed? Inspect thoroughly but maintain dignity.

Inspect

Head-to-toe assessment
Rashes and wounds
Non-blanching rash
Bruising pattern
Skin turgor

Temperature

<36°C or >38.5°C = concern
Hypothermia in neonates
Keep child warm
Fever with rash → urgent
Neonatal temp strictly normal

Lines & drains

IV/IO site and flow
Catheter output/colour
Nappy weight if infant
NG tube position
Drain output

Chart review

Medication chart
Weight-based dosing
Allergy status
Fluid balance trend
PEWS trajectory

Red flags

Non-blanching rashTemp <36°C or >38.5°CUnexplained bruisingFloppy/unresponsivePetechiae

After A–E Checklist

Reassess & escalate

Reassess from A after every intervention

Calculate PEWS score and document

Escalate using SBAR — be specific

Document & monitor

Document findings and all actions taken

Increase monitoring frequency if unwell

Review again in 15–30 minutes

Quick self-test

Sources & References

Also practice with

Core Quiz — test your recall →OSCE Stations — apply it clinically →

Discussion (0)

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