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ENPC, 5th Edition Pediatric Nursing Process 2022
ENPC, 5th Edition Pediatric Nursing Process 2022/ENPC, 5th Edition Pediatric Nursing Process 2022
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ENPC, 5th EditionPediatric Nursing Process
Demonstrated
Skill Steps Instructor Responses
Yes No
Preparation and Triage
(may occur after the across-the-room observation if not arriving by ambulance)
.
1. States the need to activate the trauma or
resuscitation team
2. States the need to prepare the trauma or
resuscitation room
• Pediatric equipment
• Length-based resuscitation tape
• Pediatric protocols and dosing guidelines
3. States the need to don PPE
“The patient has just arrived.”
Across-the-Room Observation
4. Assess for uncontrolled external hemorrhage
and the need to reprioritize to <C>ABC
5. Identifies the three components of the
Pediatric Assessment Triangle AND categorizes
the patient as “Sick, Sicker, or Sickest”
• Appearance
• Work of breathing
• Circulation to the skin
Primary Survey
Airway and Alertness
6. Assesses level of consciousness using AVPU **
7. If trauma is suspected, states the need for
a second person to provide manual cervical
spinal stabilization AND demonstrates manual
opening of the airway using the jaw-thrust
maneuver; if NO trauma is suspected, opens
airway with a head tilt/chin lift or jaw thrust or
asks patient to open mouth
8. Demonstrates and describes techniques **
for determining the patency of the airway,
using inspection, auscultation, and palpation
(identifies at least FOUR):
• Is the tongue obstructing?
• Are there any loose or missing teeth?
• Are there any foreign objects?
• Is there any blood, vomit, or secretions?
• Is there any edema?
• Is there any snoring, gurgling, or stridor?
• Is there any bony deformity?
The double starred (**) criteria are performed within the priority element. This means that double starred (**)
criteria are completed in order before moving to the next step. The single starred criteria (*) are essential skill Page 1 of 7
steps and are expected to be performed during the skill station demonstration but their sequence is not critical.
Emergency Nurses Association • 930 E. Woodfield Road, Schaumburg, IL 60173 • Course Operations: 800.942.0011 • Email: CourseOps@ena.org • Revision Date: September 2018
, ENPC, 5th Edition
Pediatric Nursing Process
Demonstrated
Skill Steps Instructor Responses
Yes No
9. Perform appropriate airway interventions
if necessary and reassess for effectiveness.
These may include but are not limited to the
following:
• Suction airway
• Place folded towel under shoulders/torso
• Allow to maintain preferred position
• Insert an oral or nasopharyngeal airway
• Indicate need for intubation
Breathing and Ventilation
10. Demonstrates and describes techniques for **
determining breathing effectiveness using
inspection, auscultation, and palpation
(identifies at least FOUR):
• Is there spontaneous breathing?
• Is there symmetrical chest rise?
• What are the depth, pattern, and general
rate of respirations?
• Is there increased work of breathing?
○○ Abnormal positioning
○○ Grunting
○○ Retractions/accessory muscle use
○○ Head bobbing
○○ Nasal flaring
• What is the skin color?
• Are there open wounds or deformities?
• Are breath sounds present and equal?
• Is there subcutaneous emphysema?
• Is there any tracheal deviation or jugular
venous distention?
11. Perform appropriate interventions if necessary
and reassess for effectiveness. These may
include but are not limited to the following:
• Apply oxygen
• Provide ventilations with a bag-mask device
• Indicate need for intubation
• Indicate need for needle thoracentesis
• Indicate need for chest tube
The double starred (**) criteria are performed within the priority element. This means that double starred (**)
criteria are completed in order before moving to the next step. The single starred criteria (*) are essential skill Page 2 of 7
steps and are expected to be performed during the skill station demonstration but their sequence is not critical.
Emergency Nurses Association • 930 E. Woodfield Road, Schaumburg, IL 60173 • Course Operations: 800.942.0011 • Email: CourseOps@ena.org • Revision Date: September 2018
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