Pediatric Assessment Mary E. Amrine, BSED, BSN, RN

What’s normal?

Awake rate: Heart rate (rate/min) Sleeping rate Sleeping rate

Infant (Under 1 year of age) Respiratory rate: Respiratory rate: Heart rate: bpm Heart rate: bpm * Differences between awake and sleeping Systolic BP (mm HG): greater than 60 Systolic BP (mm HG): greater than 60 or strong pulse or strong pulse

Toddler (1 – 3 years) Respiratory Rate: Respiratory Rate: Pulse rate: Pulse rate: Systolic BP (mm HG)” greater than 70 Systolic BP (mm HG)” greater than 70 or strong pulse or strong pulse

Pre-schooler (4-5 years) Respiratory rate: Respiratory rate: Pulse rate: Pulse rate: Systolic BP (mm HG): greater than 75 Systolic BP (mm HG): greater than 75

School-age child (6-12 years) Respiratory rate: Respiratory rate: Pulse rate: Pulse rate: Systolic BP ( mm HG): greater than 80 Systolic BP ( mm HG): greater than 80

Adolescent (13-18 years) Respiratory rate: Respiratory rate: Pulse rate: Pulse rate: Systolic BP ( mm HG): greater than 90 Systolic BP ( mm HG): greater than 90

Heart rate gradually decreases from about 150 beats per minute in newborns to normal adult values of by age 12. Heart rate goes up or down at approximately 10% per degree Celsius and 5% per degree Fahrenheit.

Differencesbetween Children and Adults

Airway Differences: Smaller upper/lower airways. Tracheal diameter approx size of little finger. Smaller upper/lower airways. Tracheal diameter approx size of little finger. Larynx located higher in the neck Larynx located higher in the neck Infants are nose breathers for first several month of life. Infants are nose breathers for first several month of life. Clinical Significance: Obstruction of airway easy. Obstruction of airway easy. Airway obstruction is a major cause of hypoxemia in children Airway obstruction is a major cause of hypoxemia in children Must keep airway clear to prevent respiratory distress Must keep airway clear to prevent respiratory distress

Tongue is larger in proportion to mouth Tongue is larger in proportion to mouth Cartilage of larynx is softer Cartilage of larynx is softer Increased Increased proportion of soft tissue in airway Tongue can cause obstruction Tongue can cause obstruction Any compression or Any compression or hyperextension can compress airway. Narrow or pharyngeal passages Narrow or pharyngeal passages More susceptible to edema More susceptible to edema

Epiglottis is floppy, trachea shorter, airway malformations more common. Epiglottis is floppy, trachea shorter, airway malformations more common. Cricoid cartilage is narrowest part of larynx, as opposed to vocal cords in adult. Cricoid cartilage is narrowest part of larynx, as opposed to vocal cords in adult. Intubation more difficult Intubation more difficult

Breathing Differences: Differences: Less compensatory reserve Less compensatory reserve Intercostal muscles are poorly developed Intercostal muscles are poorly developed Clinical Significance: Susceptible to respiratory distress. Children fatigue easily Susceptible to respiratory distress. Children fatigue easily Infants rely on diaphragm for breathing Infants rely on diaphragm for breathing

Infants breathe utilizing abdominal muscles Infants breathe utilizing abdominal muscles Ribs are horizontally oriented. Ribs are horizontally oriented. Fewer and smaller alveoli Fewer and smaller alveoli Any pressure on the diaphragm from above/below can impede respiratory function Any pressure on the diaphragm from above/below can impede respiratory function Chest expansion decreased during breathing Chest expansion decreased during breathing Less surface area for gas exchange Less surface area for gas exchange

Differences: Metabolic rate 2 times that of an adult Metabolic rate 2 times that of an adult Thin chest wall Thin chest wall Clinical Significance: Increased need for oxygen Increased need for oxygen Breath sounds easily transmitted and may be misleading Breath sounds easily transmitted and may be misleading

Circulation- Cardiovascular Differences: Circulating blood volume less Circulating blood volume less Clinical Significance: Small blood loss can cause circulatory compromise. Small blood loss can cause circulatory compromise.

Circulation-Cardiovascular Circulatory response in young children to hypoxemia is bradycardia! Circulatory response in young children to hypoxemia is bradycardia! Heart rate primary factor determining changes in pediatric cardiac output Heart rate primary factor determining changes in pediatric cardiac output Any drugs that slow heart rate will result in a drop in cardiac output and decrease circulation times Any drugs that slow heart rate will result in a drop in cardiac output and decrease circulation times Hypoxia, deep sedation and painful events can produce bradycardia Hypoxia, deep sedation and painful events can produce bradycardia

Neurological Differences: Primary brain structure at birth, additional growth occurs over years Primary brain structure at birth, additional growth occurs over years Babinski reflex is normally present until the child begins walking Babinski reflex is normally present until the child begins walking Clinical Significance: Neurologic system not well developed in children younger than 8 to 10 years old Neurologic system not well developed in children younger than 8 to 10 years old Difficult to predict degree of recovery after injury Difficult to predict degree of recovery after injury After two years of age, babinski reflex is an abnormal neurological finding. After two years of age, babinski reflex is an abnormal neurological finding.

Autonomic nervous system is not fully developed. Autonomic nervous system is not fully developed. Infant’s posture is predominantly one of flexion Infant’s posture is predominantly one of flexion Ability to control temperature is limited. Ability to control temperature is limited. Important indicator of neurological status. Important indicator of neurological status.

Exposure (Environment) Differences: Infants and young children have higher body surface area to weight Infants and young children have higher body surface area to weight Infants less than three months old are unable to produce heat through shivering Infants less than three months old are unable to produce heat through shivering Clinical Significance: Can easily become hypothermic Can easily become hypothermic This in turn increase oxygen consumption and may lead to hypoxia This in turn increase oxygen consumption and may lead to hypoxia

Other Differences: Not able to develop active immunity until 3 months of age Not able to develop active immunity until 3 months of age Children metabolize drugs at different rates Children metabolize drugs at different rates Clinical Significance: Infants can not localize infections. High risk for development of sepsis. Infants can not localize infections. High risk for development of sepsis. All drug dosages should be determined by weight. All drug dosages should be determined by weight.

Limited glycogen stores Limited glycogen stores Higher metabolic rate than adults Higher metabolic rate than adults Children’s head larger in proportion to body weight. Children’s head larger in proportion to body weight. Hypoglycemia common during illness Hypoglycemia common during illness Children have a greater maintenance fluid requirement per kg than adults Children have a greater maintenance fluid requirement per kg than adults Greater susceptibility to head injury Greater susceptibility to head injury

Differences: Decreased ability to concentrate urine. Decreased ability to concentrate urine. Normal Urine Output: Infant – 2 ml/kg/hr Child –1 ml/kg/hr Adult – 0.5/ kg/hr Clinical Significance: Kidneys can not efficiently adjust to fluid changes. Kidneys can not efficiently adjust to fluid changes.

Hepatic and renal function are less developed Length of action of drugs is longer due to reduced hepatic function Clearance time may be faster due to higher circulating volumes

Points to remember…… If you detect signs of respiratory distress or bradycardia provide supplemental oxygen immediately! If you detect signs of respiratory distress or bradycardia provide supplemental oxygen immediately! If the child won’t wear an oxygen mask, hold the mask or tubing near his mouth and nose so he can inhale “blow by” oxygen If the child won’t wear an oxygen mask, hold the mask or tubing near his mouth and nose so he can inhale “blow by” oxygen

If the child’s respiratory status continues to deteriorate, provide additional support through artificial ventilation with a properly sized bag-valve-mask device-especially if the child is tiring from the increased work load of breathing. If the child’s respiratory status continues to deteriorate, provide additional support through artificial ventilation with a properly sized bag-valve-mask device-especially if the child is tiring from the increased work load of breathing. Be prepared for possible endotracheal intubation. Be prepared for possible endotracheal intubation.

A slow or irregular respiratory rate in the acutely ill or injured child is ominous! ominous! A decreasing rate or irregular respiratory rhythm may indicate deterioration in the child’s condition.

Circulatory Assessment Should include……. Should include……. Skin temperature and color Skin temperature and color Quality of peripheral pulses as compared to central pulses Quality of peripheral pulses as compared to central pulses Level of consciousness Level of consciousness Blood pressure Blood pressure

Capillary refill at the palms, soles, forehead and central body should be less than 2 seconds.

A child often initially compensates for lost blood volume with an increased heart rate and peripheral vasoconstriction. In addition to tachycardia, other early signs of shock may include: Mental status changes Mental status changes Respiratory compromise Respiratory compromise

Early signs of shock include: Absence of peripheral pulses Absence of peripheral pulses Delayed capillary refill Delayed capillary refill Pallor Pallor Hypothermia Hypothermia

Normal vitals signs are no guarantee that the child’s circulation is uncompromised. Obvious signs of shock, such as hypotension and reduced urine output, may not occur until more than 30% of blood volume has been lost! The circulating blood volume is about 80ml/hour.

General Assessment Appearance Appearance Work of breathing Work of breathing Circulation Circulation

Primary Assessment Airway Airway Breathing Breathing Circulation Circulation Disability Disability Exposure Exposure

Secondary Assessment History History Physical exam Physical exam Check glucose Check glucose

Tertiary Assessment Laboratory studies Laboratory studies X-rays X-rays Other tests Other tests

Respiratory Assessment Is the child experiencing Is the child experiencing respiratory distress or respiratory failure?

What’s causing the respiratory distress? Upper airway obstruction? Upper airway obstruction? Lower airway obstruction? Lower airway obstruction? Lung tissue disease? Lung tissue disease? Disordered control of breathing? Disordered control of breathing?

Circulatory Assessment Compensated shock? Compensated shock? Hypotension shock? Hypotension shock? Hypovolemic shock? Hypovolemic shock? Distributive shock? Distributive shock? Cardiogenic? Cardiogenic?

Questions?