August 2019Presented by

Tami Best-Brandt, RN MSNMary Bridge Children’s Hospital

Pediatric ICU and Transport Team Nurse Manager

Pediatric Assessment & Red Flags

Objectives

The learner will be able to:– Identify pediatric age ranges– Verbalize pediatric differences– Distinguish normal assessment findings from

common “red flag” conditions in the pediatric patient

Pediatric Age Ranges Neonate – 0 to 28 days Infant – 1 to 12 months Toddler – 1 to 3 years Preschool – 3 through 5 years School Age – 6 through 10 years Adolescent – 11 to 18 years

PEDIATRIC VITAL SIGNSAGE Weight in Kg Respiratory

Rate Heart Rate Systolic BP

Newborn 2-3 30-50 120-160 50-70

Infant (1-12 months) 4-10 20-30 80-140 70-100

Toddler (1-3 years) 10-14 20-30 80-130 80-110

Preschooler (3-5years) 14-18 20-30 80-120 80-110

School Age (6-12 years) 20-42 20-30 70-110 80-120

Adolescent (13+ years) 45 - >50 12-20 55-105 110-120

Adult (18+ years) >50 12-20 50-90 113-136

Initial Assessment “From the doorway” observation

– Best time to observe patient calm and at baseline, especially if scared of medical providers

This assessment should include– LOC– Breathing (effort & rate if able)– Skin color– Motor skills (can they move all extremities – can

even involve parents in this portion)

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Pediatric Assessment Triangle

Primary AssessmentA-airwayB-breathingC-circulationD-disabilityE-exposure

Secondary AssessmentFocused historyFocused Physical ExamDiagnostic tests

AIRWAY

Airway Chest wall more compliant

– not always a good thing when respiratory effort is increased

Diaphragm is chief muscle of inspiration Intercostal muscles are undeveloped

before school age Lung compliance low in infants and

increases progressively during childhood

It doesn’t take much….

Normal infant airway vs. 1mm of swelling

Common Upper Airway Issues Croup http://www.youtube.com/watch?feature=player_embedded&v=Qbn1Zw5CTbA

Pertussis http://www.youtube.com/watch?feature=player_embedded&v=wuvn-vp5InE

Foreign-body aspiration Tracheomalacia Retropharyngeal abscess Obstruction Trauma

Common Lower Airway Issues/Lung Tissue Disease

Aspiration Asthma

http://www.youtube.com/watch?feature=player_embedded&v=YG0-ukhU1xE

Bronchiolitis Pneumonia Trauma Viral Infection

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Asthma (RAD)

Airway Red Flags

VocalizationDroolingAbnormal airway soundsPreferred postureUnable to complete sentences or

talk Bleeding

SCENARIO

BREATHING

Breathing Red Flags Increased work of breathing - rate and/or depth

of respirations Retractions Breath sound changes

– decreased air movement from previous assessment– increased rhales or rhonchi

Apnea Asymmetric chest rise and fall Decreasing oxygen saturation/increased O2

requirement Change in LOC or decreased level of

consciousness

CIRCULATION

Pediatric Circulation Cardiac output and oxygen delivery are higher

in children per kg of body weight than adults Oxygen consumption is high Stroke volume is small in children Circulating blood volume is small

-infants 80ml/kg-child 75ml/kg-adolescent 70ml/kg

Circulation Red Flags

Central and peripheral pulse rate and quality Skin color and temperature Capillary refill

Central vs. peripheral Is it <3sec? >5sec?

Bleeding Mental status changes UO <1/kg/hr HYPOTENTION and BRADYCARDIA ARE LATE

SIGNS!

Circulation Red Flags

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Scenario

NEURO

Neurological Exam

Primary Assessment– ABC’s– Mental status– AVPU, GCS

– Motor and sensory – Reflexes– Cranial nerve function– PERRLA

Neurological Exam

Pediatric considerations Many pediatric patients will not willfully

participate in a complete neurologic exam Make it a game if they are not cooperating

Allow patient to remain with caregiver during exam

Determine baseline developmental status

Glasgow Coma Scale Allows trending of neurologic

assessments Three components

Eye opening (1-4)Best verbal (1-5)Best motor (1-6)

Score ranges from 3-15

Neuro Red Flags Change in LOC or mentation-

AVPU,Glascow Coma Scale Lethargy Visual disturbances Seizure activity Posturing Slurred speech/difficulty finding words Perseverating Balance/walking difficulties Unilateral muscle weakness

REMEMBER THIS MOMENT….

NAT/Non Accidental Trauma Red Flags Family Interactions and Dynamic History – Does the story match the injury Bruising-TEN-4 rule Bruising on Torso, Ears, or Neck in kids <4yo or any bruising

in kids < 4mo.

Fractures in non-ambulating child or unexplained

Undiagnosed healing fracture

Common Signs of NAT & Areas to be concerned…

Legal definitions of child abuse vary across the United States.

Child abuse can broadly be defined as an act, or failure to act, which results in a child's serious harm or risk of harm, including physical or emotional harm, exploitation or death.

Neglect occurs when a caretaker fails to provide for a child's basic needs.

GI/GU

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GI/Abdomen

• Look• Distension• Vomiting – color, volume

• Listen• All 4 quadrants• Fast, slow, absent

• Feel• Tenderness/pain• Location

GU Red Flags

Urine output< 1/kg/hr Hematuria Cloudy urine Painful urination No urine output reported for several

hours

GI Red Flags

-Abdominal distention-Rigid/tense abdomen-No BM >3days-Pain-Hematochezia

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Scenario

KEEP IN MIND…Kids are not just small adults!!!

QUESTIONS

American Heart Association. Pediatric Advanced Life Saving. First American Heart Association Printing. 2011.

Print.

“Croup”. Mayo Clinic. Web. 20 November 2015.

Emergency Nurses Association. Trauma Nursing Core Course. 2006. Print

Hazinski, Mary. Manual of Pediatric Critical Care. St. Louis. Mosby Inc. 1999. Print.

Parks SE, Annest JL, Hill HA, Karch DL. Pediatric Abusive Head Trauma: Recommended Definitions for Public

Health Surveillance and Research. Atlanta (GA): Centers for Disease Control and Prevention; 2012

“Pertussis”. Centers for Disease Control and Prevention. Web. 20 November 2015.

References