Assess Laboratory Tertiary assessment history using the SAMPLE physical exam Secondary assessment A rapid, hands-on ABCDE approach Primary assessment A rapid visual and auditory assessment General assessment (Pediatric assessment triangle) Brief Description Clinical Assessment
General Assessment WORK OF BREATHING CIRCULATION APPEARANCE
General Assessment Abnormal skin color (eg, pallor or motting) or bleeding Circulation Increased work of breathing (eg, nasal flaring, retractions), decreased or absent respiratory effort, or abnormal sounds (eg, wheezing, grunting, stridor) Work of Breathing Muscle tone, interaction, consolability, look/gaze, or speech/cry Appearance General Assessment PAT
Breathing rate that is more rapid than normal for age. It is often the first sign of respiratory distress in infants. Tachypnea can also be a physiologic response to stress.
Tachypnea with respiratory distress associated with other signs of increased respiratory effort. “Quiet tachypnea” tachupnea is present without signs of increased respiratory effort attempt to maintain normal blood pH in creasing the amount of move in and out of the lungs, decreases carbon dioxide levels in the blood
Quiet tachypnea commonly results from nonpulmonary conditions,
Mild metabolic acidosis associated with dehydration
Breathing rate that is slower than normal for age. Slow and irregular. Possible causes include fatigue, central nervous system injury infection, hypothermia, medications that depress respiratory drive.
Bradypnea irregular respiratory rate in an acutely ill infant or child is an ominous clinical sign because it often signals impending arrest.
Increased respiratory effort reflect the child’s attempt to improve oxygenation. ventilation, or both.
head bobbing or seesaw respirations
prolonged inspiratory or expiratory times, open-mouth breathing, gasping, use of accessory muscles. Grunting is a serious sign may indicate respiratory distress or respiratory failure.
Increased breathing effort results from conditions that increase resistance to airflow cause the lungs to be stiffer and difficult to inflate cause the lungs to be stiffer and difficult to inflate severe metabolic acidosis can also cause increased respiratory rate and effort.
Nasal flaring is the enlargement of the nostrils with each inspiratory breath. Nostrils enlarge to maximize airflow during breathing. Nasal flaring is most commonly observed in infants and younger children. Usually a sign of respiratory distress.
Inward movement of the soft tissues of the chest wall or sternum during inspiration. Chest retractions are a sign that the child is impaired by increased airway resistance or by noncompliant lungs. Retractions may occur in several areas of the chest.
Retractions accompanied by stridor or and inspiratory snoring sound suggest upper airway obstruction. Retractions accompanied by expiratory wheezing suggest marked lower airway obstruction (asthma or bronchiolitis) causing obstruction during both inspiration and expiration. Retractions accompanied by grunting or labored respirations suggest lung tissue (parenchymal) disease. Severe retractions may also be accompanied by head bobbing or seesaw respirations. Retraction of the sternum toward the anterior spine Sternal Retraction in the chest, just above the breastbone Suprasternal Retraction in the neck, just above the collarbone Supraclavicular Severe (may include the same retractions as seen with mild to moderate breathing difficulty) Retraction between the ribs Intercostal Retraction of the abdomen, at the bottom of the breastbone Substernal Retraction of the abdomen, just below the rib cage Subcostal Mild to moderate Description Location of Retraction Breathing Difficulty
Head bobbing and seesaw respirations, often indicate increased patient risk for deterioration.
Head bobbing is the use of the neck muscles to assist breathing. Child lifts the chin and extends the neck during inspiration allows the chin to fall forward during expiration. Head bobbing is most frequently seen in infants and can be a sign of respiratory failure.
Seesaw respirations (abdominal breathing) are present when the chest retracts and the abdomen expands during inspiration. During expiration the movement reverses: chest expands and the abdomen moves inward. Seesaw respirations usually indicate upper airway obstruction. May also be observed in severe lower airway obstruction, lung tissue disease, states of disordered control of breathing. Seesaw respirations are characteristic of infants are children with neuromuscular weakness. Inefficient form of ventilation can quickly lead to fatigue.
Normal tidal volume is approximately 5 to 7 milliliters per kilogram of body weight and remains fairly constant throughout life. Tidal volume is difficult to measure unless a patient is intubated. To assess tidal volume clinically, you should
Heard on inspiration. It may, however, be present on both inspiration and expiration. Stridor is a sign of upper airway (extrathoracic) obstruction and may indicate airway obstruction requiring immediate intervention.
Many causes of stridor, foreign-body airway obstruction (FBAO) and infection (eg, croup). Congenital airway abnormalities (laryngomalacia) acquired airway abnormalities (tumor or cyst). Upper airway edema (allergic reaction or swelling after a medical procedure)
Short, low-pitched sound heard during expiration. misinterpreted as a small cry. Grunting occurs as the child exhales against a partially closed glottis. Grunt to help keep the small airways and alveolar sacs in the lungs open in an attempt to optimize oxygenation and ventilation.
Grunting is often a sign of lung tissue disease resulting from small airway collapse, alveolar collapse, or both. Grunting may indicate progression of respiratory distress syndrome. Grunting may be caused by cardiac conditions causing pulmonary edema, myocarditis and congestive heart failure. May also be sign of abdominal pathology causing pain and abdominal splinting (bowel obstruction, perforated viscus, appendicitis, or preitonitis).
Grunting is typically a sign of severe respiratory distress or failure from lung tissue disease. Should identify and treat the cause as quickly as possible.
Wheezing is a high-pitched or low-pitched whistling or sighing sound heard most often during expiration. Occurs less frequently during inspiration. Indicates lower (intrathoracic) airway obstruction, especially of the smaller airways. Bronchiolitis and asthma. Inspiratory wheezing suggests a foreign body or other cause of obstruction in the trachea or upper airway.
Pulse oximetry is a tool to monitor the percentage of the child’s hemoglobin that is saturated with oxygen. Can detect low oxygen saturation (hypoxemia) in a child before it becomes clinically apparent by the appearance of cyanosis or bradycardia
Calculated percent of hemoglobin that is saturated with oxygen.
Oxygen saturation readings at or above 94% while breathing room air usually indicate adequate oxygenation. Consider oxygen administration for oxyhemoglobin saturations below this value, Additional intervention is likely to be required if the oxygen saturation is below 90% in a child receiving 100% oxygen by a nonrebreathing mask.
Heart Rate: Normal 50 to 90 75 60 to 100 >10 years 60 to 90 80 60 to 140 2 years to 10 years 75 to 160 130 100 to 190 3 months to 2 years 80 to 160 140 85 to 205 Newborn to 3 months Sleeping Rate Mean Awake Rate Age
Hypotension <90 Children >10 years <70+ (age in years x 2) Children 1 to 10 years 5 th BP percentile <70 Infants (1 to 12 month) < 60 Term neonates (0 to 28 days) Systolic Blood Pressure (mm Hg) Age
Skin color ( as well as skin temperature and capillary refill time) can reflect either peripheral (end-organ) perfusion or central (cardiovascular) function. Monitor changes in skin color, temperature, and capillary refill over time to assess a child’s response to therapy.
Petechiae and purpura. Petechiae appear as tiny dots and suggest a low platelet count. Purupra appear larger spots and may represent septic shock.
Carefully evaluate pallor, mottling, and cyanosis, may indicate inadequate oxygen delivery to the tissues.
Pallor is more likely to be clinically significant if the child has pale mucous membranes, pale palms and soles. Pallor is often difficult to detect in a child with dark skin. Thick skin and variations in the vascularity of subcutaneous tissue also can make detection difficult. Central pallor (lips and mucus membranes) strongly suggest anemia or poor perfusion.
Mottling, or mottled skin, is an irregular or patchy discoloration of the skin, Mottling may occur because of variations in the amount of melanin in the skin. Also can caused by hypoxemia, hypovolemia, or shock. These conditions can cause intense vasoconstriction, resulting in and irregular supply of oxygenated blood to the skin and ever cyanosis in some areas.
Cyanosis is a blue discoloration of the skin and mucous membranes. Location of cyanosis (peripheral or central) is important.
Peripheral cyanosis (affecting the hands and feet) caused by diminished oxygen delivery to the tissues. May be seen in conditions such as shock, congestive heart failure, peripheral vascular disease, in conditions causing venous stasis.
Central cyanosis is a blue color of the lips and other mucous membranes.cyanosis is not apparent until at least 5 g/dL of hemoglobin desaturated. Oxygen saturation at which a child will appear cyanotic depends on the patient’s hemoglobin concentration. In the child with a hemoglobin concentration of 16 g/dL, cyanosis will appear at an oxygen saturation of approximately 70%(30% of the hemoglobin, or 4.8 g/dL, is desaturated). If the hemoglobin concentration is low, a very low arterial oxygen saturation (less than 40%) required to produce cyanosis. Xyanosis may be apparent with milder degrees of hypoxemia in the child with cyanotic heart disease, polycythemia but may not be apparent despite signiticant hypoxemia if the child is anemic.
AVPU To rapidly evaluate cerebral cortex function, use the AVPU Pediatric Response Scale. The child does not respond to any stimulus. Unresponsive U The child responds only to a painful stimulus, such as pinching the nail bed. Painful P The child responds only when the parents or you call the child’s name or speak loudly. Voice V The child is awake, active, and appropriately responsive to parents and external stimuli. “Appropriate response” is assessed in terms of the anticipated response based on the child’s age and the setting or situation. Alert A
GSC Scoring 3-15 Total score 1 None None None 2 Decerebrate posturing (abnormal extension) in response to pain Extension in response to pain Extensor Response 3 Decorticate posturing (abnormal flexion) in response to pain Flexion in response to pain Abnormal flexion 4 Withdraws in response to pain Withdraws in response to pain Withdraws 5 Withdraws in response to touch Localizes painful Stimulus Localizes 6 Moves spontaneously and purposely Obeys commands Obeys Best motor response † Coded Value Infant Child Adult Response
Life-threatening Conditions Signs of a Life-threatening Condition Significant hypothermia, significant bleeding, petechiae/ purpura consistent with septic shock, abdominal distention consistent with and acute abdomen E xposure Unresponsiveness, depressed consciousness D isability Absence of detectable pulses, poor perfusion, hypotension,bradycardia C irculation Apnea, significant work of breathing, bradypnea B reathing Complete or severe airway obstruction A irway