Mod 5 Pediatric Assessment Flashcards
What are some common pediatric respiratory pathologies?
- RSV
- Croup
- Asthma
- Sepsis
- Cystic fibrosis
What is Respiratory syncytial virus [RSV]?
A virus that causes bronchiolitis.
- primarily infects the respiratory epithelial cells, including those lining the upper and lower airways
- self-limiting viral infection that affects the small airways (bronchioles) in the lungs, primarily in infants and young children
which population group is most affected by RSV?
6 months and younger are most vulnerable.
- Premature infants are at high risk for this disease process
Why is Sepsis in particular hard to manage for pediatrics?
When they get an infection, they’re more at risk of hypovolemia and shock, aka they keep getting worse
What are 3 categories you should have in your initial assessment for pediatrics?
Kids decompensate quickly, pay attention to:
- WOB
- Appearance
- Circulation
When should you begin CPR for pediatrics?
- spend sometime reviewing PALs algorithms
When the pulse <60/min w/poor perfusion despite oxygenation and ventilation
What are 4 categories for the appearance assessment?
- Tone
- Interactivness
- Consolability
- Look/gaze/stare/speech/cry
How do you gather a accurate baseline assessment?
- Keep the kid calm
- Involve the parents
- Use distractions (like toys)
How do you assess circulation?
- Look at the color of the kid: (Pallor (paleness), Mottling (bruise hexagon pattern), Cyanosis (dusky))
- Signs of bleeding, bruising suggests injury
What should you do if your pt is unresponsive, not breathing/gasping respirations
Yell for help or activate emergency response
When should you give rescue breaths for pediatric pts?
If pulse is present, but no breathing or inadequate respirations
When should you proceed to your primary assessment after your initial assessment?
If the patient is responsive with no signs of impending resp. failure
What do you evaluate on your primary assessment?
ABCDE:
- Airway
- Breathing
- Circulation
- Disability
- Exposure
For the primary assessment, what elements do you evaluate for airways?
Patency: is the airway open, clear, or obstructed?
- Movement of chest/abdomen?
- airflow around mouth/nose
- bilateral breath sounds
If the airway is obstructed, how can be it be maintained?
- Positioning
- Insertion of OPA/NPA
What should you do if the airway is obstructed, and not maintainable?
Advanced airway (intubate)
For the primary assessment, what elements do you evaluate for breathing?
- RR and Pattern
- Respiratory effort
- Chest expansion and air movement
- Abnormal lung and airway sounds
- Oxygen saturation by pulse ox
How long should you assess the RR of a small infant/pediatric Pt?
30 seconds bc infants may have irregular breathing w/apnea of 10 seconds.
- Neos are assessed for a full min
What is considered as abnormal RR for pediatric Pts?
RR < 10 or > 60
What factors could increase the RR for a pediatric Pt?
Fever or pain
What signs indicate that the patients condition is improving?
Decreasing RR and improvements in LOC
What are causes for irregular respiratory patterns in pediatric patients?
Neurologic problems or Diabetic Ketoacidosis
What are possible sources for Tachypnea in Pediatric patients?
- How does WOB factor in this resp. pattern?
- Tachypnea with Increasing WOB could indicate type 1 or type 2 resp failure
- If not with increased WOB, could indicate fever, pain, sepsis, dehydration?
What are possible sources for Bradypnea in Pediatric patients? (6)
- Central nervous system injury
- Low blood oxygen content
- Sepsis
- Hypothermia
- Drugs that depress resp. drive
- Neuromuscular disease causing muscle weakness (like muscle dystrophy)
What types of WOB would you typically see with increased respiratory effort?
- Nasal Flaring
- Retractions
- Grunting
- Head bobbing
- Seesaw respirations
What are seesaw respirations?
- What is it a impending sign of?
Abdominal breathing (not synced w/chest)
- Inspiration: chest retracts inward and abdomen expands
- Expirations: chest expands and abdomen moves inward
- Sign of Diaphragm failing
How does Head bobbing present?
Inspiration: chin is lifted and extended
Expiration: chin falls forward
How does Head Bobbing help with respiratory effort?
Uses the neck muscles to assist breathing by extending the airway (makes it more patent)?
- Primarily seen in infants and young pediatrics
What are mild to moderate retractions? (3)
- where are each located?
Subcostal, substernal, and intercostal
What are severe retractions (may include mild to mod retractions) (3)
- Where are they located?
Supraclavicular, suprasternal, and sternal
What are possible reasons for decreased or unequal chest expansion
- Inadequate effort
- Airway obstruction
- Atelectasis
- Pleural effusion, pneumothorax, hemothorax
What breath sounds indicate upper airway obstruction
All are audible w/o auscultation
- Stridor
- Snoring
- Barking cough
- Hoarseness
When would you hear wheezes, crackles, and diminished air entry?
All indicate differing things, but can only be heard via auscultation
What do wheezes indicate?
- Lower airway obstruction
- Asthma
- Bronchiolitis
What do crackles indicate?
Secretions
- Pneumonia
- Atelectasis
- Cystic fibrosis
What oxygen saturations would indicate a need for supplementary oxygen on a pediatric patient on room air?
Less than 94% on room air
When should you escalate interventions past bag mask ventilation for pediatric patients?
If they have sats < 90& w/supplemental oxygen.
- LOC is probably gonna be quite low. get help.
What would you assess on your primary assessment for circulation?
- Heart rate
- pulses
- Capillary refill time
- Skin color and temp
- BP
What are asthma medication treatments for children?
- How does age affect treatment and equipment use?
Daily ICS, SABA PRN.
- Age 1-3: MDI w/spacer, and fitted mask
- Age 4-5 MDI w/spacer, consider mouthpiece if can make seal
What are non pharmalogical methods to manage asthma in children? (2)
- Asthma education and self management (action plan)
- Consult w/allergist
When are PRAM scores used for Asthma?
Used mainly in emergency department and wards to guide treatment of acute asthma exacerbations
- Needs a score < 3 for discharge
- Validated up to age 17
What Heart rate arrhythmias are a sign of life threatening condition?
- Kids vs Infants?
Tachycardias > 180 in infants
AND
Tachycardias > 160 in kids
What Heart Rate arrhythmia indicates impending cardiac arrest (potentially)
- When does it require immediate action?
Bradycardia
- Decreased responsiveness/other signs of poor perfusion need immediate action
What are potential causes of bradycardia if the patient is alert, responsive, and has no signs of poor perfusion?
Drugs or heart block
What does a large difference in central/peripheral pulse indicate?
Shock
What should you expect when correlating pulses?
Slightly stronger central pulse to peripheral.
- A large difference indicate shock
- Palpate radial and cartoid artery to correlate
What would be reasons for a longer than normal Capillary Refill? (4)
- Dehydration
- Shock
- Hypothermia
- Cold Environment
What is hypotension often a sign of?
Severe Shock
- May require immediate airway, breathing, and oxygenation
What is considered a poor urine output (u/o) and what is it indicative of?
Poor urine output, indicates poor circulation
- (normal = 1-2 ml/kg/hr)
- Poor u/o can be a sign of shock and decreased blood flow to the kidneys
Why is decreased blood flow bad?
It could stimulate the RAA system, which causes vasoconstriction as a compensatory mechanism to maintain blood pressure.
How should you monitor pediatric Pts for neurologic function (and potential disability)?
Examine:
- Confusion
- Irritability
- Lethargy
- Agitation alternating w/lethargy
What can severe decrease in O2 delivery to the brain result in?
- Decreased LOC
- Loss of muscle tone
- Decreased pupillary response
What is neurologic function (and disability) assessed with/by? (3)
- AVPU Scale (Alert, Voice, Painful Unresponsive)
- Pupil size and response to light
- Blood glucose test (normal < 2.5-3)
What are common causes of decreased LOC in pediatrics? (7)
- Decreased blood flow to the brain (shock/intracranial pressure)
- Brain injury
- Infection in the brain (meningitis, encephalitis)
- Hypoglycemia
- Drug Overdose
- Hypoxemia
- Hypercarbia
What is the focus of the secondary assessment?
Focused on medical history and a focused physical examination.
- SAMPLE abbreviation for assessment categories
What 4 common respiratory emergency categories?
- Upper Airway Obstruction
- Lower Airway Obstruction
- Lung Tissue Disease
- Disordered control of breathing
What could you expect Upper Airway Obstruction to present with?
- Increased inspiratory efforts w/retractions/nasal flaring
- Abnormal inspiratory sounds (snoring or stridor)
- Barking Cough
- Hoarsness
- Decreased air movement despite increased effort
- Gurgling respirations (blood secretions in upper airway)
What are the 2 most common causes of lower airway obstruction in pediatrics?
Asthma and Bronchiolitis
What are signs of Lower Airway Obstruction?
- Increased RR and effort (retractions, nasal flaring)
- Decreased air movement
- Prolonged expiration
- Wheezing
What are examples of lung tissue disease?
- Pneumonia
- Pulmonary edema
- Trauma
- Allergic reactions
- Toxins
What are signs of Lung Tissue Disease? (6)
- Increased RR and respiratory effort (especially on inspiration)
- Decreased air movement
- Grunting
- Crackles
- Head bobbing
- Hypoxemia
What are common causes of abnormal breathing patterns?
- Increased ICP
- Seizures
- Posisins or drug overdose
- Neuromuscular disease
- DKA (in adults)
What are potential causes of increased ICP?
- Trauma
- Brain tumor
- Infection
- Hydrocephalus
What are signs of Abnormal breathing pattern?
- Normal or decreased air movement
- Shallow breathing w/inadequate effort
- Variable or irregular RR and pattern
- Central apnea
When does most Asthma resolve for children?
60% of preschool “wheezers” become asymptomatic by age 6
- Airway remodeling (bad) has been identified in toddlers
Which group of kids are most affected by Asthma?
Preschoolers have the highest admission rate of ER visits
What helps the most in terms of managements for asthmatic children?
ICS and early diagnosis
- Preschoolers respond really well to ICS
- Exacerbations are best relieved w/SABA’s
Which age category is the most challenging to diagnose Asthma in?
Children prior to age 6
What are suggestive symptoms of Asthma?
- What evaluations direct the Dx to Asthma? (3)
- Need to ask about frequency and recurrent
Suggestive Symptoms: Wheezes, dyspnea, cough.
The following guide Dx:
- Atopy (genetic history)
- PFTs
- Suggestions by HCP (PRAM score)
What is the expected course of events that could occur if RSV causes an infection? (5)
- Airway inflammation
- Mucus production
- Airway obstruction
- Airway trapping and hyperinflammation
- Impaired gas exchange
Why are bronchodilators no longer used to treat bronchiolitis?
They would not have any affect bc the pathology caused by viral infections. Corticosteroid also have little affect.
- The best treatment is supportive care and preventive strategies
- Good hygiene and distance from agents of exposure like smoke are the best preventive strategies
What signs are evaluated in PRAM? (5)
- Suprasternal indrawing
- Scalene retractions
- Wheezing
- Air entry
- Oxygen saturation on room air
