Pediatric Assessment Flashcards
Pediatric differences in neuro system (many)
big changes in brain growth in early years
CNS immature, nerve fibres poorly developed
numerous reflexes present initially
BBB not mature until 2 years
myelinization over the first year of life
What does an immature BBB increase the risk of?
infection, especially meningitis
baby with fever - treat as though they have meningitis until you find out what they have
Fontanelle definition
fontanelles are formed at the intersection of sutures, separations of bones in skull that haven’t joined
covered by tough membranous tissue that protects the brain
allow brain growth
Posterior fontanelle closes by…
2 to 3 months
Anterior fontanelle closes by…
18 months
larger than posterior
Fontanelle - sign of dehydration
sunken
Fontanelle - sign of increased intercranial pressure
bulging
pulsating
tented
Neuro assessment components (many)
reflexes
fontanelles
GCS
PERRLA
behaviour appropriate to situation, age, development
strength and coordination of limbs
-hypertonic, hypotonic
-infants - strength of suck
cry
orientation - modified (age, teacher, pets etc)
Constant irritability cry
bad, high-pitched crying
Increased inter cranial pressure cry
screaming cat cry
What system exhibits some of the biggest differences between children and adults?
respiratory
Pediatric differences in upper airway
shorter neck and trachea
larynx and glottis high in neck
tongue is large relative to small nasal and oral airway passages
nose breathing
What does a shorter and narrower trachea increase the risk of?
obstruction
safety concern - putting things in mouth
What type of breathers are newborns?
nose breathers
will NOT automatically open mouth if nose is obstructed
nasal patency is critical**
What does the larynx and glottis being high in neck increased the risk of?
aspiration
If a code blue is called for a child, what type of issue is it usually due to?
resp!
Pediatric differences in lower airway
less alveoli, more underdeveloped
-increased by age 8
less lung volume
-decreased ability to take deep breaths
diaphragmatic breathe (til age 6)
CO2 is not effectively expired when child is distressed
What do smaller alveoli predispose infants to?
alveolar collapse
What does ineffective expiration of CO2 increase the risk of?
metabolic acidosis
Airway resistance
children have smaller, narrower airways
greater airway resistance
with edema or swelling the airway is further narrowed
increased WOB
Components of a respiratory assessment (many)
Auscultation of lungs
WOB
Skin colour
Observation - symmetry
Coughing
O2 sat
Rate, rhythm
T or F: Adventitious sounds are less obvious in children.
FALSE
more obvious
can’t clear aiways
Fine Crackles
high pitched crackling or popping sound heard on INSPIRATION
not cleared by coughing
inhaled air collides with previously deflated airways which will pop open
Course Crackles
low pitched bubbling and gurgling sounds, like velcro
start in early inspiration and may be present in expiration
inhaled air collides with secretions in trachea or large bronchi
Wheezes
constricted airways
musical high pitched squeaking sounds often heard mid to late EXPIRATION
air is squeezed or compressed through passageways narrowed almost to closure though collapsing airways, swelling, secretions
high OR low pitched
Stridor
high pitched crowing sound
originated in larynx or trachea
obstruction from swollen inflamed tissues or lodged foreign body
e.g. Croup**, post-intubation
Transmitted sounds
may seem to originate in the lungs but isreferred from the upper airway
i.e. mucous in the throat or nose
MOST COMMON*****
Signs of increased WOB
subcostal, intercostal indrawing
supra and substernal
accessory muscle use
tracheal tug
nasal flaring
head bobbing
grunting esp in infants at the end of every breath**
Where can O2 sat be taken on a child? (4)
1) foot
2) toe
3) earlobe
4) wrist
What would shallow breaths indicate?
pain
especially in the stomach
Pediatric differences in cardio system (many)
CO is rate dependent
heart is labile (easily changed)
increased HR, moreso than adults
lower BP (underdeveloped left ventricle)
radial pulse NOT palpable
lower absolute blood volume – vulnerable to fluid and electrolyte imbalances
Biggest cardiac differences between children and adults
child: CO is rate dependent
adult: CO is SV dependent
Components of a cardiovascular assessment (many)
cap refill
HR and rhythm
skin colour
edema
heart sounds
temperature
hydration status - I&O, fontanelle, weight, skin turgor, cap refill
peripheral pulses
Cap refill should be less than…
3 seconds
How long to assess HR for?
FULL MINUTE
T or F: Sinus arrhythmias are normal in children.
TRUE
Edema in children is more present in the…
face, periorbital area
Reasons infant may be cyanotic
1) cardiac
2) pulmonary
Cyanosis that WORSENS with crying
most likely associated with cardiac**
Cyanosis that IMPROVES with crying
pulmonary
Acrocyanosis (cyanosis of extremities)
NORMAL in newborn
blue hands and feet in first couple of days
Peripheral cyanosis
extremities, perioral
may represent hypothermia or decreased flow
Central cyanosis
inside mucous membranes
reduced hemoglobin saturation
Pediatric differences in GI
saliva production begins at 4 months
sucking is present until 3 – 4 months
(reflex - will suck on finger, bottle etc.)
stomach capacity increases from 30 – 300 mls in the first year of life (need less fluid)
1 – 3 years - intestinal flora becomes more adult like, stomach acidity increases
myelination of nerves to the anal sphincter allows physiologic control of bowel function around 2 years
lower esophageal sphincter muscle tone not fully developed until 1 month – babies regurg
infant small intestine is 250 cm, adult is 600 cm
bigger but immature liver
slow development of glycogen storage capacity
more body water
abdomen susceptible to trauma
gastric digestion is less functional
When babies spit up, does this cause heart burn?
no
no acidic like in adults
What does having a small intestine increase the risk of?
necrotizing enterocolitis (NEC) in infants
if removing bowel, can result in short bowel syndrome
What does a slow development of glycogen storage capacity increase the risk of?
hypoglycemia in infants
Components of a GI assessment (many)
auscultation of 4 quadrants
BMs
palpate abdomen
observe - symmetry, elevation, tubes, drains, belly button healing properly, distention
appetite
N/V
diet/feeding
colostomy/ileostomy
How do we want the abdomen to feel?
soft
T or F: Big bellies in infants and toddlers is normal
YES
gets flatter with age
want to know their normal though
Pediatric differences of the genitourinary system
kidney weight doubles in first month of life
infants - can’t concentrate urine as well
smaller bladder capacity
kidney is relatively large, susceptible to trauma
urethra is shorter in females, closer to rectum in infants
under 2 - poor bladder control due to insufficient nerve development
What is the bladder capacity of infants?
15 to 20 mls
Components of genitourinary assessment
input and output
urine characteristics
Way to measure output in infants
weight diaper
1 mg = 1 ml
What we want output to be per hour
more than 1 - 2ml/kilo
Differences in output between children and adult
child: weight dependent
adult: 30 mL/hour
Why are catheters not often used in children?
increased risk of UTIs
If NPO, IV should be run at…..
maintenance rate
(or maintenance and a half)
Conditions that INCREASE fluid requirements
fever
vomiting
diarrhea
diabetes insipidus
burns
tachypnea
chemo
Conditions that DECREASE fluid requirements
meningitis (dont’ increase intercranial pressure)
HF
renal failure
SIADH
Pediatric differences in MSK
higher % of cartilage in ribs, more flexible and compliant
softer bones, more easily bent and fractured
bones heal faster
muscles lack tone, power, and coordination during infancy
lower muscle mass compared to adults (25% vs 40%)
Components of an MSK assessment (many)
movement, strength
signs of pain
reflexes
ROM
resistance against gravity
TONE
age appropriate movements
balance, gait
Signs of MSK pain in children
compensating***
don’t want to be touched
irritable
Pediatric differences in the endocrine/metabolic system
higher metabolic rate, oxygen needs, caloric needs
thermoregulation is immature in infant
temperature lability present – temp can increase to very high levels even in minor infections
ratio of temperature elevation is 4:1 (4 extra breaths for every 1 degree F above N)
larger skin surface area
What does immature thermoregulation in infants increase the risk of?
hypothermia
For which symptoms is it most important to get the doctor for? (2)
1) dehydration
2) respiratory distress
Pediatric differences in the immune system
immune system immature, slow response to infection
infants: 6 - 9 resp infections/year
by age 6: 4 - 5 resp infections/year
GI infections common
allergies common (ask re fam history, be careful with meds)
immunization schedule – keep up to date
Pediatric pain assessment - physiologic signs of pain
resp distress
increased HR, BP
sweating
red in face
Pediatric pain scales (4)
1) Numeric
2) Faces
3) FLACC
4) NIPS
Numeric pain scale
better for older children
important to put it into context
Faces pain scale
5 faces with expressions
not the Wong Baker scale
FLACC pain scale
Faces, Legs, Activity, Crying, Consolability
behavioural scale
NIPS pain scale
Neonatal Infant Pain Scale
behavioural scale
Pharmacological pain management
Tylenol, Advil
morphine
hydromorphone - not as common
Non-pharmacological pain management
ice, heat
distraction, play
parent, toy
skin-to-skin
sucrose* - more so for infants
breastfeeding
