Minimum Systolic BP - 1 year

- 60 mmHg - 70 mmHg - 70 + twice child's age in years Median systolic BP in child > 2 years: 90 mmHg + child's age in years

What's Different About Kids? Flashcards by Bethany Cunningham

What makes Kids Different?

Anatomic, physiologic, emotional
- Subtle signs
Growth & development
Unreliable historians
Change quickly
Family involvement

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ABCDEF of Children

Airway
Breathing
Circulation
Disability (neuro, pain, LOC, response to people and environment, behaviour, and movement)
Exposure (temp, skin, bruising, rashes)
Family

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Airway - Nursing implications

Airway positioning (allow child to maintain a position of comfort)
O2 therapy
Suction - with CAUTION!!
Patent
Maintainable with positioning or suction
Unmaintainable - requiring intervention

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Head bobbing
Tracheal tug
Stridor

more intrathoracic pressure, more air into their lungs. Tracheal tugging: commonly seen in croup
Stridor: heard on inspirations (upper airway obstructions)

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Upper airway

Nasal flaring
Stridor
Tracheal tugging
Stertor

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Lower airway

wheezing
grunting
subcostal retractions
intercostal retractions

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Lower airway

wheezing
grunting
subcostal retractions
intercostal retractions

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Breathing (8)

Less O2 reserve
Higher RR
Fewer alveoli (until 8 years)
Anatomical dead space (spaces where air isn’t exchanged)
Thin chest wall
Poorly developed intercostal muscles & soft, pliable ribs (allows for retractions)
Diaphragmatic breathing
Retractions (hallmark sign for respiratory distress)

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Trachea bifurcation

In children, the trachea is shorter and the angle of the right bronchus at bifurcation is more acute than in the adult. Aspirated foreign body is more likely to land in the right side.

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Breathing - Nursing Implications
- Respiratory Effort
- Colour

Respiratory effort: low RR is sign of impending cardiovascular collapse. RR increases 4bpm for each 0.6 degree celsius change and HR increases 8-10 bpm
Retractions - note location
Stridor (indicates a narrowing or obstruction of upper airway)
Grunting
nasal flaring
Colour: central cyanosis - sign of late resp failure. shouldnt me mottled or discoloured
Auscultation
O2 therapy
Perfusion

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Cough

Barky
Harsh
Congested
Paryoxysmal (pertussis)
Secretions
Frequency

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Regularity (CREBS)

Inspiratory/expiratory ration
- inspiration slightly longer or = expiration
Increased inspiration
? upper respiratory problem (croup)
Prolonged expiration
? Asthma (air trapping)

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Adventitious Breath Sounds

Air entry (bilateral/anterior/posterior)
Wheeze (bronchospasm)
Moist sounds (rales)
Coarse sounds (rhonchi)
Crackles (fluid, secretions, inflammation)
Stridor (upper airway, foreign body)

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Saturation (oxygen)

94-100% on RA
Assess pre/post inhalation medication
Administration of O2
Assess and move probe every 4 hours/
Nasal cannula administer up to 4 L/min

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Pulse Oximetry Tips: Assess patient for factors that could cause inaccurate SpO2 readings:

presence of abnormal Hgbs
Hypoperfusion
severe anemia
venous congestion
Presence of nail polish

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Pulse Ox: Ensure good signal & measurement by observing the following

Strong signal indicator
Correlating pulse rate with palpated pulse & auscultated HR
Correlating SpO2 measurements with clinical condition

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Circulation
- Cardiac Output
- Blood pressure

CO:
- HR x SV
- CO is dependent until late school age or adolescence
Blood Pressure: hypotension is a late & ominous sign of cardiovascular collapse
Tachycardia: how children increase CO, 180-200bpm, children can tolerate tachycardia better than bradycardia

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Minimum Systolic BP
- < 1 month
- < 1 year
- > 1 year

60 mmHg
70 mmHg
70 + twice child’s age in years
Median systolic BP in child > 2 years: 90 mmHg + child’s age in years

Circulation and Heat Loss

Large surface area & higher metabolic rate
- heat loss & greater insensible water loss
- Higher fluid requirements

Less absolute circulating blood volume
- infants
- adults

Infants: 80-90 mL/kg
Adults: 65-70 mL/kg
Adequate systemic perfusion depends on adequate circulating blood volume

Relatively Anemic

Hgb levels slightly less than adults
Early signs of hypoxemia may be pallor or ashen colour
Absence of cyanosis can be misleading

Circulation - Nursing Implications

Apex vs radial pulse
- use apex for < 6 years
- sinus arrhythmia common
- decreased HR is very late sign
Assess: peripheral pulses, capillary refill, tearing (do they produce tears), mucous membranes, skin turgor, fontanelles (post - 2-3 months, ant. 12-18 mos), urine output, weight loss

Late Signs

hypotension
Bradycardia
Bradypnea
Central cyanosis

Disability

Level of consciousness
Response to people & the environment
Reaction to assessments & interventions by health care providers
Behaviour
Pupil size & reactivity
Pain
Fontanels: limited room for brain swelling, family input & impression of child, modified Glasgow Coma Scale. Rapid unexpected neurological change can indicate increased ICP

Disability - Nursing Implications

Child's response to environment Paradoxical irritability (more content when laying flat and not held) Signs of serious illness - inability to recognize parents - limp/flaccid muscle tone; posturing - sluggish or absent pupillary responses - moaning, whimpering, or "cat-like" high-pitched cry

Decorticate Decerebrate

dysfunction of cerebral cortex dysfunction of midbrain both show signs of significant brain involvement

Decorticate Decerebrate

dysfunction of cerebral cortex dysfunction of midbrain both show signs of significant brain involvement

Pediatric Warning System (PEWS): Key Elements

1. PEWS score 2. Situational Awareness 3. Escalation Protocols 4. SBAR

Examination of Infants < 6 Months

- Praise parental presence and responses - Promote physical comfort and relaxation - Distract infant with colorful toys - Use gentle, warm hands and warm stethoscope - Auscultate when quiet or sleeping - Do procedures that provoke crying at end of exam - Keep the infant as close to parent as possible to allay developing separation/stranger anxiety - Promote comfort - warm room, warm hands

Examination of Toddlers

- Keep child close to parent - Provide a security object - Demonstrate instruments on parent or other before examining child - Allow child to have as much control and choice as possible - Examine ears, eyes, mouth at end of the exam

Examination of Pre-Schoolers

- Consider what sequence is best - Allow children to touch and play with equipment - Use games to reduce anxiety - Give positive feedback

Examination of Older Children & Adolescents

- Ensure modesty and privacy - Offer choices - Explain body parts and functions - Decide on parental presence or absence - Consider need for nonparent chaperones - Reassure adolescents of normalcy

Pediatric Assessment Triangle

Appearance Work of breathing Circulation

PAT: WOB

breath sounds positioning retractions flaring apnea/gasping

PAT: Circulation

Pallor Mottling Cyanosis

PAT: Appearance

Tone Interactiveness Consolability Look/Gaze Speech

Common Abnormal Findings

Too quiet... could mean serious illness, developmental delay, dehydration... Movement not symmetrical... could mean injury, developmental delay, cerebral palsy... Low muscle tone... dehydration, neurological delay... Extra movement... could be seizures, jitters

Skin Findings

Jaundice Cyanosis Pallor Hypercarotenemia Bruising Mongolian spots Rashes Atopic dermatitis Skin lesions Ringworm, scabies

Facial Features

Evidence of pain or comfort, emotional status Symmetry Position of eyes & ears Cleft lip Cranial nerve function Strabismus

Normal development at 2-3 months

posture and spinal curves - holds head erect when held upright; thoracic kyphosis when sitting

Normal development at 6-8 months

posture and spinal curves - sits without support, spine is straight

Normal development at 10-15 months

posture and spinal curves - walks independently; straight spine

Normal development Toddler

posture and spinal curves - protruding abdomen; lumbar lordosis

Normal development School-age child

height of shoulders and hips is level; balanced thoracic convex and lumbar concave curves