What's Different About Kids? Flashcards
What makes Kids Different?
Anatomic, physiologic, emotional
- Subtle signs
Growth & development
Unreliable historians
Change quickly
Family involvement
ABCDEF of Children
Airway
Breathing
Circulation
Disability (neuro, pain, LOC, response to people and environment, behaviour, and movement)
Exposure (temp, skin, bruising, rashes)
Family
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
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)
Upper airway
Nasal flaring
Stridor
Tracheal tugging
Stertor
Lower airway
wheezing
grunting
subcostal retractions
intercostal retractions
Lower airway
wheezing
grunting
subcostal retractions
intercostal retractions
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)
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.
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
Cough
Barky
Harsh
Congested
Paryoxysmal (pertussis)
Secretions
Frequency
Regularity (CREBS)
Inspiratory/expiratory ration
- inspiration slightly longer or = expiration
Increased inspiration
? upper respiratory problem (croup)
Prolonged expiration
? Asthma (air trapping)
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)
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
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
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
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
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
- PEWS score
- Situational Awareness
- Escalation Protocols
- 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
