Vitals (VS) and Assessment
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Outline
Overview
Children are still developing and growing, because of this they respond differently to illnesses than adults. This requires nurses to adapt their approach to assessments in order to recognize when a child is deteriorating.
Nursing Points
General
- Not just small adults
- Anatomy & Physiology
- Immature lungs
- Big heads, small airways
- Immature blood brain barrier
- Larger BSA
- Immature kidneys
- Increased metabolism
- Growth & Development
- Communication
- Cognition
- Anatomy & Physiology
- Technique
- Be opportunistic
- Be prepared
- Be efficient
- Be flexible
- Be thorough
- Tips and tricks
- Developmentally appropriate
- Least invasive first
- Involve caregivers
- Keep scary things out of site
- Play and make-believe
- Distraction
- Avoid yes or no questions
- Give praise, and stickers!
- Know your cartoons! (and movies and video games)
Assessment
- Vitals
- As the child ages, vital signs shift closer to the normal range for adults.
- HR & RR ↓ with age
- BP ↑ with age
- Best Practice
- Temperature
- Age appropriate method
- EX: no oral temp until 4-5 yrs
- Age appropriate method
- Pulse
- Use pulses to assess perfusion
- <2 years old
- Most accurate = apical
- Auscultation x 1 minute
- 3rd-4th ICS, nipple line
- Respirations
- Infants = irregular breathers.
- Count x1 minute
- Infants = irregular breathers.
- Blood Pressure
- Use correct cuff size
- Drop in BP is a late sign
- Pain
- FLACC
- Face
- Legs
- Activity
- Cry
- Consolability
- FACES
- FLACC
- Temperature
- Normal ranges-
- 1 yr
- Temp – 97-99
- Pulse – 90-140
- Resp – 25-40
- BP – 85/60
- Toddler
- Temp – 97.5-98.6
- Pulse – 80-130
- Resp – 20-30
- BP – 95/65
- Preschooler
- Temp – 97.5-98.6
- Pulse – 80-120
- Resp – 20-30
- BP – 95/65
- School-Age
- Temp – 97.5-98.6
- Pulse – 70-110
- Resp – 15-30
- BP – 100/65
- Adolescent
- Temp – 97.5-98.6
- Pulse – 60-105
- Resp – 12-20
- BP – 115/75
- 1 yr
- As the child ages, vital signs shift closer to the normal range for adults.
- Physical Assessment-
- Recognizing sick kids
- Pediatric Arrest
- End point of long process
- Hypoxia and acidosis
- Resuscitation usually ineffective.
- Identify deterioration before ominous signs
- Hypotension
- Hypoxia
- End point of long process
- A- Airway and Appearance – red flags
- Unable to talk, absent cry
- Drooling
- Stridor
- Poor tone
- Lethargy
- Bulging fontanelle
- B- Breathing- red flags
- Work of breathing
- Nasal flaring
- Retractions
- Tachypnea
- Grunting
- Work of breathing
- C- Circulation- red flags
- Capillary refill >2 sec
- Peripheral temp
- Cool, cold
- Color
- Pale
- Mottled
- Cyanosis
- Pediatric Arrest
- Recognizing sick kids
Nursing Concepts
- Clinical Judgement
- Prioritization
- Oxygenation
- Perfusion
Patient Education
- Educate the children, not just the adults
- Speak to them at their eye level
- Use objects like dolls, stuffed animal to explain procedures
- Give older children the option to speak without caregivers present.
- Allow them to hold equipment
- Use simple, concrete language to explain procedures
- Example: “This is going to give your arm a quick hug/squeeze.”
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Transcript
Hey guys! Welcome to your lecture on vital signs and assessment pediatric patients. So, there is a ton of stuff that we could talk about on this topic and your textbooks will go on and on and on and on about it – but what I want to do is tell you what I wish someone had told me! We will cover some basic info about assessments and vitals – but what I really want you to take away from this is how to spot a sick kid – the ones who are deteriorating and need you to intervene!
So, let’s get started!
So, first things first! Kids are different! They respond differently to being sick and because of this we have to look for slightly different things when we are assessing them.
So let’s start with a quick chat about their A&P – One of the first things you’ll notice is that kids have big heads compared to the rest of their body. This impacts their airway and also makes them more prone to injury and falling over. Second, their organs are not fully developed. For example their lungs and kidneys don’t actually fully mature until they reach the age of 2. This is why something that would be a common cold for me or you can knock a baby flat on their back.
Kids also have a larger body surface making them more prone to hypothermia and dehydration. Their increased metabolism impacts medication dosing as well as nutritional considerations.
And as for growth and development goes – you already know that your patient interactions are 100% influenced by the child’s ability to communicate and process what’s happening to them. That’s all you need to know for this lesson- I’ll give more specifics in the growth and development lessons.
Let’s talk about technique. The things listed here are super basic and straightforward- but they are worth mentioning because they are going to help you out. We talk a lot about making sure the kids are happy and stress free- but I want you guys to have less stress too!
First things first, be opportunistic. All this means is that you do your best to work around the kid. So, you’re not necessarily starting at the top of a checklist in working your way down. If you walk into a room and a baby is a little sleeping beauty – THIS is when you listen to heart and lung sounds and then you quietly fist pump the air because you could hear everything perfectly! OR, If you walk in and he’s screaming his little head off, you can use that to your advantage also! You know his airway is fine! Then, you can take a quick look in his mouth. Do they have thrush? Are mucous membranes moist? Are they teething?
Before moving on to the next point, I want to add a quick BUT here. Be opportunistic, but also be thorough. Yes, we want kids to get sleep in hospital. Yes, I want them to be happy – But don’t get in the habit of cutting corners to avoid upsetting a kid because you’ll end up missing something.
Okay so one thing you can do to work with them is to start with the easy things and leave the painful invasive things last. Usually, this means ears, throats and genitals.
Involve your caregivers. There is almost always someone in the room that can help and they know this kid better than anyone else. They can be your best friend when it comes to getting a child to cooperate.
Last but not least, make it playful! Use games and movies and superheroes and princesses to get it done. Little hulks can show you how strong they are and little princesses can walk and twirl around showing you their coordination.
Alright let’s talk about vital signs. For Temp and pulse ox we pretty much look for the same range as adults same as in adults. Temp (97.8-99.1). Pulse ox (95-100%)
Pulse rate and RR decrease as they get older with your upper limit for infants pulse being 160 and 60 for RR. BP increases with age- going up from the 80/60 which is normal for babies.
A few points on technique- 1) Make sure you use the right type of thermometer. Kids <4-5 years old can’t use oral thermometers. 2) In your patients who are < 2 years old, you need to count an apical pulse for a full minute for accuracy. This is because irregularities are common and it’s really tough to feel a radial pulse in kids <2 years. It’s rapid and they are tiny, so you are very likely to feel your own pulse instead. 3) Infants are irregular, abdominal breathers so watch their little tummies for a full minute for accuracy. 4) For BP’s make sure you use the right cuff size and sometimes it helps if you tell kids that you are going to give their arm a hug. Sounds silly but it does take the scary out of it a little. Make sure you take a look at the lesson outline and the cheatsheet attached to this lesson - you’ll find the correct vitals for each age group here, as well as a few other important details, including information about pain assessments in kids. Okay, like I said at the beginning- this lesson isn’t going to be taking you through a head to toe checklist. It’s going to be about understanding what is happening when kids deteriorate and then highlighting the assessment findings you absolutely cannot miss. I want you to know when a kid is tanking, before they actually tank. When I was a new nurse I did NOT have a solid understanding of what I'm about to talk about, and I found myself taking care of a 3 month old baby that was really, really, sick. I wasn't connecting the dots, thankfully a senior nurse stepped in and helped me see what was happening. I do not want you to find yourself in this situation. The first thing to understand about really sick kids is that if a cardiac arrest occurs it is usually the end point of a really long process. Usually, the initial problem is respiratory and then if their heart stops it’s because of hypoxia and acidosis. This means that when a kid arrests they are in such a bad state metabolically that resuscitation efforts are much less likely to work. This is why it is so important for us to identify the deterioration long before we get to that point. Hypotension and hypoxia are late signs- you can’t wait until those two things happen to intervene. So, what should we look for to make sure we intervene before it’s too late? The assessment triangle here is probably most often used in an emergency setting - but we are going to use it and apply it to any environment - because guess what, when a kid is struggling to breath, becoming septic or losing consciousness - it’s an emergency! It doesn’t matter where you are. Let’s start with A - airway and appearance. Remember, our young kids cannot tell us how they feel so we have to pay extra close attention so their behavior. Basically, the scariest presentations are the quiet ones. If you are poking and prodding a kid and they are just laying there quietly, alarm bells should be going off. If an adolescent with asthma can’t talk because they are having such a hard time breathing - alarm bells. We want our pediatric patients upset and pushing against us- if they aren’t we need to know why. Other red flags for airway and appearance are stridor, drooling, lethargy, and poor tone. B - In peds we talk a lot about work of breathing. How hard is this child having to work to move air in and out? We know a kid is working hard when we see 1) nasal flaring, 2) retractions, 3) grunting 4) increased RR. I want to highlight tachypnea as a red flag. It’s a tricky one because everything else may look pretty normal, but a lot of times it’s your first sign that something is wrong. Remember, we said their lungs are immature until 2 years? Well when they are sick is that it’s easier for young kids to just breathe faster than it is for breathe more deeply- so pay attention if you see that resp rate creeping up. C - stands for circulation. For this we need to get our hands on our patients. Are they cold, cool, clammy? Are pulses weak? Capillary refill is probably the most important part of checking a child’s circulation and one of the first things you should assess on every single patient you see. We expect it to be 2 seconds or less. If it’s anything longer than that something is wrong with their perfusion. This is when we start to treat. Not, when you get a low blood pressure reading. Your priority nursing concepts for this lesson are, clinical judgement, prioritization and oxygenation. I really really hope you guys found this lesson helpful. The info here is 100% foundational for pediatrics. If you could only listen to one lecture during your pediatric course I would want it to be this one. Your key learning points - 1) knowing that kids are different and they respond differently to illnesses, which means you have to use different skills and know what to look for! 2) Be opportunistic, but also thorough. Keep anxieties down and be developmentally appropriate, but know that hospitals aren’t hotels. We have a job to do! 3) For best outcomes, we have to detect deterioration early on. Don’t wait on your vital signs machine to tell you a kid needs help. 4) Think about your ABC’s - even if you aren’t in an emergency room - it is a very helpful tool for making sure you don’t miss those early signs. 5) Commit those red flags to memory and don’t ignore them when you see them - even if the child doesn’t look ‘that bad’. Act early! Don’t wait for them to deteriorate! That’s it for our lesson on Vitals and Assessments. Again, make sure you check out all the resources attached to this lesson. Now, go out and be your best self today. Happy Nursing!
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Monalisa’s Study Plan
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