pediatric red flags - marybridge.org
TRANSCRIPT
August 2019Presented by
Tami Best-Brandt, RN MSNMary Bridge Children’s Hospital
Pediatric ICU and Transport Team Nurse Manager
Pediatric Assessment & Red Flags
Objectives
The learner will be able to:– Identify pediatric age ranges– Verbalize pediatric differences– Distinguish normal assessment findings from
common “red flag” conditions in the pediatric patient
Pediatric Age Ranges Neonate – 0 to 28 days Infant – 1 to 12 months Toddler – 1 to 3 years Preschool – 3 through 5 years School Age – 6 through 10 years Adolescent – 11 to 18 years
PEDIATRIC VITAL SIGNSAGE Weight in Kg Respiratory
Rate Heart Rate Systolic BP
Newborn 2-3 30-50 120-160 50-70
Infant (1-12 months) 4-10 20-30 80-140 70-100
Toddler (1-3 years) 10-14 20-30 80-130 80-110
Preschooler (3-5years) 14-18 20-30 80-120 80-110
School Age (6-12 years) 20-42 20-30 70-110 80-120
Adolescent (13+ years) 45 - >50 12-20 55-105 110-120
Adult (18+ years) >50 12-20 50-90 113-136
Initial Assessment “From the doorway” observation
– Best time to observe patient calm and at baseline, especially if scared of medical providers
This assessment should include– LOC– Breathing (effort & rate if able)– Skin color– Motor skills (can they move all extremities – can
even involve parents in this portion)
6
Pediatric Assessment Triangle
Primary AssessmentA-airwayB-breathingC-circulationD-disabilityE-exposure
Secondary AssessmentFocused historyFocused Physical ExamDiagnostic tests
AIRWAY
Airway Chest wall more compliant
– not always a good thing when respiratory effort is increased
Diaphragm is chief muscle of inspiration Intercostal muscles are undeveloped
before school age Lung compliance low in infants and
increases progressively during childhood
It doesn’t take much….
Normal infant airway vs. 1mm of swelling
Common Upper Airway Issues Croup http://www.youtube.com/watch?feature=player_embedded&v=Qbn1Zw5CTbA
Pertussis http://www.youtube.com/watch?feature=player_embedded&v=wuvn-vp5InE
Foreign-body aspiration Tracheomalacia Retropharyngeal abscess Obstruction Trauma
Common Lower Airway Issues/Lung Tissue Disease
Aspiration Asthma
http://www.youtube.com/watch?feature=player_embedded&v=YG0-ukhU1xE
Bronchiolitis Pneumonia Trauma Viral Infection
14
Asthma (RAD)
Airway Red Flags
VocalizationDroolingAbnormal airway soundsPreferred postureUnable to complete sentences or
talk Bleeding
SCENARIO
BREATHING
Breathing Red Flags Increased work of breathing - rate and/or depth
of respirations Retractions Breath sound changes
– decreased air movement from previous assessment– increased rhales or rhonchi
Apnea Asymmetric chest rise and fall Decreasing oxygen saturation/increased O2
requirement Change in LOC or decreased level of
consciousness
CIRCULATION
Pediatric Circulation Cardiac output and oxygen delivery are higher
in children per kg of body weight than adults Oxygen consumption is high Stroke volume is small in children Circulating blood volume is small
-infants 80ml/kg-child 75ml/kg-adolescent 70ml/kg
Circulation Red Flags
Central and peripheral pulse rate and quality Skin color and temperature Capillary refill
Central vs. peripheral Is it <3sec? >5sec?
Bleeding Mental status changes UO <1/kg/hr HYPOTENTION and BRADYCARDIA ARE LATE
SIGNS!
Circulation Red Flags
23
Scenario
NEURO
Neurological Exam
Primary Assessment– ABC’s– Mental status– AVPU, GCS
– Motor and sensory – Reflexes– Cranial nerve function– PERRLA
Neurological Exam
Pediatric considerations Many pediatric patients will not willfully
participate in a complete neurologic exam Make it a game if they are not cooperating
Allow patient to remain with caregiver during exam
Determine baseline developmental status
Glasgow Coma Scale Allows trending of neurologic
assessments Three components
Eye opening (1-4)Best verbal (1-5)Best motor (1-6)
Score ranges from 3-15
Neuro Red Flags Change in LOC or mentation-
AVPU,Glascow Coma Scale Lethargy Visual disturbances Seizure activity Posturing Slurred speech/difficulty finding words Perseverating Balance/walking difficulties Unilateral muscle weakness
REMEMBER THIS MOMENT….
NAT/Non Accidental Trauma Red Flags Family Interactions and Dynamic History – Does the story match the injury Bruising-TEN-4 rule Bruising on Torso, Ears, or Neck in kids <4yo or any bruising
in kids < 4mo.
Fractures in non-ambulating child or unexplained
Undiagnosed healing fracture
Common Signs of NAT & Areas to be concerned…
Legal definitions of child abuse vary across the United States.
Child abuse can broadly be defined as an act, or failure to act, which results in a child's serious harm or risk of harm, including physical or emotional harm, exploitation or death.
Neglect occurs when a caretaker fails to provide for a child's basic needs.
GI/GU
34
GI/Abdomen
• Look• Distension• Vomiting – color, volume
• Listen• All 4 quadrants• Fast, slow, absent
• Feel• Tenderness/pain• Location
GU Red Flags
Urine output< 1/kg/hr Hematuria Cloudy urine Painful urination No urine output reported for several
hours
GI Red Flags
-Abdominal distention-Rigid/tense abdomen-No BM >3days-Pain-Hematochezia
37
Scenario
KEEP IN MIND…Kids are not just small adults!!!
QUESTIONS
American Heart Association. Pediatric Advanced Life Saving. First American Heart Association Printing. 2011.
Print.
“Croup”. Mayo Clinic. Web. 20 November 2015.
Emergency Nurses Association. Trauma Nursing Core Course. 2006. Print
Hazinski, Mary. Manual of Pediatric Critical Care. St. Louis. Mosby Inc. 1999. Print.
Parks SE, Annest JL, Hill HA, Karch DL. Pediatric Abusive Head Trauma: Recommended Definitions for Public
Health Surveillance and Research. Atlanta (GA): Centers for Disease Control and Prevention; 2012
“Pertussis”. Centers for Disease Control and Prevention. Web. 20 November 2015.
References