OB NURSING 2.30
NURSE ANGIE 2018
Pediatric Assessment
AIRWAY/BREATHING
CIRCULATION
‣ Respiratory rate
‣ Respiratory effort
Air Entry
‣ Adequate
‣ Adventitious breath sounds
Respiratory Distress
‣ Tachypnea
Mechanics of Breathing
‣ Retractions
‣ Tracheal tug
‣ Nasal flaring
‣ Head bobbing
‣ Grunting on exhalation
‣ Prolonged expiratory phase
‣ Diminished air entry
‣ Change in breath sounds
‣ Stridor
‣ Wheezing
Late Signs
‣ Skin color changes - dusky/cyanotic
‣ Inaudible air entry
‣ Apnea/irregular respiration
‣ Changes in LOC/activity
‣ Bradycardia
‣ Warmth of skin
Heart Rate
‣ Regularity/rhythm/rate
Pulses
‣ Strength and regularity
‣ Central vs. peripheral
Perfusion
‣ Capillary refill
‣ Skin Color (e.g. pale, mottled)
Cardiovascular Collapse
‣ Tachycardia
‣ Altered perfusion
Skin
‣ Prolonged capillary refill > 2 seconds
‣ Increased core to skin temperature gradient
Brain
‣ Altered LOC/activity
‣ Decreased response, “worried” appearance
Kidneys
‣ Decreased urinary output <1ml/kg/hr
‣ Decrease in pulse quality
Late signs
‣ Decreased response to pain
‣ Flaccid tone
‣ Hypotension
‣ Bradycardia
NEUROLOGICAL
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LOC
Mental status, interaction
Activity, movement, muscle tone
Age appropriate responses
GI/GU
‣ Bowel sounds
‣ Appetite
‣ Bowel movement
‣ Emesis
Hydration Status
‣ Urine output
‣ Moist oral mucosa
‣ Skin turgor
‣ Fontanelle
VITAL SIGNS
Newborn
‣ Resp: 30 - 50
‣ Heart: 120 - 160
Infant (1-12 months)
‣ Resp: 20 - 30
‣ heart: 80 - 140
Toddler (1-3 yrs.)
‣ Resp: 20 - 30
‣ Heart: 80 - 130
Preschooler (3-5 yrs.)
‣ Resp: 20 - 30
‣ Heart: 80 - 120
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