Pediatric Assessment. High Stress Situation l Child l In pain l Frightened l Guilty.
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Transcript of Pediatric Assessment. High Stress Situation l Child l In pain l Frightened l Guilty.
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Pediatric AssessmentPediatric Assessment
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High Stress SituationHigh Stress Situation
Child In pain Frightened Guilty
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High Stress SituationHigh Stress Situation
Parent Frightened Guilty Exhausted
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High Stress SituationHigh Stress Situation
Paramedic Frightened May over-empathize
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High Stress SituationHigh Stress Situation
Who has to control situation?
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Basic PointsBasic Points
Oxygenation, ventilation adequate to preserve life, CNS function?
Cardiac output sufficient to sustain life, CNS function?
Oxygenation, ventilation, cardiac output likely to deteriorate before reaching hospital?
C-spine protected? Major fractures immobilized?
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Basic PointsBasic Points
If invasive procedure considered, do benefits outweigh risks?
If parent is not accompanying child, is history adequate?
Transport expeditiously Reassess, Reassess, Reassess
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Patient AssessmentPatient Assessment
Priorities are similar to adult Greater emphasis on airway,
breathing
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Patient AssessmentPatient Assessment
Limit to essentials Look before you touch
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Pediatric Assessment Triangle:Pediatric Assessment Triangle:First ImpressionFirst Impression
Appearance - mental status, body position, tone
Breathing - visible movement, effort
Circulation - color
Appearance B
reathingCirculation
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Pediatric Assessment TrianglePediatric Assessment TriangleInitial AssessmentInitial Assessment
Appearance - AVPU Breathing - airway
open, effort, sounds, rate, central color
Circulation - pulse rate/strength, skin color/temp, cap refill, BP ( use at early ages)
Appearance B
reathingCirculation
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Initial AssessmentInitial Assessment
Categorize as: Stable Potential Respiratory Failure or Shock Definite Respiratory Failure or Shock Cardiopulmonary Failure
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Initial AssessmentInitial Assessment
Identify, correct life threats If not correctable,
Support oxygenation, ventilation, perfusion
Transport
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Vital SignsVital Signs
Essential elements Proper equipment Knowledge of norms
Carry chart of norms for reference
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WeightWeight
Why is weight a pedi vital sign? (Age[yrs] x 2) + 8
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Heart RateHeart Rate
Apical auscultation Peripheral palpation Tachycardia may result from:
Fear Pain Fever
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Heart RateHeart Rate
Tachycardia + Quiet, non-febrile patient = Decrease in cardiac output Heart rate rises long before BP falls!
Bradycardia + Sick child = Premorbid state Child < 60 Infant <80
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Blood PressureBlood Pressure
Proper cuff size Width = 2/3 length of upper arm Bladder encircles arm without overlap
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Blood PressureBlood Pressure
Children >1 year old Systolic BP = (Age x 2) + 80
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Blood PressureBlood Pressure
Hypotension = Late sign of shock Evaluate perfusion using:
Level of consciousness Pulse rate Skin color, temperature Capillary refill
Do not delay transport to get BP
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RespirationsRespirations
Before touching For one full minute Approximate upper limit of normal =
(40 - Age[yrs])
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RespirationsRespirations
> 60/min = Danger!! Slow = Danger, impending arrest Rapid, unlabored
Metabolic acidosis Shock
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Capillary RefillCapillary Refill
Check base of thumb, heel Normal < 2 seconds Increase suggests poor perfusion Increases long before BP begins to fall Cold exposure may falsely elevate
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TemperatureTemperature
Cold = Pediatric Patient’s Enemy!!! Large surface:volume ratio Rapid heat loss
Normal = 370C (98.60F) Do not delay transport to obtain
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TemperatureTemperature
Measurement: Axillary Hold in skin fold 2 to 3 minutes Normal = 97.60F Depends on peripheral
vasoconstriction/dilation
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TemperatureTemperature
Measurement: Oral Glass thermometers not advised May be attempted with school-aged
children
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TemperatureTemperature
Measurement: Rectal Lubricated thermometer 4cm in rectum, 1 - 2 minutes Do not attempt if child
Is < 2 months old Is struggling
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Physical ExamPhysical Exam
Do not delay transport for full secondary survey
Children under school age: go toe to head Examine areas of greatest interest first
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Physical ExamPhysical Exam
After exposing during primary survey, cover child to avoid
hypothermia!
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Physical Exam: Special PointsPhysical Exam: Special Points
Head Anterior fontanel
Remains open until 12 to 18 months Sinks in volume depletion Bulges with increased ICP
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Physical Exam: Special PointsPhysical Exam: Special Points
Chest Transmitted breath sounds Listen over mid-axillary lines
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Physical Exam: Special PointsPhysical Exam: Special Points
Neurologic Eye contact Recognition of parents Silence is NOT golden!
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HistoryHistory
Best source depends on child’s age Do not underestimate child’s ability
as historian Imagination may interfere with facts Parents may have to fill gaps, correct
time frames
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HistoryHistory
Brief, relevant Allergies Medications Past medical history Last oral intake Events leading to call Specifics of present illness
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HistoryHistory
On scene observations important Do not judge/accuse parent Do not delay transport
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General Assessment ConceptsGeneral Assessment Concepts
Children not little adults Do not forget parents Do not forget to talk to child Avoid separating children, parents
unless parent out of control
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General Assessment ConceptsGeneral Assessment Concepts
Children understand more than they express Watch non-verbal messages Get down on child’s level Develop, maintain eye contact Tell child your name Show respect Be honest
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General Assessment ConceptsGeneral Assessment Concepts
Kids do not like: Noise Cold places Strange equipment
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General Assessment ConceptsGeneral Assessment Concepts
In emergency do not waste time in interest of rapport
Do not underestimate child’s ability to hurt you
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Developmental StagesDevelopmental Stages
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NeonatesNeonates
Gestational age affects early development
Normal reflexive behavior present Sucking Grasp Startle response
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NeonatesNeonates
Mother, father can usually quiet Knows parents, but others OK Keep warm Use pacifier, finger Have child lie on mother’s lap
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NeonatesNeonates
Common Problems Respiratory distress Vomiting, diarrhea Volume depletion Jaundice Become hypothermic easily
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Young Infants (1 - 6 months)Young Infants (1 - 6 months)
Follows movement of others Recognizes faces, smiles Muscular control develops:
Head to tail Center to periphery
Examine toe to head
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Young Infants (1 - 6 months)Young Infants (1 - 6 months)
Parents important Usually will accept strangers Have lie on mom’s lap Keep warm Use pacifier or bottle
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Young Infants (1 - 6 months)Young Infants (1 - 6 months)
Common problems Vomiting, diarrhea Volume depletion Meningitis SIDS Child abuse
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Older Infants (6 - 12 months)Older Infants (6 - 12 months)
May stand, walk with help Active, alert Explores world with mouth
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Older Infants (6 - 12 months)Older Infants (6 - 12 months)
Intense stranger anxiety Fear of lying on back Assure parent’s presence Examine in parent’s arms if possible Examine toe to head
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Older Infants (6 - 12 months)Older Infants (6 - 12 months) Common problems
Febrile seizures Vomiting, diarrhea Volume depletion Croup Bronchiolitis
MeningitisForeign bodiesIngestionsChild abuse
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Toddlers (1 - 3 years)Toddlers (1 - 3 years)
Excellent gross motor development Up, on, under everything Runs, walks, always moving Actively explores environment Receptive language
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Toddlers (1 - 3 years)Toddlers (1 - 3 years)
Dislike strange people, situations Strong assertiveness Temper tantrums
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Toddlers (1 - 3 years)Toddlers (1 - 3 years)
Examine on parent’s lap, if possible Talk to, “examine” parent first Examine toe to head Logic will not work Set rules, explain what will happen,
restrain, get it done
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Toddlers (1 - 3 years)Toddlers (1 - 3 years)
Common problems Trauma Febrile seizures Ingestions Foreign bodies
Meningitis Croup Child abuse
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Preschoolers (3 - 5 years)Preschoolers (3 - 5 years)
Increasing gross, fine motor development
Increasing receptive, expressive language skills
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Preschoolers (3 - 5 years)Preschoolers (3 - 5 years)
Totally subjective world view Do not separate fantasy, reality Think “magically” Intense fear of pain, disfigurement,
blood loss
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Preschoolers (3 - 5 years)Preschoolers (3 - 5 years)
Take history from child first Cover wounds quickly Assure covered areas are still there Let them help Be truthful Examine toe to head
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Preschoolers (3 - 5 years)Preschoolers (3 - 5 years) Common problems
Trauma Drowning Asthma Croup Meningitis
Febrile seizures Ingestions Foreign bodies Child abuse
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School Age (6 - 12 years)School Age (6 - 12 years)
Able to use concepts, abstractions Master environment through
information Able to make compromises, think
objectively
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School Age (6 - 12 years)School Age (6 - 12 years)
Give child responsibility for history Explain what is happening Be honest
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School Age (6 - 12 years)School Age (6 - 12 years)
Common problems Trauma Drowning Child abuse Asthma
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AdolescentsAdolescents
Wide variation in development Seeking self-determination Peer group acceptance can be critical Very acute body image Fragile self-esteem
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AdolescentsAdolescents
Reassure, but talk to them like adult Respect need for modesty Focus on patient, not parent Tell truth Honor commitments
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AdolescentsAdolescents
Common problems Trauma Asthma Drugs/alcohol Suicidal gestures Sexual abuse Pregnancy