NUR 425 Pediatrics Exam 1
Infant VS (1-12 mo) - answerHR awake: 100-180
HR sleeping: 75-160
RR: 30-60
hypotension systolic: <70
Toddler VS (1-3 years) - answerHR awake: 100-150
HR sleeping: 75-150
RR: 24-40
hypotension systolic: <70 + (2 x age in years)
Preschool VS (3-6 years) - answerHR awake: 60-150
HR sleeping: 60-90
RR: 22-34
hypotension systolic: <70 + (2 x age in yrs)
School age VS (6-10 years) - answerHR awake: 60-110
HR sleeping: 60-90
RR: 18-30
hypotension systolic: < 70 + (2 x age in yrs)
Pre-teen/Teenager VS (>10 yrs) - answerHR awake: 50-110
HR sleeping: 50-90
RR: 12-16
hypotension systolic: <90
Pediatric Assessment Triangle - answer1. appearance: tone, interactiveness,
consolability, look/gaze, speech/cry
2. work of breathing: abnormal breath sounds, abnormal positioning, retractions, nasal
flaring
3. circulation to the skin: pallor, mottling, cyanosis
if any of the three are off, nurse should reassess
Assessments and communication for infant (up to 12 mo) - answer1. development:
dependent on parent, will look to parents for security and reacts to parent anxiety
2. exam: interview parents, least invasive first
3. position: before 4-6 mo: can be on table make sure parent is in view; after 6 mo: best
in parent arms or laying on parent lap (parent active part of exam, asses parent
attachment)
,4. sequence: if quiet, auscultate heart, lungs, abdomen; perform traumatic procedures
last (eyes, ears, mouth)
stranger anxiety will set in around 6 mo
Assessment and communication for toddlers (1-3 yrs) - answer1. development: utilizes
parent as safety, but begins to explore in sight of parent
2. interview: interview with parent, some anxiety to new faces, begin communication
with child based on their vocab
3. position: best to begin in parent arms or lap; assess on parent first and then child
4. sequence: warm child up to you first (toys, play), let them touch equipment before
use, first attempt to auscultate heart lung abdomen, invasive assessments last, may
cooperate well at first due to curiosity
Assessment and communication for preschoolers (3-5 yrs) - answer1. development:
increasing exploring; intentional limit pushing
2. interview: interview with parent, some anxiety to new faces, begin communication
with child based on their vocab, if timid try averting eye contact
3. position: child may want to begin on parents lap or holding hand, assess on parent
first then child
4. sequence: use play and toys to become acquainted and non-threatening; inspect
body through counting fingers with minimal contact; introduce equipment through play
(let them feel/touch equipment), auscultate ASAP
Assessment and communication for school age (5-12 yrs) - answer1. development:
seeking autonomy; exploring (self exploration/stimulation common); still prefers parent
close
2. interview: include child in interview/subjective info; the kids like to answer questions
about themselves
3. position: sitting alone
4. sequence: head to toe assessment; examine genitalia last
Assessment and communication for adolescent (12-18 yrs) - answer1. development:
autonomy important
, 2. interview: let patient speak for themselves; clarify questions at the end; allow parents
to add at the end
3. positioning: sitting/alone; may want parent to leave the room during physical
assessment
4. sequence: head to toe assessment; genital area last
confidentiality unless safety is a concern
Infant response to pain - answer-body response (generalized to location)
-loud crying
-facial expression
-physical resistance
Young child response to pain - answer-loud crying, screaming
-verbal expression
-thrashing arms and legs
-lack of cooperation
-clings to other (parents, nurses)
-behaviors begin in anticipation of pain
School-age response to pain - answer-same as young child during the painful episode
but not so in anticipation
-stalling behaviors to avoid pain
-muscular rigidity
Adolescent response to pain - answer-less vocal and motor response
-more verbal expression
-increase muscle tension and body control
Behavioral pain scale (FLACC) - answer-used for children three and below
-can also be used for non-verbal, developmentally delayed, intubated/sedated, sleepy
children
Self Report Scales: - answer1. Wong-Baker FACES pain scale: used for ages 3-9;
when describing #10, do not say "is it the worst pain you've ever had"
2. numerical rating scale: used for ages 9 and above
Care for pain in children - answer-pain is 5th vital sign
-know when and how to use the different pain scales
-don't delay pain management
-non pharm methods used in conjunction with pharm methods if pain
-if no pain or short term pain, nonpharm methods can be used alone
-medication combination is beneficial based on time effectiveness
Infant VS (1-12 mo) - answerHR awake: 100-180
HR sleeping: 75-160
RR: 30-60
hypotension systolic: <70
Toddler VS (1-3 years) - answerHR awake: 100-150
HR sleeping: 75-150
RR: 24-40
hypotension systolic: <70 + (2 x age in years)
Preschool VS (3-6 years) - answerHR awake: 60-150
HR sleeping: 60-90
RR: 22-34
hypotension systolic: <70 + (2 x age in yrs)
School age VS (6-10 years) - answerHR awake: 60-110
HR sleeping: 60-90
RR: 18-30
hypotension systolic: < 70 + (2 x age in yrs)
Pre-teen/Teenager VS (>10 yrs) - answerHR awake: 50-110
HR sleeping: 50-90
RR: 12-16
hypotension systolic: <90
Pediatric Assessment Triangle - answer1. appearance: tone, interactiveness,
consolability, look/gaze, speech/cry
2. work of breathing: abnormal breath sounds, abnormal positioning, retractions, nasal
flaring
3. circulation to the skin: pallor, mottling, cyanosis
if any of the three are off, nurse should reassess
Assessments and communication for infant (up to 12 mo) - answer1. development:
dependent on parent, will look to parents for security and reacts to parent anxiety
2. exam: interview parents, least invasive first
3. position: before 4-6 mo: can be on table make sure parent is in view; after 6 mo: best
in parent arms or laying on parent lap (parent active part of exam, asses parent
attachment)
,4. sequence: if quiet, auscultate heart, lungs, abdomen; perform traumatic procedures
last (eyes, ears, mouth)
stranger anxiety will set in around 6 mo
Assessment and communication for toddlers (1-3 yrs) - answer1. development: utilizes
parent as safety, but begins to explore in sight of parent
2. interview: interview with parent, some anxiety to new faces, begin communication
with child based on their vocab
3. position: best to begin in parent arms or lap; assess on parent first and then child
4. sequence: warm child up to you first (toys, play), let them touch equipment before
use, first attempt to auscultate heart lung abdomen, invasive assessments last, may
cooperate well at first due to curiosity
Assessment and communication for preschoolers (3-5 yrs) - answer1. development:
increasing exploring; intentional limit pushing
2. interview: interview with parent, some anxiety to new faces, begin communication
with child based on their vocab, if timid try averting eye contact
3. position: child may want to begin on parents lap or holding hand, assess on parent
first then child
4. sequence: use play and toys to become acquainted and non-threatening; inspect
body through counting fingers with minimal contact; introduce equipment through play
(let them feel/touch equipment), auscultate ASAP
Assessment and communication for school age (5-12 yrs) - answer1. development:
seeking autonomy; exploring (self exploration/stimulation common); still prefers parent
close
2. interview: include child in interview/subjective info; the kids like to answer questions
about themselves
3. position: sitting alone
4. sequence: head to toe assessment; examine genitalia last
Assessment and communication for adolescent (12-18 yrs) - answer1. development:
autonomy important
, 2. interview: let patient speak for themselves; clarify questions at the end; allow parents
to add at the end
3. positioning: sitting/alone; may want parent to leave the room during physical
assessment
4. sequence: head to toe assessment; genital area last
confidentiality unless safety is a concern
Infant response to pain - answer-body response (generalized to location)
-loud crying
-facial expression
-physical resistance
Young child response to pain - answer-loud crying, screaming
-verbal expression
-thrashing arms and legs
-lack of cooperation
-clings to other (parents, nurses)
-behaviors begin in anticipation of pain
School-age response to pain - answer-same as young child during the painful episode
but not so in anticipation
-stalling behaviors to avoid pain
-muscular rigidity
Adolescent response to pain - answer-less vocal and motor response
-more verbal expression
-increase muscle tension and body control
Behavioral pain scale (FLACC) - answer-used for children three and below
-can also be used for non-verbal, developmentally delayed, intubated/sedated, sleepy
children
Self Report Scales: - answer1. Wong-Baker FACES pain scale: used for ages 3-9;
when describing #10, do not say "is it the worst pain you've ever had"
2. numerical rating scale: used for ages 9 and above
Care for pain in children - answer-pain is 5th vital sign
-know when and how to use the different pain scales
-don't delay pain management
-non pharm methods used in conjunction with pharm methods if pain
-if no pain or short term pain, nonpharm methods can be used alone
-medication combination is beneficial based on time effectiveness
