TIPS AND TOOLS FOR PEDIATRIC

ASSESSMENT
Children Are Not Just Little Adults
• Children can compensate physiologically longer than adults; however, their status can deteriorate much faster and
with little warning, but also get well faster. Children’s metabolic and cardiovascular systems respond quickly to
maintain homeostasis; however, the younger the child, the less reserve is available. Therefore, the margin for error
in assessment and treatment is narrower than an adult.
• A child’s response to stress is different than that of an adult as the response is related to the developmental level of
the child, previous experiences to stress and how they cope with anxiety (generally have less inner resources).
Illness generally affects the response to stress more acutely in children than in the adult patient.
• Children are inseparable from their family and significant others in terms of assessment and management of the
problem.
• Fear and pain can be two of the greatest barriers to the willingness of the child to be assessed. Communication with
the child can be difficult as they may have less ability to understand and less experience with hospitals and illness
than an adult. However, on the other hand, do not underestimate the child’s ability to comprehend and try to
include them in conversation, i.e. try to include them in the decisions and give them choices when appropriate.
• Equipment used to assess and monitor the child must be related to the child’s size in order to ensure accuracy, i.e.
BP cuffs, oxygen masks, O2 Sat probes, etc.
• Nutritional Needs - The child has less body stores of carbohydrates, fats and proteins than an adult and are
therefore depleted faster. Carbohydrates stores are depleted first then protein and fat are used causing massive
tissue wasting and weight loss.

SYSTEM DIFFERENCE CLINICAL SIGNIFICANCE NURSING INTERVENTION

VITAL SIGNS -higher heart and respiratory -smaller quantitative changes -obtain VS with child at rest as
rates, lower B/P may be more significant fear, stress, pain etc. may affect
findings

-weight considered a “fifth” VS -medications calculated -weigh all children on admission

according to weight (kgs) and as ordered

TEMPERATURE -the younger the child the less -hypothermia may occur rapidly, -keep infants warm
REGULATION stable the temperature- leading to acidosis, hypoxemia,
regulating mechanism and hypoglycemia

Adapted from BC Children’s Hospital 7th Floor Student Learning Guide by R. Houweling, RN, CNE; January 2019
 SYSTEM DIFFERENCE CLINICAL SIGNIFICANCE NURSING INTERVENTION

-larger surface to volume ratio -heat loss through convection, -control environment and keep
evaporation, conduction infants warm, especially during
procedures where they are
-more susceptible to heat loss d/t
uncovered for a long time (i.e. LP,
 surface area relative to size
assessments)

-infants younger than 6 months -breaking down fat requires -keep infants warm; observe
cannot shiver (they break down energy, which  oxygen infants who are uncovered for
fat to conserve heat) consumption procedures for signs of
respiratory distress (give Oxygen
prior to, i.e. LP’s)

CARDIO- -infant heart is less compliant -therefore depend on  heart -monitor all sources of blood
VASCULAR and less able to  stroke volume rate to maintain adequate CO loss, including phlebotomy
to maintain cardiac output (CO),
-because stroke volume depends
blood volume larger per unit
on heart rate, a  in stroke
body weight but absolute blood
volume due to loss in blood
volume remains relatively small
volume  heart rate in an
attempt to compensate

-child has less blood volume than -even a small blood loss in a child -monitor any amount of bleeding
an adult can be significant carefully

-immature baroreceptors -poor ability to compensate for -normal BP unreliable

hypotension assessment parameter in infants

-heart is very sensitive to vagal -can become bradycardic easily

stimulation

-less muscular left ventricular - radial pulse not always palpable -always take apical heart rates
wall in infants & young children (until
about 6 yo)

-heart rhythm varies more in -sinus arrhythmia is normal

children than adults during infancy and throughout
childhood (heart rate  with
inspiration &  with expiration)

-less than 8 yo, the heart is -the apical pulse is at the 3rd to
proportionately larger. 4th intercostal space and lateral
to the left midclavicular line

Adapted from BC Children’s Hospital 7th Floor Student Learning Guide by R. Houweling, RN, CNE; January 2019
 SYSTEM DIFFERENCE CLINICAL SIGNIFICANCE NURSING INTERVENTION

ELECTROLYTE -more total body water (a larger -rapid dehydration from fluid loss -monitor intake and output;
BALANCE portion is extracellular), adult is through vomiting, diarrhea,  frequently assess for signs of
about 60% while a child is 70- intake, hemorrhage dehydration if vomiting &/or
80% diarrhea occurs

-higher metabolic rate and -higher daily fluid requirement -individualize fluid administration
per kg of body weight (although according to calculated
greater insensible and
the absolute amount of fluid requirements; control all fluids
evaporative water losses
required is small) through the use of IV pump;
monitor intake and output in
cc/kg/hr

HEAD AND -head is larger in proportion to -children most often fall head -suspect head injury in any young
NECK torso; center of gravity is shifted first, resulting in a higher % of child who has fallen or been
toward center head injuries thrown; observe for symptoms

-skull is not rigid in infants (up to -head injury may be present -take careful head circumference
18 months); bones are softer and without fracture; skull expansion measurements on all children
more pliable, can expand may occur to accommodate  younger than 2 years; monitor
fontanelles & at suture lines intracranial pressure or tumor anterior fontanel for bulging
growth

-sinuses (except ethmoid) -facial bones more resistant to -in facial trauma, observe for
underdeveloped injury; severe direct trauma injury to underlying structures
necessary to produce fracture even if fracture not present

-greater % of blood in head -heavy bleeding may come from -observe for signs of
scalp lacerations hypovolemia, especially in infants
younger than 1 year

-eustachian tubes shorter and -children are prone to ear -teach parents about anatomy
straighter infections because of easy and related risk factors, such as
entrance of bacteria through infant drinking bottle lying down
eustachian tubes

-muscle support of neck weak -hyperextension or hyperflexion -teach families that shaking
can cause respiratory/airway babies can cause severe damage
problems, cervical fractures or or death; support the heads of
bleeding infants

-cricoid cartilage narrowest -cuffed ET tubes in children -ensure that cuffed ET tubes are
portion of infant’s trachea younger than 8 years can not used in children younger
damage trachea than 8 years

Adapted from BC Children’s Hospital 7th Floor Student Learning Guide by R. Houweling, RN, CNE; January 2019
 SYSTEM DIFFERENCE CLINICAL SIGNIFICANCE NURSING INTERVENTION

-auto regulation of cerebral -blood flow is pressure

blood flow is impaired in sick dependent &  pressure can lead
newborns to intraventricular hemorrhage

IMMUNE -immature -more prone to infections (i.e. -isolation

SYSTEM viral respiratory)
-hand washing

RESPIRATORY -infants breathe through nose for -nasal obstruction can cause -keep nares cleared of secretions,
first 2-4 months of life respiratory distress mucous, vomitus, be aware of
N/G tube, phototherapy
eyepatches etc.

-airways smaller in diameter and -small amounts of -observe for distress in children
have  resistance secretions/edema can cause with asthma or bronchiolitis
major airway obstruction

-thorax more pliable -rib cage and sternum resist -observe trauma victims closely
fracture but provide little even if no external injury is
protection to heart and lungs; apparent
injuries can cause contusions and
laceration of heart or lungs

-lungs have fewer alveoli until 8 -tendency for small airways to -observe children with asthma
yo collapse & become hypoxic faster for rapid onset of distress

-intercostal muscles poorly -with  lung compliance and  -observe for “see-saw”
developed therefore use intrathoracic pressure during abdominal breathing and
diaphragm for respirations inspiration, chest wall moves in retraction, which indicates 
instead of out respiratory effort and distress

-tongue is large for mouth size -obstruction risk  -observe position of neck &
airway

-airways lack strong cartilaginous -hyperextension & hyperflexion -observe position of neck &
support (&  neck muscle can cause problems in provide additional support
development in infants) maintaining an open airway
(especially with infants)

-oxygen consumption is greater -less oxygen reserves when in -clump stressful activities
due to  basal metabolic rate difficulty together
(generally, lungs are less
-ensure adequate rest times & 
effective & efficient d/t
stimulation
immaturity)

Adapted from BC Children’s Hospital 7th Floor Student Learning Guide by R. Houweling, RN, CNE; January 2019
 SYSTEM DIFFERENCE CLINICAL SIGNIFICANCE NURSING INTERVENTION

GASTRO- -food remains in stomach a

shorter time than adults
INTESTINAL
SYSTEM & -length of small intestine is -an infant secrets proportionately -monitor carefully for signs of
ABDOMEN proportionately greater than an more fluids & electrolytes into dehydration & electrolyte
adult but supplied with an adults the intestine than an adult imbalances
proportion of functional
secretory glands per unit of area

-small intestine has larger surface -if an infant has diarrhea, more -replace diarrhea loses with
for absorption relative to body electrolytes are lost from electrolyte solutions (i.e.
size intestinal secretions Pedialyte)

-monitor carefully for signs of

dehydration & electrolyte
imbalances

-infants large intestine is -accounts for more frequent & -careful care of skin & more
proportionately shorter than an softer stools in infancy frequent diaper changes
adult

-liver (proportionately larger & -severe internal injury may result -observe trauma victims for signs
may extend 1cm below right from blunt trauma of injury to internal organs
costal margin) and spleen larger
and have poor muscle protection

-underdeveloped abdominal wall -children are more ticklish & -wait for child to exhale to
makes palpation easier than an tense than adults palpate abdomen
adult

GENITO- -kidneys are proportionately

larger than an adult
URINARY
SYSTEM -bladder in an infant is behind
the middle of the symphysis
pubica (by 3 yo, the bladder will
have descended into the pelvis,
assuming the adult position)

-kidneys are functionally -this affects child's ability to -specific gravity may be
immature for first 12 months control fluid volume, i.e. affects unreliable indicator of hydration
(less effective & efficient) ability to handle sodium, status until after infant is 3
concentrate and dilute urine and months old
to acidify urine

Adapted from BC Children’s Hospital 7th Floor Student Learning Guide by R. Houweling, RN, CNE; January 2019
 SYSTEM DIFFERENCE CLINICAL SIGNIFICANCE NURSING INTERVENTION

-total body water content is 20% -  risk of acidosis, hypoglycemia, -monitor carefully for signs of
higher in newborns hyponatremia, and dehydration dehydration & electrolyte
imbalances

NERVOUS -central nervous system -reflexes present in adults may -know normal neurological
SYSTEM immature in young children be absent normally in children; findings and how to elicit them in
reflexes present in infants may infants and young children
-muscle tone & reflexes are
be absent normally in adults (i.e.
different
a positive Babinski reflex is
normal in a newborn but not an
adult, hypotonia is abnormal &
tremors is normal in infants)

-immature peripheral nerves -unable to evaluate motor co- -prevent falls

ordination

General Approaches to Physical Examination During Childhood

AGE POSITION SEQUENCE PREPARATION

INFANT Before able to sit alone - supine If quiet, auscultate heart, lungs, Keep the parent with child as
or prone (in parents lap abdomen and palpate, percuss much as possible; enlist help
0-18 MONTHS
preferably) the areas, proceed in the usual with restraining during exam
head to toe direction
After able to sit alone - sit in Undress but leave diapers on
parents lap is preferable Perform traumatic procedures and exam diaper area
last (temp, EENT)
If on the stretcher place them Gain cooperation with
in full view of parents Elicit reflexes as the body part is distraction (toys, keys)
examined (Moro last) and for
Smile at infant, use soft, gentle
neurologic exam
voice

Pacify with feeding

Avoid abrupt, jerky, rough

movements

Adapted from BC Children’s Hospital 7th Floor Student Learning Guide by R. Houweling, RN, CNE; January 2019
 AGE POSITION SEQUENCE PREPARATION

TODDLER Sitting on or standing by parent Inspect body area through play If necessary, have parents
(i.e. count fingers) undress child to underwear,
18 MONTHS - Prone or supine in parents lap
remove and exam genitalia last
Establish a rapport with parent
3 YEARS
first, may help to gain child’s Allow the child to inspect &
trust touch equipment,
demonstrate use to child
Use minimal physical contact
initially, talk to child If uncooperative, perform
procedures quickly
Introduce equipment slowly
Enlist parents help with
Perform any traumatic
restraining during exam as
procedures last
necessary
Explain procedures using
Praise for cooperative
appropriate language or
behaviour
parents “special” language

PRESCHOOL CHILD Prefer standing or sitting If cooperative, do head to toe If necessary, request self
undressing and allow to wear
3 - 6 YEARS Usually cooperative prone or If uncooperative, proceed the
underpants if child feels shy,
supine same as with the toddler
use gown
Prefer parents close by in view
Offer equipment for inspection
& demonstrate

Explain procedure in simple,

direct, appropriate language
(i.e. “I am going to listen to
your heart now”

Give choices when possible

Expect cooperation & give

praise for behaviour

SCHOOL AGE Prefer sitting Proceed with head to toe exam If necessary, request self
but examine genitalia last (if undressing and allow to wear
CHILD Cooperative in most positions
cooperative) underpants if child feels shy,
6 - 11 YEARS Younger age prefer parents use gown
Respect need for privacy
presence
Explain procedure, equipment
Older age may need privacy in appropriate language

Teach about body function and

care as appropriate

Adapted from BC Children’s Hospital 7th Floor Student Learning Guide by R. Houweling, RN, CNE; January 2019
 AGE POSITION SEQUENCE PREPARATION

ADOLESCENT Provide choice for position Same as older school age child Allow to undress in private if
necessary
11 - 18 YEARS Offer option of parents
presence Give gown

Older age need privacy and Expose only area to be

confidentiality examined

May require chaperone for Respect need for privacy

physical exam
Explain equipment, exam and
findings in a matter-of-fact way
and emphasize the normalcy of
development

Examine genitalia quickly if

necessary

Pediatric Vital Signs

Adapted from BC Children’s Hospital 7th Floor Student Learning Guide by R. Houweling, RN, CNE; January 2019
 Helpful Calculations to Know
Hourly Maintenance Formula:
CHILD’S WEIGHT kg BODY WEIGHT FORMULA

0-10 kg 4ml/kg/hr

11-20 kg 40ml/hr for 1st 10kg + 2ml/kg/hr for 11-20 kg

21-30 kg 60ml/hr for 1st 20kg + 1ml/kg/hr for 21-30 kg

Daily Maintenance Fluid Requirements:

CHILD’S WEIGHT kg BODY WEIGHT FORMULA

newborn - up to 72 hours old 60-100ml/kg

up to 10kg 100ml/kg (to 150ml/kg if renal & cardiac function adequate)

11-20kg 1000ml for 1st 10kg + 50ml/kg for each kg over 10kg

21-30kg 1500ml for 1st 20kg + 20-25ml/kg for each kg over 20kg

Urine Output: 0.5-2ml/kg/hr

Full Term Baby: Feeding Patterns & Output
DAY OF AGE # OF FEEDS IN 24 HRS LENGTH OF FEEDS # OF STOOLS IN 24 HRS # OF WET DIAPERS IN
24 HRS

ONE some babies “graze” frequently at breast, others are At least one meconium At least one
disinterested

TWO some babies “graze” frequently at breast, others are At least one meconium At least two
disinterested

THREE 8-12 feeds, not Most feeds will be completed At least one transitional At least three
necessarily evenly in <1hr. May have periods of
spaced. cluster feeding.

FOUR 8-12 Same as day three two - yellow/seedy At least four, more
heavily soaked

FIVE 8-12 Same as day three two - yellow/seedy At least five, more
heavily soaked

SIX + 8-12 Same as day three two - yellow/seedy, Six- eight, and will
may become less remain this way for
frequent after six weeks many months

Adapted from BC Children’s Hospital 7th Floor Student Learning Guide by R. Houweling, RN, CNE; January 2019
Pain

Adapted from BC Children’s Hospital 7th Floor Student Learning Guide by R. Houweling, RN, CNE; January 2019
Communication Tips

Adapted from BC Children’s Hospital 7th Floor Student Learning Guide by R. Houweling, RN, CNE; January 2019