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Nursing

Signs of Deterioration


Airway / Breathing

Early Signs and Symptoms

  • Tachypnea (increased respiratory rate)
  • Retractions - in the child this is due to a soft compliant chest wall, horizontally placed ribs and poorly developed intercostal muscles

Late Signs and Symptoms

  • Tachypnea with increased effort- will lead to bradypnea when fatigued or the inability to maintain own airway (e.g. evidenced by gasping)
  • Diminished breath sounds

Arrest

  • Gasping, ineffective breathing or no respiratory effort

Circulation

Early Signs and Symptoms

  • Tachycardia (increased heart rate) - this is an early sign of cardiovascular compromise
  • Pale and cool extremities
  • Normal blood pressure
  • Oliguria - this occurs when the kidneys are not adequately perfused.  The child produces <1mL/kg/hr of urine

Late Signs and Symptoms

  • Cyanosis
  • Mottled and/or poorly perfused skin
  • Cyanosed mucous membranes - mouth and nipples may be the best place to observe cyanosis in children with dark skin
  • Hypotensive - low blood pressure is a late sign; 20-25% of blood loss may occur before hypotension develops

Arrest

  • Bradycardia - low heart rate is a late sign of cardiovascular compromise
  • Weak thready pulse with poor perfusion
  • Arrhythmia
  • Asystole (no cardiac contractions)

CNS

Early Signs and Symptoms

  • Assess for changes in Level of Consciousness (LOC) including:
    • Irritability
    • Restlessness
    • Lethargy

Late Signs and Symptoms

  • Stupor - due to decreased brain perfusion

Arrest

  • Unresponsive
  • Flaccid
  • Tonic posturing