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Nursing

Paediatric Physical Assessment

Basic Head to Toe Assessment

Airway / Breathing

  • Respiratory rate
  • Respiratory effort
  • Air entry
    • adequate
    • adventitious breath sounds

Circulation

  • Warmth of skin
  • Heart rate
    • regularity/rhythm/rate
  • Pulses
    • strength and regularity
    • central vs. peripheral
  • Perfusion
    • capillary refill
    • skin color (e.g. pale, mottled)

Neurological

  • Level of consciousness
  • Mental status, interaction
  • Activity, movement, muscle tone
  • Age appropriate responses

GI/GU

  • Bowel sounds
  • Appetite
  • Bowel movementEmesis
  • Hydration status
    • Urine output
    • Moist oral mucosa
    • Skin Turgor
    • Fontanelle

Warning Signs

Red Flags of 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/cynotic
  • Inaudible air entry
  • Apnea/irregular respiration
  • Changes in level of consciousness/activity
  • Bradycardia

Red Flags of Cardiovascular Collapse

  • Tachycardia
  • Altered perfusion
  • Skin
    • Prolonged capillary refill > 2 sec
    • Increased core to skin temperature gradient
  • Brain
    • Altered level of consciousness/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