Peds, part 4: Principles - Pediatric Assessment, Vital Signs, and Pain
by Meris Shuwarger BSN, RN, CEN, TCRN December 15, 2021 Updated: June 16, 2022 12 min read
In this article, we discuss some of the key components of a pediatric assessment.
The Pediatric Nursing series follows along with our Pediatric Nursing Flashcards, which are intended to help nurses and nursing students learn and retain information about caring for pediatric patients. The flashcards are a clear, complete study tool and a helpful reference for practicing RNs, PNs, and other medical professionals.
Components of a pediatric assessment
From general appraisal to pain assessment, many of the elements of a pediatric assessment are the same as for an assessment of an adult patient.
A general appraisal is a general survey to observe the child’s appearance and behavior, assess for signs of abuse. How does the child look? What is their state of hygiene? How are they dressed? Etc.
These are the same sorts of observations for a general appraisal of an adult.
The difference between obtaining this information for a child and an adult is that it will come from a discussion with the caregiver and not the child, although that may change as the child gets older.
Additional information that pertains to the child’s health history includes a family history, any medications the child is taking, and the child’s personal health history.
Another child-specific thing to know includes assessing their birth history. Were they born prematurely? If so, how premature? Did they spend time in the NICU? Did they have any sort of birth trauma? All of those things are important to know because it can change what we expect to see and what we might need to delve into further.
The child’s immunization status should be recorded. Are there any immunizations that they haven’t received? Are they behind on any and need catching up?
Order of vital signs
The order of vital signs is especially important in very small children because they get agitated easily and may start to cry, which may affect their other vital signs.
First, count the respirations before even touching the child. This should keep them calm (they are most likely hanging out with a parent or a caregiver).
Next, measure their apical heart rate.
Then, if indicated, take the child’s blood pressure. Note that this is not always indicated for children, so it is not something to do routinely. Only take a child’s blood pressure reading if necessary.
Last, take the child’s temperature. Small children, especially infants, often make a big fuss when their temperature is taken. For example, when a probe is placed underneath their arm, they might start screaming.
It is important to use the age-appropriate scale when making this assessment. These scales are discussed in the next section below.
Physical growth and development
There are many measurements to take when it comes to assessing a child’s physical growth and development.
- Length or height: these are the same, but are called “length” when a child cannot stand upright and “height” when they can
- Head circumference: a measurement typically made of younger children (to ensure proper development)
- Assessment of fine and gross motor skills
When collecting anthropometric data (data pertaining to the physical body), plot those measurements on a proper growth chart. Use the correct graph/chart — there are different ones for boys and girls, for different diseases as well as charts based on ethnicity.
When charting anthropometric data, remember that what matters is the trend, not any specific number. A child who is in the 15th percentile for height and the 20th percentile for weight should remain in those approximate ranges as they develop. A drastic change up or down might indicate an issue that needs to be explored and, potentially, diagnosed. For a child who charts at less than the 5th percentile or greater than the 95th percentile needs further investigation. It doesn’t necessarily mean something is wrong with them; just that further investigation should be made to ensure everything is okay.
In addition to the child’s physical growth, ask questions about other developmental skills, for example, the number of words that they know. Do they do certain things? Do they smile at you? Do they make eye contact, etc.?
Assess the child's ability to communicate (vocabulary, gestures), and take note of the way they think as well as their problem-solving skills.
Assess how the child plays, including their temperament, and communication skills (with other children, adults, etc.).
Expected vital signs for infants versus children
When it comes to expected vital signs, infants have slightly different vital signs than older children, who have slightly different vital signs than adults.
Ideal temperature ranges are the same for both infants and children. 97.4 to 99.6 degrees Fahrenheit, 36.3 to 37.6 degrees Celsius.
In infants, the normal pulse range is 100 to 160 beats a minute, which is very fast. (If an adult had a heart rate of 160 beats per minute, they could need cardioversion, a medical procedure that restores a normal heart rhythm in people with certain types of abnormal heartbeats). For older children, their range is a little bit lower — 70 to 120 beats per minute — but still higher than for adults.
Respirations of infants are expected to be 30 to 60 breaths per minute; in children, 20 to 30 breaths per minute.
In infants, the systolic blood pressure is 65 to 90, and the diastolic blood pressure is 45 to 65. This is normal for an infant. (If an adult patient had an extremely low pressure of 65 over 45, this could indicate something serious, like hypotension).
The normal range of blood pressure in a child is: systolic, 90 to 110; diastolic, 55 to 75.
Remember: pulse and respirations are faster in children than in adults. Blood pressure is lower in children than in adults.
Pediatric pain scales
It’s easy to ask an adult to rate their pain on a scale of 0 to 10, because adults have the ability to think in abstractions. Adults can think in terms of describing pain as a numeric form. A child cannot do this, and an infant certainly can’t. To assess a child’s pain, we have adapted different scales that pertain to the child’s stage of development and/or age range.
CRIES pain scale
The CRIES scale is for neonates, preterm, and full-term newborns. Because babies cry, it is the quickest/simplest way to assess the potential cause of their crying.
CRIES is an acronym: Crying, Requires O2, Increased vital signs, Expression, Sleepless. Each of these is a variable scored on a scale of 0 – 2 (e.g., Crying: 0 = Not Crying; 1 = High Pitched; 2 = Inconsolable).
FLACC pain scale
The FLACC scale is for children ages 2 months to 7 years.
FLACC stands for Face, Legs, Activity, Cry, and Consolability. Like the CRIES scale, this set of variables is scored on a scale of 0 – 2.
FACES pain scale
The FACES scale is most common for children ages 3 and older.
It uses six drawings of faces to help the patient rate their pain on a scale of 0 to 5.
Oucher pain scale
The Oucher scale is for children ages 3 to 13. It is similar to the FACES scale but uses photographs to help them rate their pain on a scale of 0 to 10.
Numeric pain scale
The numeric pain scale is one most adults are used to; anyone over 8 can use the numeric scale. Patients report their pain level rated on a scale of 0 to 10. 0 is no pain, 10 is the worst pain they’ve ever experienced.
Remember, turning pain into a number is a logical, abstract way of thinking. Small children are not going to be able to do that. Hence these various scales and systems.
For a more in-depth look at assessments, our Health Assessment Flashcards are designed to help both nursing students, or nurses transitioning roles, to master the flow and sequence of a head-to-toe patient assessment and to retain details of expected and abnormal results.
Hi, I'm Meris with Level Up RN, and in this video, I'm going to be talking to you about some key components of pediatric assessment. I'm going to be following along using our pediatric nursing flashcards, which are available on our website, leveluprn.com, if you want to grab a set of your own, which I highly recommend. And if you already have your own deck, I would invite you to follow along with me. All right, let's go ahead and get started.
So, first up, we're going to be talking about some key components of pediatric assessments. Now, for the most part, a lot of things are going to be the same. You're going to do a general appraisal, right? You're going to do your general survey where you look at how the child looks and appears and what their hygiene is and what kind of clothes they're dressed in, all of that stuff, same as I would do for an adult. I'm also going to be assessing their health history. Obviously, the difference here being I'm probably going to be talking to the caregivers and not to the child themselves, although that may change when they get older. But I'm going to be asking things about their family history, medications that they take, personal health history. But other things that I may be asking about a child versus an adult would be about their birth history as well. Were they born prematurely? If so, how premature? Did they spend time in the NICU? Did they have any sort of birth trauma? All of those things are important for us to know about a child because it can change what we expect to see and what we might need to delve into further for the child now.
Now, other things that we may need to know are going to be their immunization status, right? We're going to ask adults this too, but it's important for us to know where a child is in their immunization status. Are there any that they haven't received? Are there any that they are behind on? Do we need to catch up? That sort of a thing. Now, one thing that I do want to point out here on this list is - third on this list on this card - is the order of vital signs. This is especially important when we're thinking about very small children because they get agitated easily and start to cry. And when they cry, their other vital signs can be affected. So, first off, we want to count the respirations before we ever touch the child, right? When they're nice and calm and they're hanging out with Mom or Dad or a caregiver, we're going to count their respirations first. Then we're going to do the apical heart rate, and then, if indicated, we're going to do a blood pressure. This is not always indicated for children. This is not something that we're going to do routinely; only if we have a reason to be doing it. And then, lastly, we're going to do temperature. If you've ever taken care of small, small children, infants, they lose their minds when you take their temperature. You put that probe underneath their arm and they start screaming. So that is something that we are going to do last, for sure.
Now, pain assessment we're going to talk about in a minute, but we need to make sure we're using the age-appropriate scale. And then, when it comes to their physical growth and development, we're going to measure a bunch of different things. First, of course, we're going to measure their length or their height. It's the same thing, but we call it length when a child cannot stand upright. It is height when they now are able to stand upright. So same measurement, different word. We're going to measure their weight and their head circumference. Again, this is typically for younger children. We're not going to do that for older ones, but we are going to do that for the younger ones. We're going to assess their fine and gross motor skills. And we typically are going to ask questions about other developmental skills as well, like the number of words that they might know. Do they do certain things? Do they smile at you? Do they make eye contact? All of those things will be assessed as well. And along with their cognitive status and their psychosocial development, we're going to assess all of that.
Now, when it comes to anthropometric data, which means the data of the physical body, right - the height, the weight, the head circumference - all of those things are going to be plotted onto a graph, but it's important to remember to use the correct graph, right? There's one for boys, for girls, for different diseases, right? If we know that a child has a certain condition, we need to plot them on the correct graph for that condition. And there's also charts based on ethnicity as well. Now, the thing that matters most is not the specific number but rather, the trend. So if my child is in the 15th percentile for height and the 20th percentile for weight, that's cool. We just want to see, are they staying in those same kind of ranges, plus or minus a little bit? Or are they suddenly dropping drastically or going up drastically in that percentile? But there are two things that we do need to assess further. A child who is less than the 5th percentile or greater than the 95th percentile needs further investigation. Doesn't necessarily mean something is wrong with them; just that we need to investigate further to make sure everything is okay.
All right. Moving on, we're going to talk about expected vital signs. So on here, we have this very nice chart for you. We have the vital sign, infants and children here, because infants have slightly different vital signs than children who have slightly different vital signs than adults, so it's important to know each. Temperature, luckily, it's the same for both 97.4 to 99.6 degrees Fahrenheit, or 36.3 to 37.6 degrees Celsius. Now, in infants, the normal pulse range is 100 to 160 beats a minute. That is very fast. If an adult had a heart rate of 160 beats per minute, we'd be thinking that they need cardioversion, right? Very, very important to know they are expected to be much higher. Children, though, their range is a little bit lower than that. They're going to be 70 to 120 beats per minute. Still higher than adults, right? Respirations of infants are expected to be 30 to 60 breaths per minute, whereas in children, it's 20 to 30 breaths per minute.
And lastly, blood pressure. In infants, the systolic blood pressure - and you're going to think I'm wrong - the systolic blood pressure is 65 to 90 and the diastolic blood pressure is 45 to 65. If I had an adult patient with a pressure of 65 over 45, I would be absolutely panicking, right? But this is normal for an infant. Now, when we're talking about the blood pressure of a child, systolic, 90 to 110 is the normal range, diastolic, 55 to 75. So we do have a nice key point here to help you remember. Pulse and respirations are faster in children versus adults, but blood pressure is lower, so everything is going to be elevated, except for blood pressure is going to be lower, right?
Lastly, we're talking about pain assessment. It's very easy for me to ask you as an adult to rate your pain from 0 to 10. Right. We have that sort of abstract thinking. We can think in terms of putting my pain into a numeric form. A child can't, and an infant certainly can't, right? So we have had to adapt to different ways to assess a child's pain. We have a bunch of different scales for you. I'm going to hit some of the major ones here. The cries scale; well, easy to remember who this is for. It's for neonates, preterm and full term. Who cries newborns, right? Neonates, they cry. So that's the cry scale. The FLACC scale. FLACC, that stands for face, legs, activity, cry, and consolability. So who is that for? It's for two months to seven years of age.
Now, the faces scale. This is the one that I personally have seen the most in my clinical practice when we're talking about children. This is the faces scale. This is six drawings of faces to rate pain from a scale of 0 to 5. But this is used for anyone who is greater than or equal to three years old. They can use those faces scale. Oucher is for 3 to 13, and then the numeric pain scale, what we are used to. Tell me about your pain: 0 being no pain, 10 being the worst thing you've ever experienced. That's numeric pain scale, and that is for children greater than or equal to eight years old. Personally, I would be using that more for older children as well who have that ability of abstract thinking. I myself would say probably 11 years, but per the terms of the scale, anyone over 8 can use that scale. But just remember, turning pain into a number is a really logical, abstract sort of way of thinking. Little kids are not going to be able to do that. All right. I hope that review was helpful for you. Stay tuned because I have some quiz questions for you to test your knowledge of some key facts I provided in this video.
Okay, so, first up, which vital sign should the nurse obtain first when assessing an infant? What is the first vital sign to obtain? Next up, I want you to tell me which of the following - select all that apply - which of the following vital signs are out of normal limits for an infant? Okay. BP 72 over 50, respirations, 25 breaths per minute temperature, 99.5 degrees Fahrenheit, pulse, 158 beats per minute. Which of those are outside of the normal limits for an infant? All right. Moving on, after which age is the faces pain scale appropriate to use? When can we use the faces pain scale? Let me know how you did. I can't wait to hear. Thanks so much, and happy studying.
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