| Assessment Type | Findings |
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| First assess ABCs (airway, breathing, circulation) and then perform relevant portions of the assessment based on the child’s condition and known or suspected diagnosis | Expected findings in black font; pathological findings and possible indications in red font |
| Airway/Oxygenation* |
| * Also see “O2 saturation” under Circulation |
| Observe patency of airway | - Airway patent and free of foreign body and excess mucus
- Airway impaired by foreign body, mucus, inflammation, or bronchospasm; note that smoke inhalation may cause inflammation
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| Listen | - Respirations quiet
- Audible wheezes may indicate bronchospasm, bronchiolitis, or foreign body in airway; wheezes should be recorded as inspiratory or expiratory or biphasic (both)
- Expiratory grunt indicates an effort to increase end-expiratory pressure in order to keep alveoli expanded and to increase alveolar gas exchange
- No pursed-lip breathing
- Older children may purse lips during expiration in an attempt to keep the airway open for a longer period
- No stridor
- Acute inspiratory stridor (a grating or crowing sound) is a sign of upper airway obstruction; above the glottis—usually croup
- Chronic inspiratory stridor is a sign of laryngomalacia—a congenital abnormality in which the laryngeal soft tissue collapses
- Expiratory stridor is a sign of obstruction in the lower trachea
- Biphasic stridor may indicate swelling in the cricoid cartilage that surrounds the trachea
- Drooling may indicate airway obstruction
- Restlessness is an EARLY sign of air hunger
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Smell
Assess trauma or burn victims for smoky odor to breath | - No smoky odor to breath
- Smoky odor to breath may indicate smoke inhalation and indicates the need to observe for delayed airway swelling
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| Breathing |
| Observe rate, rhythm, and effort | - Respiratory rate even with rate appropriate for age (see respiratory rate table)
- Irregular respiratory rate or apnea may indicate airway obstruction, pain, or neurological abnormality
- Note that periodic breathing (no breathing for 15–20 seconds) is common in young infants and is not known to be associated with pathology
- No soft tissue retractions or flaring of nostrils
- Soft tissue retractions, head bobbing, or flaring of the nostrils indicate increased work of breathing; retractions may be one or more of the following types:
- Intercostal (between ribs)
- Subcostal (under ribs)
- Suprasternal (above sternum)
- Substernal (under sternum)
- Supraclavicular (above clavicle)
- Shallow respirations may indicate fatigue and need for assisted ventilation; this may occur in infant with RSV infection
|
Auscultate lungs, all lobes; anterior and posterior
Right middle lobe is auscultated in the right axilla | - Bronchial sounds are loud and high-pitched hollow sounds that are heard over the upper anterior chest
- Bronchovesicular sounds are softer tubular sounds heard in the anterior central chest and between the scapula in the posterior chest
- Vesicular sounds are soft blowing sounds heard throughout peripheral lung fields
- Adventitious sounds (abnormal) heard with auscultation may indicate foreign body or mucus in airway, bronchiolitis, asthma, pneumonia, or other pathology; child may have more than one type of adventitious sound such as the following:
- Rales: Crackling sound; common in pneumonia
- Rhonchi: Coarse sounds; often clear with coughing
- Wheezing, musical, or sibilant rales: Whistling sounds; common with asthma and bronchiolitis
Note that when mucus has collected in the pharynx or upper airway, a loud rhonchi-like sound may be transmitted and heard throughout the lung fields during auscultation; place the stethoscope on the child’s neck to determine whether this has happened; finding an indication of mucus in the upper airway does not eliminate the possibility of lung pathology; it is possible for a child to have both excess mucus in the upper airway AND lung pathology; adventitious sounds caused only by mucus in the upper airway will clear when the child coughs |
| Observe activity and feeding | - Child active, playing, or interacting appropriately with environment and eating well
- In infants, decreased oxygenation may result in hunger and irritability due to short periods of frequent feeding that are interrupted by the need to rest
- Older child may lean forward in “tripod position” during shortness of breath; this position lessens pressure on diaphragm and maximizes chest expansion
|
| Circulation |
| Auscultate apical pulse for rate, rhythm, and abnormal sounds | - Apical pulse has regular rhythm, and rate is appropriate for age (see Heart and Respiratory Rate by Age Category)
- Note that child’s heart rate and rhythm will vary with respiratory effort
- No murmur heard
- A murmur is a blowing sound that is heard between “lub” and “dup” (systolic murmur) or between “dup” and “lub” (diastolic murmur); murmurs indicate turbulent blood flow or movement of blood under increased pressure; see grading of murmurs
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| Palpate peripheral pulses and perfusion | |
| Observe O2 saturation (pulse oximetry) if indicated | - O2 saturation = 95% or above
- O2 saturation of less than 95% indicates decreased oxygenation of tissue
- Note: A pulse oximeter indicates the amount of hemoglobin that is saturated with oxygen; thus, an anemic child may have a “false high” O2 saturation because it takes less oxygen to saturate less hemoglobin
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| Measure blood pressure (BP) | |
| Temperature |
| Measure using age appropriate method and device | - Temperature appropriate for assessment site:
- Oral temperature is near 98.6°F or 37°C in most children
- Ear or rectal temperature is near 99.6°F; axillary temperature near 97.6°F
- Note that small, premature infants normally have little variation in temp based on assessment site
- Elevated temperature may indicate infection
- In a newborn or young infant, a subnormal body or an elevated temperature and poor feeding are important indicators of sepsis
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| Lymph Nodes |
| Palpate with fingertips, using a circular motion | - Lymph nodes are nonpalpable (see figure for location of lymph nodes)
- Lymph nodes that are enlarged, tender, and mobile are signs of infection
- Lymph nodes that are nontender and nonmobile may be attached to an underlying tumor
- Small, 1- to 2-mm size nodes that are nontender are common in young children; referred to as “shotty” nodes and thought to be indicators of past infection
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| Neurological Status |
| Observe behavior and test reflexes | - Behavior and reflex responses appropriate for stimuli
|
| Test using Glasgow Coma Scale if child has a neurological injury | |
| Perform tests for meningeal irritation (meningitis is an example) if child is febrile and diagnosis has not been established | |
- Flex neck to move the head forward
| - Neck moves without pain, stiffness, or flexion of the legs
|
- Flex the hip and knee, then, attempt passive extension of the knee
| |
| Mouth and Pharynx |
| Observe | - Mucous membranes pink without lesions
- White coating that cannot be removed from tongue or mucous membranes may indicate thrush, a candidal infection that is common in children who are immunosuppressed or who are taking antibiotics
- Mucosal ulcers may indicate immunosuppression, autoimmune disease, or viral infection
- Pharynx pink without exudate or swelling of pharynx or tonsils
- Pharyngeal or tonsillar redness, exudate, or enlargement may indicate viral or bacterial infection
|
| Skin |
Observe for skin temperature and hydration
If abdomen is distended, check skin turgor in another body area such as over sternum or over tibia | - Skin warm and slightly moist
- Skin has elastic turgor
- Skin recoils slowly or “tents” when lightly pinched, indicating dehydration
- Note: Because of a large body surface area, young children rapidly become dehydrated
- Taut, shining skin indicates swelling or edema that my be caused by excess IV fluid, kidney malfunction, or heart failure
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| Observe skin for irritation, breakdown, lesions, and pressure areas; include diaper area inspection in children who are not toilet-trained | - Skin is intact and free of lesions, including diaper area
- If reddened areas or skin breakdown is observed, note and record size, characteristics, and number of lesions as well as distribution (see Skin Lesion table)
- Notes:
- Ill children are prone to have diaper dermatitis—always assess for this
- Children who have been taking antibiotics have an increased risk for a candidal diaper rash; this rash often appears beefy red with satellite lesions
- Irritation or pressure areas may form when a child is on bed rest, in one position, for extended periods of time, or when tape or equipment is in constant contact with skin; children with edema or swelling and those who are being treated with topical steroids are at higher risk for skin breakdown
- Pustules with honey-colored crust are characteristic of impetigo, a common skin infection that is highly contagious
- A sandpaper-like rash on the trunk is characteristic of scarlet fever or scarlatina; caused by strep pharyngitis
- Desquamation (peeling) of skin on palms of hands, feet, and diaper area may occur after Kawasaki disease or strep infection
- Circular lesions with central clearing are characteristic of tinea, or ringworm, which is caused by a fungus
- Roseola is a common viral condition that occurs in children ages 6 mo to 3 yr; the child has high fever and possibly a mild upper respiratory illness (URI) and cervical lymphadenopathy for several days, followed by lower or normal temperature and a macular or papular pinkish-red rash that begins on the trunk and may spread over the entire body; the rash blanches when pressure is applied, and individual spots may appear to be surrounded by halos
|
| Abdomen |
| Observe | - Abdomen flat without visible peristalsis
- Abdominal distention may indicate obstruction, heart failure, internal bleeding, or gastrointestinal infection
- Visible peristalsis may indicate obstruction
- An olive-shaped mass in the upper abdomen, accompanied by vomiting, may indicate pyloric stenosis
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| Auscultate | - Bowel sounds heard in four quadrants
- Hyperactive or absent bowel sounds may indicate infection or obstruction
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| Palpate abdomen for masses | - No palpable masses
- Palpable mass; record location and approximate palpable size
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| Palpate liver | - Edge of liver may be palpable below right costal margin (RCM)
- Liver more than 2 cm below RCM may indicate heart failure, hepatitis, biliary atresia, and other illnesses
|
| Palpate spleen | - Spleen usually not palpable
- Spleen that is palpable in left upper quadrant may occur in a child with infectious mononucleosis (as part of the lymphatic system) or in a child with sickle cell anemia (as an organ that removes defective red blood cells)
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Perform scratch test
- Used to estimate size of the liver or spleen, the scratch test is a useful alternative to abdominal percussion
- Use one hand to place stethoscope over the organ (liver or spleen) while using the index finger of the opposite hand to make light scratching movements over the organ; move stethoscope toward each edge of the organ while continuing scratching motion near the stethoscope
| - A dull sound is heard over the organ and a hollow sound beyond the edges of the organ; see previous palpation assessment findings for comments on organ size
- Note that a full bowel may distort test sounds
|
| Extremities |
| Palpate each extremity for warmth and mobility while assessing for pain | - All extremities pink, warm, and mobile without painful movement
- Limited movement may occur with cerebral palsy (see Cerebral Palsy) or with the formation of contractures following trauma
- Pain in joints may indicate Lyme disease, rheumatoid arthritis, infection, or rheumatic fever, which is an autoimmune reaction to a strep infection
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| Observe, following treatments and procedures, to be certain that no tourniquets or inappropriate restraints have been left on any extremity and no needles or syringes have been left in the bed | No tourniquets, nonessential restraints, or other nonessential medical devices left in the child’s bed
Note: When more than one attempt has been made to start an IV, a forgotten tourniquet may be inadvertently left on an extremity or small medical devices (such as needles or caps) may be hidden under sheets or other bedding |
| Observe and palpate extremities for evidence of fracture after suspected or validated traumatic injury | - No report of pain when extremities are palpated
- No swelling, false motion (movement at a point where there is normally no motion), or obvious deformity of extremities
- No crepitation (grating or popping sound)
- Peripheral pulses strong
- Pain, deformity, swelling, false motion, or crepitation may occur with fracture (see Types of Fractures for illustration of fracture types)
|
| Elimination |
| Observe and record time, size, color, and consistency of stools and recent frequency of bowel elimination | - Stools brown and soft
- Red blood-tinged stools indicate bleeding from lower gastrointestinal (GI) tract or rectal area
- Note: Cranberry-colored stools should be guaiac-tested for blood; consumption of red gelatin may cause cranberry-colored stools in child with diarrhea
- Black stools may indicate GI bleeding (from upper GI tract) or may be caused by supplemental iron intake
- Pale stools may indicate liver pathology
- Fatty stools (steatorrhea) may indicate high-fat diet, celiac disease, or cystic fibrosis
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| Observe color and frequency of urination | - Urine pale yellow with at least four urine voidings per day
- Dark urine in a child most often indicates dehydration
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| Measure urine specific gravity (s.g.) if indicated (especially if child has had vomiting or diarrhea or has been without fluid intake for longer than usual) | - Urine s.g. of 1.002–1.028
- Urine s.g. that is higher than 1.023 and that does not decrease in response to conservative treatment (oral fluids) may indicate need for intravenous fluids
- High urine s.g. may indicate contamination or high urine glucose content
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| Secretions/Drainage |
| Observe and record amount, color, and consistency of nasal mucus secretions and sputum | - Mucus is scant and clear
- Profuse amounts of clear mucus secretions may indicate irritation and/or allergy
- Bloody mucus or sputum may indicate trauma, infection, or a bleeding disorder
- Green or yellow mucus may indicate infection
- Note that respiratory tract mucus may be slightly yellow during a viral infection but that prolonged yellow or green secretions generally indicate a bacterial infection; viral infections may predispose to bacterial infections
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| Observe drainage from wounds or lesions | - Wound or lesion drainage is serous (pale yellow and thin) or serosanguineous (a mixture of serous and bloody secretions)
- Dark yellow or greenish wound or lesion drainage may indicate bacterial infection
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| Appetite and Activity |
| Observe intake | - Child eating, sleeping, playing, and showing interest in surroundings
- Failure to eat, sleep, play, or show an interest indicates illness and may precede changes in vital signs
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| Environment, Equipment, and Medical Devices |
| Observe environment for safety hazards, including possible need for bubble-top crib | - Side rails up without indication that child may climb out of crib
- Infants and toddlers who are able to pull to a standing position may be able to climb over crib rails and should be placed in a bubble top bed if they will be left unattended
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| Observe bedding and immediate area for bottles, cups, medications, tubing, tourniquets, needles, needle caps, writing pens, paper, etc., that may have been accidently left in child’s bed | - No unsafe objects in child’s bed or within reach
- No excess linens in bed
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| Observe appearance, function, and readings of medical devices in room | - Monitors indicate that vital signs are appropriate for age and condition
- Feeding tube properly placed and secured
- GI contents can be aspirated from nasogastric (NG) tube, or small quantity of air forced into tube can be heard or palpated over gastric area
- Note: Before each feeding, check back of infant’s mouth where NG tube can be regurgitated and displaced
- IV delivering prescribed fluids at prescribed rate
- No swelling or redness at IV site
- Foley catheter draining clear pale yellow urine
- Oxygen and respiratory devices operating at prescribed settings
- Suction equipment operational and clean
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