Pneumonia: Examination (Pediatric Nursing)

by Paula Ruedebusch

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    00:00 So this is a pediatric assessment triangle.

    00:03 It's a rapid assessment technique.

    00:05 And it's an objective tool that clinicians can use to aid in their respiratory assessment.

    00:09 There are 3 components and using this tool, the clinician should be able to just scan the room, look at the child, and in about 30 seconds or less decide how sick this child is regarding their respiratory status.

    00:21 You can use this tool throughout your management of a patient to see if they're improving or actually deteriorating.

    00:27 The acronym TICLS, pronounced "tickles," is sometimes used by emergency medical providers to remember the components of the appearance item.

    00:37 Regarding the child's appearance, the clinician's going to look at the patient for, first, their tone.

    00:42 Look at their muscle tone.

    00:43 Is this a limp child? Is this child rigid? Are they laying on the exam table? Are they running around the room eating goldfish crackers? What's sort of the activity and the appearance of this child? Is it a sick child or a non-sick child? Normally, infants are going to have good muscle tone.

    01:00 They're going to stay in a flexed position, and they should want to resist your attempts to straighten their limbs.

    01:05 It's concerning when a baby is not able to resist.

    01:11 There are variations on the theme for the letter I.

    01:13 It's either interactiveness or level of irritability.

    01:17 So, normally, a child is able to interact with caregivers and staff based on age-appropriate milestones.

    01:23 It would be abnormal if the child is not interactive or engaged with their caregivers or their surrounding activities.

    01:30 The C stands for consolability.

    01:33 Normally, a child can be comforted by its usual caregivers and the child is acting like themselves in regard to environmental stimuli.

    01:41 An abnormal presentation would be the child cannot be consoled or comforted by their usual caregivers, and the parents will tell you this.

    01:49 They will say, you know, "Normally, my child is in a great mood.

    01:52 Normally, I pick them up and I do this or that and they stop crying, and they just won't stop crying," and that's a concerning sign.

    01:58 The child doesn't respond normally to their environmental stimuli and their preferred toys and they're just not acting like themselves.

    02:06 The L stands for the look or the gaze.

    02:09 So, normally, depending on the child's age, they should be able to make really good eye contact and maintain that eye contact.

    02:15 Abnormally, the patient's going to have a vacant stare.

    02:19 They're not going to maintain eye contact, and it kind of looks like these kids have checked out.

    02:23 They might not recognize their normal caregivers, and they may just look out of it.

    02:28 And the final component of the appearance section is the speech or cry.

    02:32 Normally, a child will use age-appropriate verbal communication.

    02:36 And when speech and crying are normal, this also lets the provider know that the child has a patent and clear airway.

    02:43 Abnormally, the child will be unable to use their age-appropriate communications, or their speech or cry is absent or abnormal, and this raises a huge concern for an occluded airway or an altered mental status.

    02:56 The next component of the pediatric assessment triangle is the work of breathing.

    03:01 The first part of that involves looking for nasal flaring.

    03:04 Nasal flaring is a compensatory system that increases the upper airway diameter to decrease the resistance of airflow through the nose.

    03:11 This is where the patient increases the air that can move through their nostrils.

    03:16 Next, you can assess the work of breathing by looking for retractions, and this is under the patient gown and under the shirt.

    03:21 You're looking right at their skin.

    03:23 Retractions are a sign that someone is working really hard to breathe.

    03:27 Normally, when you take in a breath, the diaphragm and the muscles around your ribs create a vacuum that will pull that air into your lungs.

    03:34 But if a person is having trouble breathing, they will involve these extra accessory muscles and the muscles between their ribs to kick in and try to help.

    03:43 Next, you'll assess the patient's work of breathing by looking at their posturing.

    03:47 Just look at your patient.

    03:49 Are they propped up in an abnormal position to breathe? Are they in a tripod position trying to open their chest? What is the patient's position of comfort? Do they have difficulty breathing if they lay flat on their back? If so, you can always raise the head of their bed.

    04:04 Next, you're going to listen to the breath sounds.

    04:07 Look for abnormal sounds.

    04:08 Is there any wheezing? Do you hear crackles, rales, stridor, or any cough? Circulation's next and that's measured by skin color and capillary refill.

    04:20 Those are great indicators of perfusion in children.

    04:23 So capillary refill is defined as the time taken for the color to return to an external capillary bed after pressure's applied.

    04:30 So, basically, you press on the distal extremity, you let go, and you count and see how long it takes for that blood to reperfuse.

    04:37 You'll next look for pallor.

    04:39 Pallor is associated with early stages of hypoxia, and occurs as a result of the peripheral vasoconstriction.

    04:46 This means your patient looks pale.

    04:49 The skin can become mottled, which is another sign of compromised perfusion.

    04:54 It indicates abnormal capillary tone, and this skin will have a speckled, lacy look.

    05:00 Perhaps your patient has blue cyanotic coloring because of low oxygen levels in the blood.

    05:05 The peripheral blood vessels are going to vasoconstrict and this is going to decrease the hemoglobin causing a bluish hue to the skin and the mucous membranes.

    05:14 It's most easily seen around the mouth and in the oral mucosa.

    05:17 And this is perioral cyanosis.

    05:21 These indicators of poor perfusion might be your only clues to intervene with your patient.

    05:27 These can be the early signs that your patient is experiencing shock.

    05:32 The clinician should review the health history completely to evaluate for any underlying cardiac or pulmonary disease, immune deficiencies, neuromuscular disorders, or any other high risk conditions.

    05:44 The clinician should also ask maybe the child had access to a foreign body aspiration or ingestion of toxic substances.

    05:51 These also need to be excluded.

    05:54 The physical exam starts next, and this begins with an overall assessment of the child's well-being and identification of obvious signs of hypoxia and dehydration.

    06:04 You're going to check a younger child, especially, for a toxic appearance.

    06:08 And this is basically if a lay person looked at this child, would they say, "Wow, that child looks really sick," or does this child appear okay pretty well? Next, look for tachypnea, which is an increased respiratory rate.

    06:21 Check the vital signs to look for their temperature.

    06:23 Observe for retractions.

    06:25 Listen for grunting, and look at the chest wall for the use of accessory muscles.

    06:30 The upper respiratory tract should also be examined for evidence of otitis media, which is ear infections, rhinorrhea, which is a runny nose, nasal obstruction, and swelling or redness in the throat.

    06:44 The most common causes of pneumonia are also common causes of infection in the upper respiratory tract, so this can help the clinician solidify a diagnosis.

    06:54 Next, on exam you'll look at physical signs, such as heart murmurs or nail clubbing, which can suggest an underlying cardiac or pulmonary disease.

    07:04 Next, you do the full assessment.

    07:06 You do a full respiratory exam, including inspection, palpation, percussion, and auscultation.

    07:13 Now, older children and adults are more likely to have findings that are abnormal on their respiratory exam such as rales, dullness to percussion, bronchial breath sounds, changes in their tactile fremitus, and maybe a pleural rub.

    07:27 Careful auscultation with an appropriate sized stethoscope can reveal a lot of clues and localize rales and wheezing in younger children.

    07:35 So, remember, your stethoscope is going to have 2 sides.

    07:37 An adult-sized diaphragm and bell and a pediatric-sized diaphragm and bell.

    07:41 This is when it's important to use the appropriate sized stethoscope.

    07:46 So, children with dehydration may not have any abnormal auscultatory findings.

    07:50 And this is really important because classically, when these kids present, they're really sick with their pneumonia.

    07:55 They haven't been drinking well.

    07:57 They're not tolerating PO.

    07:58 They're not thirsty, and they can easily become dehydrated.

    08:01 And so, when the clinician listens to the lungs, they may sound okay.

    08:06 It's only when you hydrate these children and actually fluff up their pneumonia, that you can actually hear a difference.

    08:11 So be sure that you're listening to a child who is hydrated and if they're not hydrated, get them hydrated before you make the decision on whether or not they have pneumonia.

    About the Lecture

    The lecture Pneumonia: Examination (Pediatric Nursing) by Paula Ruedebusch is from the course Respiratory Disorders – Pediatric Nursing.

    Included Quiz Questions

    1. Tone
    2. Interactiveness
    3. Consolability
    4. Look and gaze
    5. Height and weight
    1. Nasal flaring
    2. Retractions
    3. Posturing
    4. Breath sounds
    5. Speech and cry
    1. Mottling
    2. Jaundice
    3. Cyanosis
    4. Pallor
    1. Inspection
    2. Palpation
    3. Percussion
    4. Auscultation
    5. Retraction

    Author of lecture Pneumonia: Examination (Pediatric Nursing)

     Paula Ruedebusch

    Paula Ruedebusch

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