Infants Part I (1 Hour)

The Pediatric Assessment Triangle is a structure for assessing the pediatric patient that focuses on the most valuable information for pediatric patients and is used to ascertain if any life-threatening condition exists.  The components of the Pediatric Assessment Triangle are Appearance, Work of Breathing, and Circulation.  Let’s look at each component individually:

• Appearance – We look at the mental status and muscle tone of the child
• Assess level of consciousness (LOC) with the AVPU pneumonic (Alert, Alert to Verbal Stimuli, Alert to Painful Stimuli, Unresponsive)
• Assess muscle tone by looking at the infant (hypotonia).  An infant is said to have low muscle tone if the infant appears limp.  Infants should be able to move their extremities and neck (usually not capable of supporting their own head weight at this point, however movement is possible.
• Is the infant consolable?  If the infant can be comforted by the parent or caregiver, then the patient is consolable.  If the infant cannot be consoled by the parent or caregiver, then the infant is inconsolable.
• The infant should be able to maintain eye contact for a period of time. 
• The infant should be able to cry loudly.
• Work of breathing – Assess respiratory rate and assess for distressed breathing.
• Assess for ‘see saw’ breathing.  ‘See saw’ breathing is observed when the patient’s chest and abdomen are moving opposite to one another.  Generally, infants will breathe with their abdomen as their muscular development is limited at this stage. 
• Assess for use of accessory muscles.  Look at the chest wall and see if you can see the muscles under the ribs.  Intercostal retractions are the result of respiratory distress that causes a change in the intrathoracic pressure (pressure in the chest wall) causing the skin to literally be sucked onto the ribs.   Along the same lines is nasal flaring.  Nasal flaring is seen when the nares are opened as wide as possible to promote better air flow.
• Assess for adventious breath sounds.  Breathing by design is supposed to be a quiet process.  Anything other than quiet is adventious.  The noise you hear determines the problem you are dealing with. 
• Grunting: Grunting is a sign of distress that is caused by a variety of reasons.  Grunting can be an indication of reflux, pain, fever, a cardiac or respiratory problem.  If you hear grunting respirations, be sure to look for signs that can lead you to the root of the problem. 
• Stridor: Stridor is a high pitched sound produced during expiration.  Stridor is always the result of an upper respiratory tract obstruction of some point and can be caused by a foreign body airway obstruction, thermal injury or trauma to the upper airway, croup, or epiglottis
• Wheezing: Wheezing is high pitched sound produced during inspiration and/or expiration that are caused by obstructions in the lower airways.  Sometimes you can hear wheezing from the door as you make entry.  You should always listen to breath sounds in all the lung fields when any patient (any age) complains of respiratory distress.  Wheezing in the infant may be asthma or bronchiolitis.  If wheezing is heard in only one area of the lungs, foreign body airway obstruction may also be the culprit.
• Crackles or rales: Crackles or rales are breath sounds produced by the alveoli when they pop open after being collapsed with fluid.  The distinctive sound sounds a lot like Rice Crispies when they are covered with milk.  Crackles or rales can be caused by a variety of conditions, but you should think pneumonia with infants (especially when combined with a fever or history of a fever).  Bronchitis is another cause of crackles in infants (with or without a fever).
• Rhonchi: Rhonchi are offensive noises that sound like snoring inside the lung fields.  The lower airways are partially obstructed with secretions.  The patient will probably cough or have a history of a productive cough (green sputum). 
• Coughing: Coughing is a forced reflex action designed to force secretions, irritants, or other offensive matter out of the upper respiratory tract.  The forceful exhalation of air removes the items from the respiratory tract.
• Circulation – 
  • Skin Color: Look for skin signs like mottling and the overall skin color of the patient.  When looking at skin color, always keep in mind that Caucasians will turn blue while African Americans will turn gray or ashy.
  • Heart Rate: Assess the pulse at the brachial.  Depending upon the age (in months) the rate can be anywhere between 108 and 178 (ballpark, you know the drill).  Be sure to assess the pulse for weakness or threadiness.
  • Capillary Refill Time (CRT): Lightly squeeze a fingertip or toe tip until the color under the nail changes.  Observe the return of the nail bed and count (in seconds) the time it takes for the nail bed to return to its normal color.  It shouldn’t take more than 3 seconds for the nail to return to the normal color, if it does, the CRT is considered prolonged.