Routine patient assessments are essential competencies for respiratory therapists and medical professionals, predominantly focused on adult patients.
However, neonatal and pediatric assessments require a nuanced approach.
This article delves into the specifics of evaluating younger patients and also provides valuable practice questions to reinforce understanding.
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How to Perform a Neonatal or Pediatric Patient Assessment?
At its core, a patient assessment is a combination of a physical examination and the accumulation of initial patient data. This holds true across all age groups, including infants and children.
Therefore, a typical neonatal or pediatric patient assessment includes the following:
Always start by obtaining and recording the patient’s vital signs, which include body temperature, heart rate, respiratory rate, and blood pressure.
While the methods used for measuring these remain largely consistent across age groups, it’s essential to have age-appropriate equipment, especially for blood pressure cuffs.
Moreover, understanding age-specific normal ranges for vital signs is crucial.
Beyond the numbers, understanding a patient’s feelings and symptoms is invaluable.
This information is typically gleaned from patient accounts or, in the case of younger children, their caregivers.
Unlike quantifiable data, subjective information is inherently qualitative.
Once you’ve gathered all pertinent information, it’s time to recommend treatments. This could span from oxygen therapy to various medications.
Given the sensitive nature of neonatal and pediatric care, it’s essential to engage the patient and their family in decision-making processes, ensuring they understand the rationale behind each recommendation.
Evaluating Patient Progress
After initiating treatment, regular evaluations of the patient’s progress are vital.
This involves not just revisiting vital signs but also gathering updated subjective data to gauge improvement or identify potential setbacks.
Recognizing Adverse Reactions
Closely monitor patients for any undesirable reactions to treatments.
If any adverse effects surface, document them promptly and notify the supervising physician to optimize patient care.
Summary: While the foundational principles of patient assessment remain consistent across age groups, neonates and pediatric patients demand a more nuanced approach. This requires not only a mastery of technique but also an inherent understanding of the age-specific variations that can influence outcomes.
Neonatal and Pediatric Patient Assessment Practice Questions
1. While attending to a neonatal patient in the neonatal intensive care unit (NICU), the respiratory therapist notices that a transcutaneous electrode is affixed to the upper chest of the neonate. What should the therapist do at this time?
The therapist should continue monitoring because the electrode is properly placed.
2. What is the Apgar scale?
It is a standard measurement system that looks for a variety of indications of good health in newborns.
3. During a physical examination of a child’s chest, the respiratory therapist assesses increased tactile fremitus over the patient’s right lower lobe. Which of the following conditions may cause this physical finding?
4. Which of the following is the main physiologic factor responsible for deriving accurate transcutaneous data?
5. What is the normal heart rate for a neonate?
6. The mean blood pressure (MAP) of a 30-week gestation newborn should be at least what?
7. A 12-hour-old infant is experiencing respiratory distress, and the neonatologist orders a heel stick to assess the infant’s oxygenation status. What action should the therapist take at this time?
Inform the physician that the results from this procedure will not provide accurate information about the patient’s oxygenation status.
8. Two pulse oximeters are placed on a newborn. One is on the right wrist and shows a reading of 96% on room air, while the other one is placed on the left foot and shows a reading of 85% on room air. This is suggestive of what?
Significant shunting through a patent (open) ductus arteriosus.
9. A respiratory therapist has been ordered to obtain a blood gas sample from a non-intubated premature baby. After selecting the best site to obtain the sample, what should the RT suggest to ameliorate the pain associated with the procedure?
Give a pacifier dipped in 24% sucrose.
10. Which of the following factors would adversely affect the correlation between arterial puncture measurements and those from a capillary sample?
11. While auscultating a young child’s thorax, the therapist hears bilateral fine crackles. Which of the following conditions can produce these adventitious sounds?
12. Which of the following components compose the history of present illness section of a patient’s medical history?
Aggravating or alleviating factors
13. What is the most common invasive procedure to assess the fetal condition?
15. As the head of a neonate contaminated with meconium emerges at birth, the heart rate monitor indicates 120 beats/minute, and the physician notices that the infant has good muscle tone and a strong respiratory effort. What should the physician do at this time to provide airway care?
Only routine monitoring of respiratory vital signs is needed at this time
16. What is the APGAR score of a newborn with the following assessments: HR 80 bpm; Cyanotic; Grimace; Some flexion; Respiratory Rate 0.
APGAR score of 3
17. What is the main potential problem associated with the premature rupture of membranes?
18. A pregnant woman at 30 weeks of gestation with premature rupture of membranes has been admitted to the hospital with preterm labor. The physician has ordered betamethasone. When does the maximal benefit of antenatal corticosteroid occur to reduce RDS?
After 48 hours
19. Which of the following pieces of information DO NOT represent components of patient history for a new pediatric patient?
20. The respiratory therapist has evaluated a neonate’s oxygenation status to be as follows: PaO2, 40 mm Hg, and SpO2 (oxygen saturation as determined by pulse oximetry), 80%. What should the therapist do at this time?
An FiO2 sufficient to raise the SpO2 to 90% needs to be given.
21. A respiratory therapist notices that an infant presents with irregular areas of dusky skin alternating with areas of pale skin. On the basis of this observation, which of the following conditions should the therapist anticipate this patient is having?
22. While percussing the thorax of a child during a physical examination, the respiratory therapist hears a dull percussion note over the child’s right lung. Which of the following conditions WOULD NOT cause this physical finding?
23. When is surfactant developed?
It is developed at 34 weeks in gestation.
24. What happens if there is not enough surfactant?
It will cause low lung compliance, so the lungs can’t keep the alveoli open, which may cause RDS.
25. What are important questions to ask about a neonate’s history?
The type of delivery, presence of meconium or risks of infection, and whether or not the baby is full term. Also, it would be helpful to ask about the baby’s ability to breathe or cry at birth, as well as their muscle tone.
26. How can you know if a baby has good muscle tone?
If they appear to be somewhat in a ball; you do not want them to appear limp.
27. How often should you do the APGAR scale?
1 and 5 minutes
28. What is a good goal of the APGAR scale?
A score of 7 by 5-10 minutes post birth
29. What should the SpO2 do after birth?
It should increase by 5% each minute for 1st 5 minutes of life.
30. In general, how do neonates breathe?
They are obligate nose breathers and they have rapid shallow breaths to maintain their FRC.
31. What is the breathing pattern of a baby?
Rapid and fast with periods of apnea.
32. What are the breath sounds for neonates?
Bronchovesicular breath sounds that are mostly heard during the expiratory phase.
33. What kind of suction would you use for babies?
Bulb suction for the mouth and nose.
34. What is the larynx like in a pediatric airway?
It has a forward tilt.
35. What is the most narrow spot in a pediatric airway?
The glottis, which is narrow from coracoid cartilage.
36. What are babies’ blood pressures like at birth?
They usually start out being hypotensive.
37. When does blood pressure normalize in pediatric patients?
After 10 years, it will be the same as adults.
38. What are common respiratory issues in pediatrics?
Cough, runny nose, ear pain, sore throat, fever, and sputum production.
39. What are the common symptoms of respiratory issues in pediatrics?
Wheezing, SOB, chest pain/tightness, lethargy, irritability, unresponsiveness, and stridor.
40. What are the signs of respiratory distress in pediatrics?
Grunting, retractions, nasal flaring, tachypnea, cyanosis, abdominal breathing, head bobbing, and respiratory distress.
41. What are some good questions to think about when doing a pediatric assessment?
Gather their history, chief complaint, nutritional status, breathing issues, and family, social, or environmental history.
42. What do we not do that is normally part of a physical assessment with babies?
Palpation, as we should not assess for vocal fremitus.
43. With a pediatric physical assessment, what should you look for on inspection?
Scoliosis, retractions, pectus carinatum (pigeon chest), and pectus excavatum (sunken chest).
44. With a pediatric physical assessment, what should you look for during palpation?
45. With a pediatric physical assessment, what should you look for during percussion?
If resonant, this is normal; if hyperresonant, there is air trapping and possibly a pneumothorax;
if dull, it’s atelectasis; and if there is consolidation, there may be a pleural effusion.
46. With a pediatric physical assessment, what should you look for during auscultation?
Listen to see if they are clear, or they may exhibit crackles, rhonchi, stridor, or fine crackles.
47. What is the most frequent blood test performed in newborn infants?
The blood glucose test is frequently performed because hypoglycemia can damage the developing brain just as much as hypoxia.
48. What are the causes of hypoglycemia in an infant?
Infection, hyperinsulinemia, and low glycogen stores.
49. What is the fundamental difference between newborn and adult PFT?
Their ability to cooperate.
50. What PFT volumes can be measured easily in newborns independent of their cooperation?
(1) Their FRC (by closed system helium dilution or closed system nitrogen wash out), (2) Their thoracic gas volumes (TGV) (requires the use of plethysmography and measures all the gas in the thoracic cavity), and their crying vital capacity (done by measuring the tidal volume while the infant is crying); the infant should be able to cry vigorously.
51. What type of x-ray films are most often used on infants?
AP films and lateral chest films
52. What are the indications for an infant chest x-ray?
Unexplained tachypnea, cyanosis, abnormal breath sounds, malformation of the chest or airway, sick appearance, and mechanically ventilated infants.
53. Why is the airway assessment of a newborn infant on a ventilator much more difficult to assess than an adult?
An infant has a short tracheal length (less than 10 cm), an increased compliance of the chest wall (chest rise), and bilateral air movement and sounds.
54. How is hemodynamic assessment easy and hard in an infant?
Cannulation of umbilical vessels allows easy venous and arterial access. (Cannulation of the aorta and superior vena cava is easy). Pulmonary artery monitoring is difficult (due to right to left shunting, PDA, and PFA making cardiac output calculations difficult to assess).
55. What respiratory disease, common in young children, is a viral disease typically preceded by cold symptoms, may present with fever, may have stridor in severe cases; symptoms worsen when crying or upset, typically self-limiting but can require intubation?
56. What respiratory disease, common in young children, is a bacterial disease, that typically presents abruptly with drooling, dysphagia (difficulty swallowing), and respiratory distress; where the patient is usually febrile, with stridor and no cough; and requires intubation?
57. What should you look for with palpation on a pediatric assessment?
Palpation is not helpful in patients under 3 years old; otherwise, you look for the tracheal position, spinal abnormalities, pulses, capillary reflex, and tactile rhonchi.
58. Where should you get a pulse on a pediatric patient?
Feel for their brachial pulse, where the pattern should be normal.
59. What should the capillary reflex be on a pediatric patient?
It should be less than or equal to 2 seconds.
60. When is percussion useful?
When the patient is older than 2 years of age.
61. What are adventitious breath sounds with pediatric patients?
Wheezes (rhonchi), crackles (rales), pleural rub, stridor, and decreased breath sounds.
62. What is the length of inspiration vs. expiration with pediatric patients?
63. What is RDS?
It is respiratory distress caused by immature lungs and a lack of surfactant, and the treatment is to administer surfactant and assist in lung inflation and ventilation.
64. What is the most common respiratory emergency in children?
A lodged object in the airway.
65. What are the symptoms of a lodged object in the airway?
Wheezing that is heard around an object.
66. What parameter demonstrates the largest difference when capillary blood is compared with arterial blood?
The PaO2 does not correlate well.
67. What condition is associated with an infant that is born early in gestation?
68. What is a common cause of hypothermia in an infant?
69. What effect does abdominal distention have on respiration?
It impedes diaphragm movement.
70. If an infant’s entire hemithorax “lights up” during transillumination, what does this signify?
It means that there is a significant pneumothorax present.
71. A child presents to the ER with difficulty breathing and a harsh, barking cough, and history reveals a runny nose. What is most likely the diagnosis?
72. A 4-year-old presents to the ER with difficulty breathing, a dry cough, and audible inspiratory and expiratory wheezing. The child was playing outside prior to the difficulty breathing, and their condition is progressively worsening. What is the diagnosis?
73. Premature infants are susceptible to what?
74. Post-term infants are susceptible to what?
Meconium aspiration, persistent pulmonary hypertension, and perinatal asphyxia.
75. What is indicated by the presence of retractions in a newborn?
76. Nasal flaring is a cardinal sign of what in an infant?
Respiratory distress (i.e., increased work of breathing)
77. What is a congenital diaphragmatic hernia?
An absence or incomplete development of one of the hemidiaphragms that allow abdominal organs to enter the thorax.
78. The lateral film of a child with epiglottitis will show what?
It will show a swollen epiglottis blocking the upper airway that looks like a “thumb sign”.
79. In a child with croup, the AP neck radiograph showing a narrowed subglottic airway looks like what?
It has the appearance of a “steeple sign”.
80. How is the airway secured in a patient with epiglottitis?
It is secured via intubation.
81. Infants with heart disease tend to have what?
Intercostal retractions on the sides of their bodies.
82. Infants with lung disease tend to have what?
Substernal and subcostal retractions toward the center of the body.
83. What are the fundamentals for assessing an infant or child?
A good history, a physical exam, and interpreting the lab work and radiographic information.
84. Infants that are born between 37 and 42 weeks of gestation are called what?
85. Infants that are born fewer than 37 weeks of gestation are called what?
Preterm Infants or “preemies” (i.e., premature)
86. Infants born at 43 or more weeks of gestation are called what?
87. A person younger than 3 months old is called what?
A young infant
88. A person between 12 months old to adolescent is called what?
89. A newborn baby up to 28 days is called what?
90. The prenatal assessment of the fetus includes what?
(1) Fetal movement, (2) biophysical profile (reactive HR, body tone, amniotic fluid), (3) lecithin/sphingomyelin (L/S) ratio (2:1), surfactant and lung maturity, (4) fetal monitoring (tachycardia, deceleration and late decelerations are signs of fetal distress in uterine environment, (5) non-stress tests (NST), (6) monitors heart rate changes with fetal movement.
91. Information that may suggest perinatal asphyxia includes what?
Late HR deceleration, low biophysical score, decreased fetal movement, meconium (first feces of an infant) in amniotic fluid, long labor, and abnormal vaginal bleeding.
92. A simple, quick, and reliable means to assess and document the newborn’s status immediately after birth is what?
The APGAR scale.
93. APGAR scores are checked at what times?
First at 1 minute, and then again at 5 minutes.
94. Bluish colorization of the hands and feet is called what?
95. An APGAR score of 7-10 is considered what?
96. An APGAR score of 4-6 is considered what?
Moderate depression; this infant needs an added FiO2 with BVM ventilation.
98. What are the events leading to neonatal death?
Late decelerations, accelerations disappear, fetal breathing stops, fetal movement ceases, fetal tone absent, and/or still born.
99. Hyperthermia in a newborn is what?
37.5 Celsius (i.e., 99.5 Fahrenheit)
100. Hypothermia in a newborn or infant is what?
36.5 Celsius (i.e., 97.7 Fahrenheit)
101. What is NTE?
Neutral thermal environment (NTE) is the environment temperature at which the infant’s metabolic demands and oxygen consumption are the least.
102. Why are newborns and infants more prone to excessive inward movement of the chest?
Their chest is more compliant, and they breathe rapidly and shallowly to help avoid retractions and chest wall collapse.
103. What are all of the techniques of examination?
Inspection, palpation, auscultation, and transillumination.
104. What is the most important portion of the examination?
105. How will respiratory distress manifest itself in a newborn?
The newborn will show signs of retractions (due to more negative pressure in the pleural space), nasal flaring (attempts to dilate airways to decrease airway resistance), and grunting (attempts to increase the lung gas volume).
106. What is indicated by a capillary refill time longer than 3 seconds in an infant?
Decreased cardiac output
107. Normal breath sounds for infants can be described as?
Bronchovesicular and harsher than adults.
108. A common disorder that mostly affects premature infants is what?
RDS; it occurs when the lungs are not fully formed to make enough surfactant.
109. In using transillumination, what suggests a normal lung in an infant?
When there is a small halo around the light source.
110. Leukocytosis in an infant is commonly an indication of what?
An increase in WBCs (i.e., > 15,000/mm3) and it’s normally due to the infant’s environment (i.e., hyperthermia or crying), but can also indicate that an infection is present.
Neonatal and pediatric patient assessments are not merely scaled-down versions of adult assessments.
They require a comprehensive understanding of the developmental, anatomical, and physiological differences that characterize these age groups.
Ensuring accurate and thorough assessments in this patient demographic is pivotal for ensuring optimal health outcomes and the early detection of potential issues.
As healthcare professionals, a commitment to continuous learning and adaptation in our approaches can provide the best care for our most vulnerable patients.
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
- Faarc, Walsh Brian Rrt-Nps Accs. Neonatal and Pediatric Respiratory Care. 5th ed., Saunders, 2018.
- Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020.
- Wilkins’ Clinical Assessment in Respiratory Care. 8th ed., Mosby, 2017.