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Paediatric Respiratory Assesment - respiratory disorders in children

Paediatric Respiratory Assesment-respiratory disorders in children

Queensland Paediatric Emergency Care
Nursing Skill Sheets
Respiratory assessment in children
Respiratory assessment includes the assessment of airway patency and efficacy of breathing.
A guide to Mild, Moderate, Severe and Life-threatening respiratory features:
Mild Moderate accessory Severe accessory Life-threatening
ALL the following: muscle use and muscle use and
ANY of the following: ANY of the following: ANY of the following:
Alert Occasional irritability Agitated, restless, Drowsy or unconscious
Talks in sentences Some limitation distressed Unable to vocalise due
Behaviour in ability to talk - Marked limitation to dyspnoea
talking in phrases to ability to talk -
talking in words only
Can walk or crawl Lethargic Lethargic Collapsed or
Tripod sitting Tripod sitting exhausted
Mild accessory Moderate accessory Severe accessory Severe accessory
muscle use muscle use muscle use muscle use or poor
respiratory effort
Skin Colour Normal Pale Cyanosis Cyanosis
Respiratory Rate
Heart Rate
Normal or mild Tachypnoea Tachypnoea Severe tachyopnoea
tachypnoea or bradypnoea or
Normal or mild Tachycardia Tachycardia Cardiac arrhythmia
tachycardia or bradycardia
(preterminal sign)
Respiratory Assessment:
Least invasive to most invasive Chest Auscultation
Start your assessment with the `hands off' elements allowing ? If possible, it is beneficial to wait for a time when the
the child to assume a position of comfort. With the assistance infant or child is not crying to ensure subtle sounds are
of caregivers to expose the chest, the following can be done not missed.
without touching the infant or child: ? For younger children you may find it helpful to first let
? Observe the infant or child's behaviour, colour, them play with your stethoscope or integrate the use of
presence of respiratory muscle recession and their toys to build rapport and encourage compliance.
categorise accordingly with the table above. ? If old enough, ask the child to sit up in bed or if they
? Obtain the respiratory rate. prefer on their caregiver's lap.
? Observe for equal rise and fall of the chest.
? Without a stethoscope listen for any sounds such as ? Asking the child to take deep breath ("big breaths")
coughing, nasal congestion, snoring, grunting, auscultate the front and back of the chest.
wheezing or stridor. Compare right to left in a `Z' pattern.
Finish the respiratory assessment with the `hands on' elements: ? Note any noises such as wheezing or crackles on the
? Ensure the trachea is centred with no deviation.
inspiratory or expiratory phase of the respiration cycle.
? Auscultate the chest. ? Document your findings.
? Obtain and document a full set of observations including
heart rate and oxygen saturations.
? Document your findings and seek assistance as required.
CHQ-NSS-51013 Respiratory Assesment v1.0
Developed by the State-wide Emergency Care of Children Working Group, March 2020 Page 1/2
Children's Health Queensland Hospital and Health Service
A `silent chest' is a medical emergency. Seek urgent medical attention. A silent chest is suggestive of little to
no gas exchange and is a warning that respiratory failure is imminent.
Children with stridor should be made as comfortable as possible. Take special care not to distress the child as
this may exacerbate their symptoms.
Guide to Normal Parameters
Age < 1 year 1-4 years 5-11 years > 12 years
Respiratory rate (RR)
(breaths/minute) 21-45 16-35 16-30 16-25
Heart rate (HR)
(beats/minute) 100-159 90-139 80-129 60-119
Location of intercostal muscles
Other Signs of When to escalate care
respiratory distress
in children Urgently seek medical advice in
? Head bobbing in the child with signs of severe
infants or life-threatening respiratory
? Tripod position distress.
? Paradoxical
abdominal breathing Seek prompt senior nursing/
? Flat affect medical advice in a child with
moderate respiratory distress or
? Absence of cry worsening symptoms.
? Grunting
For further information:
Clinical Assessment of the Paediatric Patient - Rapid Assessment / Primary and Secondary Survey / Vital Signs (QH only)
Nursing Standard: Clinical Observations - Considerations in Children (QH only)
This Queensland Paediatric Emergency Nursing Skill Sheet was developed by the Emergency Care of Children working group
(funded by the Queensland Emergency Department Strategic Advisory Panel) with the help of the following resources:
Children's Health Queensland Hospital and Health Service. (2019b, September 26). Asthma - Emergency management in children.
Children's Health Queensland Hospital and Health Service. (2019, September 26). Bronchiolitis - Emergency management in
children. https://www.childrens.health.qld.gov.au/guideline-bronchiolitis-emergency-management-in-children/
Children's Health Queensland Hospital and Health Service . (2019, September 26). Pre-school Wheeze - Emergency management
in children. https://www.childrens.health.qld.gov.au/guideline-preschool-wheeze-emergency-management-in-children/
Hockenberry, M.W., D., Wong's nursing care of infants and children. 10th ed. 2015, Canada: Elsevier.
Queensland Health Statewide ED Nurse Educator Committee, Pearson, N., Cole, T., & Carney, S. (Eds.). (2016). Unit 5 Respiratory.
In Queensland Health: Transition Support Program - Emergency. Module 3 - Paediatric Care in the Emergency Department
(4th ed., pp. 68-78). State of Queensland (Queensland Health).
CHQ-NSS-51013 Respiratory Assesment v1.0
Developed by the State-wide Emergency Care of Children Working Group, March 2020 Page 2/3
Children's Health Queensland Hospital and Health Service
Nursing Skill Sheet Legal Disclaimer
The information contained in the Queensland Paediatric Emergency Care nursing ? Advising consumers of their choices in an environment that is culturally
skill sheets are intended for use by nursing staff for information purposes only. The appropriate and which enables comfortable and confidential discussion.
information has been prepared using a multidisciplinary approach with reference to This includes the use of interpreter services where necessary.
the best information and evidence available at the time of preparation. No assurance ? Ensuring informed consent is obtained prior to delivering care.
is given that the information is entirely complete, current, or accurate in every respect. ? Meeting all legislative requirements and professional standards.
The nursing skill sheets are not a substitute for clinical judgement, knowledge and ? Applying standard precautions, and additional precautions as necessary,
expertise, or medical advice. Variation from the nursing skill sheets, taking into account when delivering care.
individual circumstances may be appropriate. This does not address all elements ? Documenting all care in accordance with mandatory and local
of standard practice and accepts that individual clinicians are responsible for the requirements.
following: Children's Health Queensland disclaims, to the maximum extent permitted by
? Providing care within the context of locally available resources, expertise, law, all responsibility and all liability (including without limitation, liability in
and scope of practice. negligence) for all expenses, losses, damages and costs incurred for any reason
? Supporting consumer rights and informed decision making in partnership associated with the use of this nursing skill sheet, including the materials within or
with healthcare practitioners including the right to decline intervention referred to throughout this document being in any way inaccurate, out of context,
or ongoing management. incomplete or unavailable.
CHQ-NSS-51013 Respiratory Assesment v1.0
Developed by the State-wide Emergency Care of Children Working Group, March 2020 Page 3/3

What is the most common respiratory disease? Chronic respiratory diseases (CRDs) are diseases of the airways and other structures of the lung. Some of the most common are asthma, chronic obstructive pulmonary disease (COPD), occupational lung diseases and pulmonary hypertension. In addition to tobacco smoke, other risk factors include air pollution, occupational chemicals and dusts, and ...


Title: Paediatric Respiratory Assesment
Subject: Paediatric Respiratory Assesment
Keywords: Paediatric Emergency Nursing skills
Queensland Paediatric Emergency Care
Paediatric Nursing Respiratory Assesment
Work of breathing
Increased work of Breathing
Mild work of breathing
Moderate work of breathing
Severe work of breathing
Nasal flaring
Head bobbing

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