Vital signs in Pediatrics

Vital signs or cardinal signs are the important signs that indicate the status of the body’s vital function. Temperature, pulse, respiration and blood pressure are called vital signs.

Preparation

• Explain the procedure to the mother and child as appropriate.
• Depending on the site/route of checking, assess for the following:
• Oral-feeding, age, oral problems, level of consciousness, and understanding
• Rectal-diarrhea, imperforated anus, etc.

Procedure

Temperature

• Oral route (above 6 years)
• Wash hands
• Shake the thermometer down to bring the reading below 35°C.
• Clean the thermometer with dry swab from bulb to stem in circulatory motion.
• Keep the thermometer under the patient’s tongue, to the right or left of the pocket at the base of the tongue.
• Tell the child to close his/her lips but not to the teeth around the thermometer.
• Leave the thermometer in place for at least 2 minutes.
• Take out the thermometer and read the temperature.
• Wipe the thermometer with wet swab or wash it in soapy lukewarm water and rinse it in cold water, dry it, and store it.
• Wash your hands and record the temperature.

Axillary temperature

• To take an axillary temperature, the thermometer is kept under the patient’s arm.
• Wash your hands
• Prepare the thermometer just as you would take an oral temperature.
• Keep the thermometer under the child’s arm in the axilla.
• Hold the child’s arm tight against the chest and leave the thermometer in place for 5 minutes.
• Take out the thermometer and read the temperature and clean and store the thermometer.
• Wash your hands and record the temperature.

Checking axillary temperature using digital thermometer.

• Wash your hands
• Take the digital thermometer out of its holder
• Insert the tip of the thermometer into single-use plastic cover or clean the tip with soap and warm water (or clean with alcohol wipes).
• Switch on and place the tip of thermometer in the center of armpit.
• Tuck the child’s arm closely against the body.
• Leave the thermometer in place until a beep sound appears, and temperature reading appears in the window of thermometer.
• Note the readings
• Clean the tip with alcohol wipe (dispose the tip cover if it used)
• Put the thermometer back to the holder.

Rectal temperature 

• Wash hands
• Place the child on sideline or prone position or on mother’s alp.
• Prepare the thermometer as explained earlier.
• Apply some water-soluble lubricant on a tissue or gauze piece and then on to the first 2.5cm of the thermometer form bulb. Ask the child to take a deep breath (if older enough) and keep the thermometer into the anus from1.5 to 4cm, depending on the child’s age and size.
• Do not force the thermometer.
• Hold the thermometer in place for 2 minutes.
• Remove the thermometers, wipe it with a tissue or dry cotton swab, and discard the tissue.
• Read the mercury level.
• Wash and rinse the thermometer, wipe it with disinfectant, dry it, and store it.
• Wash hands
• Record the temperature.

Tympanic membrane

• Note the age child if younger than 3 years, pull the earlobe back and down.
• Insert the tympanic thermometer gently into the ear canal with infrared sensor beam directed towards the center of the tympanic membrane rather than the side of the ear canal.
• Push the button to take the temperature and hold until a reading is obtained. The length of time required for the temperature to register varies per manufacturer but only a few seconds at most.

Pulse

• Wash hands
• Clean the chest piece and earpiece with alcohol wipes
• Turn the chest piece to on mode; check for audibility.
• Keep the diaphragm on the site explained above and once you hear the heartbeat start to count from 0,1,2,3,4, till the completion of one minute.
• In order children palpate the radial pulse for a full minute.
• Note any irregularities in strength or rhythm
• Document the method used to obtain pulse measurement as well as any activity of the child during the assessment and any action taken.

Respiration

• Wash hands
• Ask the caregiver/parents to hold the child on lap or keep in lying position.
• Count the respiratory rate for a full minute
• Infant’s respirations are primarily diaphragmatic so count the abdominal movements
• After 1 year of age count the thoracic movements
• Document the rate and activity of the child, any deviations from normal and any action taken.

 Blood pressure

• Wash hands.
• Place the correct size cuff on infants or child’s bare arm.
• Inflate the cuff until the radial pulse disappears or about 30 mm Hg above expected systolic reading.
• Place the stethoscope light over the artery and slowly release air until pulse is heard.
• Record reading as in adults.
• Record the BP on paper to be transferred to permanent document.

Doppler or electronic monitor

• Obtain the monitor, dual air hose, and proper cuff size.
• Plug in monitor (unless battery operated) and attach dual hose if necessary.
• Attach appropriate size BP cuff and wrap around child’s limb.
• Turn on power switch and record the reading.

Temporal scanning

It is a new method of temperature measurement that uses infrared scanning on the skin over the temporal artery combined with a mathematical computation to determine the child’s arterial temperature. The arterial temperature is considered the most accurate reflection of body temperature.

• Measure the temperature on the exposed side of the head (not the side that has been lying on a pillow or covered by a hat).
• Slide the sensor tip externally in a horizontal line across the child’s forehead, midway between the eyebrows and hairline and ending at the temporal artery.
• Hold it in position until the device registers the temperature reading, which usually requires one second.
• Accuracy may be affected by excessive sweating.

Nurse’s responsibility in checking temperature

• Take an oral or tympanic temperature for children older than 6 years.
• Take a tympanic, axillary, or rectal temperature for children who are younger than 6 years, disoriented, unconscious, or in severe respiratory distress.
• Do not take a rectal temperature if a child has had any immune or hemolytic disorder, rectal surgery, or diarrhea.
• Do not take a tympanic temperature if a child has had ear surgery or has ventilation tubes or infection.
• Use axillary method only if other methods are not possible.
• Regardless of method you use, remain with the child to ensure safety.
• Hold the temperature probe in place for required time. Do not use glass and mercury thermometers if possible.

Pulse

  Sites for checking pulse

• For children <2 years: Apical pulse-the point of maximum intensity (PMI), the point on the chest wall where the heartbeat is heard, most distinctly, is just above and outside the left nipple of the infant at the third or fourth intercostal space. The PMI moves to a more medial and slightly lower area until 7 years of age, when it is heard best at the fourth or fifth intercostal space at the midclavicular line.
• Apical pulse rate should also be taken if the child has a cardiac problem, such as an irregular heart rate or a congenital heart defect, as well as before administering certain medications, such as digoxin.
• For children >2 years: Radial pulse. Other sites are:
• Carotid pulse (unconscious child)
• Brachial pulse
• Femoral pulse
• Popliteal pulse
• Posterior tibialis pulse
• Dorsalis pedis pulse

Preparation

• Explain the procedure to the parent and the child as appropriate.
• Allow the child to examine or handle the stethoscope to become familiar with equipment.
• Make the child to be calm and quiet.
• Give any play material for distraction.

Equipment needed

• A stethoscope (pediatric size)
• Wristwatch with seconds or pulsometer
• Alcohol wipes for cleaning earpiece and chest piece
• Paper and pen

Procedure

• Wash hands.
• Clean the chest piece and earpiece with alcohol wipes.
• Turn the chest piece to on mode; check for audibility.
• Keep the diaphragm on the site explained above and once you hear the heartbeat start to count from 0, 1, 2, 3, 4, till the completion of 1 minute.
• In older children palpate the radial pulse for a full minute.
• Note any irregularities in strength or rhythm.
• Document the method used to obtain pulse measurement as well as any activity of the child during the assessment and any action taken.

General instructions

• Assess the heart rate while the child is resting or sleeping
• The heart rate in infants is much faster than in adults, it also varies in infants and children who are anxious, fearful, or crying.
  For an accurate heart rate, wait for several seconds until the heart rate slows, then count for one full minute.
• As the child grows, the heart rate slows and the range of normal value narrows.
• The radial pulse is difficult to palpate accurately in children <2 years of age because the blood vessels lie close to the skin surface and are easily obliterated.

Respiration

Preparation of client

• Explain the procedure to the parents and the child as appropriate.
• Assess the respiration when the child is resting or sitting quietly.

Procedure

• Wash hands.
• Ask the caregiver/parents to hold the child on lap or keep in lying position.
• Count for respiratory rate for a full minute.
• Infant’s respirations are primarily diaphragmatic so count the abdominal movements.
• After 1 year of age count the thoracic movements.
• Document the rate, activity of the child, any deviations from normal and any action taken.

General instructions

• Infants normally display an uneven or irregular breathing pattern with short pauses between some breaths. This may be accentuated when they are ill.
• Take respirations before taking other vital signs, as you will be unable to obtain an accurate respiratory rate if a child is crying
• If you cannot obtain a respiratory rate because of crying, observe for signs of respiratory distress by checking skin color, pallor, and the presence of breath sounds. Signs of respiratory distress include xiphoid retraction, dilation of nostrils, and expiratory grunt.
• Assess the respiration when the child is resting or sitting quietly, since the respiratory rate often changes when infants or young children cry, are fed, or become more active.

Blood Pressure

Equipment needed

• Pediatric stethoscope
• BP cuff (appropriate size for child)
• Doppler or electronic monitor (if available) or sphygmomanometer
• Paper and pen

Preparation

• Explain the procedure to the parent and the child as appropriate.
• Allow the child to handle the equipment when appropriate. Encourage preschool or school-age child to use equipment to take BP on a doll or stuffed animal.
• Use terminology appropriate to child’s age.

Sites for checking blood pressure

• Upper arm: 2 cm above antecubital fossa, auscultation area-brachial artery.
• Lower arm/forearm: 2 cm above wrist, auscultation area-radial artery.
• Thigh: 2 cm above popliteal fossa, auscultation area-popliteal artery.
• Calf/ankle: 2 cm above ankle, auscultation area-posterior tibialis and dorsalis pedis artery.

Procedure

• Wash hands.
• Place the correct size cuff on infant’s or child’s bare arm.
• Inflate the cuff until the radial pulse disappears or about 30 mm Hg above expected systolic reading.
• Place the stethoscope light over the artery and slowly release air until pulse is heard.
• Record reading as in adults.
• Record the BP on paper to be transferred to permanent document.

Doppler or electronic monitor

• Obtain the monitor, dual air hose, and proper cuff size.
• Plug in monitor (unless battery operated) and attach dual hose if necessary.
• Attach appropriate-size BP cuff and wrap around child’s limb.
• Turn on power switch and record the reading.

General instructions

• When choosing a cuff, measure the width of the cuff against the width of the child’s arm.
• The cuff should cover approximately two-third of the upper arm.
• The bladder of the cuff should be long enough to encircle the arm without overlapping.
• Be sure to use the same size of cuff each time.
• The cuff size will vary with the child’s age and size.
• The cuff bladder width should be at least 40% of the circumference of the upper arm at its midpoint.
• The cuff bladder length should cover 80-100% of the circumference of the upper arm.
• To measure BP using the upper arm, place the limb at the level of the heart, place the cuff around the upper arm, and auscultate at the brachial artery.
• When obtaining BP in the lower arm again position the limb at the level of heart, place the cuff above the wrist, and auscultate the radial artery.
• For measurement in thigh, place the cuff above the knee and auscultate the popliteal artery.
• To obtain BP on calf or ankle, place the cuff above the malleoli or at the midcalf and auscultate the posterior tibialis or dorsalis pedis artery.
• Systolic pressure in children is read at the moment you hear the first Korotkoff sounds as you lower the manometer pressure. The point at which the sound disappears is the diastolic pressure.
• The systolic BP sometimes can be heard to a measurement of zero, so document the reading as systolic pressure P for pulse.
• Due to the small arm vessels in infants and young children, it may be very difficult to hear the Korotkoff sounds by auscultation.
• In children older than 1 year, the systolic pressure in the thigh tends to be 10-40 mm Hg higher than in the arm.
• Systolic BP will increase if the child is crying or anxious. So measure the BP when the child is quiet and relaxed.
• If the reading is lower in the leg than in the arm, always consider coarctation of aorta or interference with circulation to the lower extremities.
  Also pay attention to the pulse pressure, unusually wide (>50 mm Hg) or narrow (>10 mm Hg) pulse pressure readings suggest a congenital heart defect.
• Infants and children presenting with cardiac complaints should have BP assessed in all four extremities and also in the sitting, lying, and standing positions.

The normal values of vital parameters vary based on their age. Normal temperature ranges based on measurement methods in paediatrics:

• Rectal: 36.6-38°C (97.9-100.4°F)
• Ear: 35.8-38°C (96.4-100.4°F)
• Oral: 35.5-37.5°C (95.9-99.5°F)
• Axillary: 34.7-37.3°C (94.5-99.1°F)

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

Stories are the threads that bind us; through them, we understand each other, grow, and heal.

JOHN NOORD

Connect with “Nurses Lab Editorial Team”

I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.