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Premature:
HR:
RR:
BP:
100-180, >40, 55-75/35-45
0-3 months:
HR:
RR:
BP:
100-150, 25-35, 65-85/45-55
3-6 months:
HR:
RR:
BP:
80-150, 25-35, 70-90/50-60
6-12 months:
HR:
RR:
BP:
70-150, 20-30, 80-100/55-65
2-3 yo:
HR:
RR:
BP:
70-120, 20-30, 90-100/55-70
4-5 yo:
HR:
RR:
BP:
70-110, 20-30, 90-100/60-70
6-8 yo:
HR:
RR:
BP:
60-110, 12-25, 100-110/65-75
10-12 yo:
HR:
RR:
BP:
60-90, 12-25, 110-120/70-80
>12 yo
HR:
RR:
BP:
60-100, 12-25, 110-120/75-80
signs of poor perfusion
______
mottled color/____
____ skin
_____
diminished ___ pulses
____ acidosis
late = ____, bradycardia
tachycardia, pallor, cool, oliguria, peripheral, metabolic, hypotension
signs of respiratory distress
tachy____/____
retractions
____ flaring
_____
stridor or _____
mottled color
change in ____
decrease in ____ sats
pnea, cardia, nasal, grunting, wheexing, responsiveness, O2
signs of increased ICP
decreased ____
inability to _____
decreased ____ movements
decreased responsiveness to ____ stimuli
pupil dilation with ____ response to light
responsiveness, follow commands, spontaneous, painful, decreased
neonatal-infant pain scale
used for ___ and ____ term infants
looks at 6 things = ____
scored ___-___
pre, post, fascial expression, cry, breathing patterns, arms, legs, state of arousal, 0, 7
good pain scale to use if child cannot communicate
FLACC
FLACC pain scale
examines = ______
each category ___-___ pts
score ___-___ = moderate pain
score ___-___ = severe pain
face, legs, activity, cry, consolability, 0-2, 4-6, 7-10
pain scale used mostly in the ICU
CRIES
CRIES pain scale looks at
C = ____
R = ____
I = ____
E = ____
S = ____
crying, requires SpO2 for O2>95, increased vital sign (HR and BP), expression
CRIES pain scale
each category = ___-___pts
higher score = _____
<____ months old
0, 2, more severe pain, 6
adolescent pain scale to use with patients who cannot communicate
COMFORT
COMFORT scale loos at ____ (4)
BP, facial tension, crying, muscle tone