1. Pediatric Assessment Tools
Presented by Danyel Dorn RN, MSN, CPN, Clinical Nurse Educator-Pediatric Service Line

2. Purpose
The Perianesthesia registered nurse will recognize some of the tools and scoring systems created to help develop and implement appropriate treatment plans for the pediatric patient. The first scoring system addressed in this chapter assists with identifying potential surgical and anesthesia risks and the need for a higher level of care (PEWS). The second supports the assessment of sleep disordered breathing (STBUR) to determine associated potential complications.

3. Competency Statement
The perianesthesia registered nurse will demonstrate knowledge of the three dynamic areas of the Pediatric Early Warning System (PEWS) and will identify the critical components of the Snoring, Trouble Breathing, Un-Refreshed (STBUR) Screening tool.

4. Purpose of PEWS
The Pediatric Early Warning System (PEWS) systematically assesses the pediatric patient and identifies those at risk for potential deterioration.
Application of the PEWS tool
Improves patient outcomes
Prevents potentially avoidable patient deaths
Utilization of PEWS helps identify the need for patient interventions and/or appropriate transfer

5. Purpose of PEWS Staff and/or family initiating the PEWS scoring have
Secured extra help
Appropriately activated a Rapid Response Team
Determined the need to transfer the patient to a higher acuity area
PEWS scoring also addresses the Joint Commission’s 2009 National Safety Goal to “Improve recognition and response to changes in a patient’s condition”
There are a variety of PEWS scoring tools available and individual institutions may alter or create their own tool to address their specific patient population

6. Three Dynamic Variables
Level of consciousness/behavioral
Alert, responds to voice, responds to pain, unresponsive
Playing, sleeping, irritable, lethargic, confused
Cardiovascular
Heart rate (too fast, too slow), pulses, cap refill, fluid bolus, blood pressure and color
Respiratory
Resp. rate (too fast, too slow), O2 sat, need for O2, resp. effort, retractions, nasal flaring, grunting, head bobbing, stridor, breathing treatments

7. Basic Interpretation of the PEWS
The PEWS score contains five common variables that are evaluated
Respiratory rate, oxygen saturation, heart rate, blood pressure, capillary refill
A low score may mean the patient should be re-scored with the next routine vital signs
A high score, may trigger additional help and/or activation of the Rapid Response Team

8. Basic Interpretation of the PEWS
The grouping of heart rate, respiratory rate and blood pressure “norms” by age as printed on the tool is especially helpful for newer nurses. The patient’s score will help determine the nurse’s next action.
Education about the tool an institution adopts is important for all nurses. Each nurse must understand the tool and utilize it appropriately for it to be effective.

9. Static Variables and its Impact on the PEWS Score
Patients with complex medical histories may need to be scored differently. This subset of patients may need consideration for static variables.
Examples of static variables include: airway abnormalities, home ventilator, CPAP or O2 use, complex syndromes, severe developmental delays, complex cardiac defects or conditions, previous PICU admissions, the number of physician specialists who provide care for the patient, medications, previous cardiac arrest.

10. STBUR
Many children with sleep disordered breathing (SDB) or obstructive sleep apnea (OSA) remain undiagnosed when presenting for surgery
SDB refers to the clinical spectrum of repetitive episodes of complete or partial obstruction of the airway during sleep
Children with SDB or OSA are at higher risk of perioperative complications including respiratory depression, decreased pharyngeal tone, hypercarbia, hypoxia, and cardiopulmonary arrest

11. Assessment Goals of STBUR
STBUR is comprised of five parental screening questions aimed at identifying clinical symptoms consistent with SDB in pediatric patients
STBUR is useful for predicting patients who may have an increased perioperative risk related to undiagnosed SDB
Polysomnography (PSG) or “sleep study” is gold standard for diagnosis for SDB and OSA

12. Assessment Goals of STBUR
The STBUR questionnaire consists of five clinical symptoms
A three fold increase of risk of perioperative respiratory adverse events (PRAE) with presence of any three STBUR symptoms
A tenfold increase when all five STBUR symptoms are presents

13. Five Questions to Determine Risk
STBUR Airway Risk Questions
Snore more than half the time? Yes=1, No=0
Snore loudly? Yes= 1, No=0
Trouble breathing or struggle to breathe? Yes=1, No=0
Ever stop breathing during the night? Yes=1, No=0
Wake up feeling unrefreshed? Yes=1, No=0
Risk Score 0-2 = Low risk for PRAE
3 or higher = moderate to high risk for PRAE

14. Postoperative Recommendations
Reduce dosage of opioid medications
Possible admission overnight for observation
Continuous pulse oximeter and cardio-respiratory monitoring
Non-opioid multimodal analgesia
Elevate head of bed or position laterally. Avoid supine position until fully awake

15. References
ASPAN (2016). A Competency Based Orientation and Credentialing Program for the Registered Nurse Caring for the Pediatric Patient in the Perianesthesia Setting.

16. Answers D C B A