1. Normal Vital Signs and Head to Toe Assessment
Presented by: Danyel Dorn RN, MSN, CPN
Pediatric Clinical Educator

2. Purpose
In order to provide safe care to pediatric patients recovering from anesthesia requires knowledge of normal vital signs and is impacted by the various stages of growth and development.

3. Competency Statement
The perianesthesia nurse will recognize normal and abnormal vital signs for the pediatric population and identify the required elements of complete head to toe assessment of the patient.

4. Newborn (0-3 month) Heart Rate: 115-155 bpm BP: 65-85/45-55 RR: 38-53
Temp:

5. Infant 3-6 months 6-12 months Heart Rate: 130-150 BP: 70-90/50-65
RR: 36-50
6-12 months
Heart Rate:
BP: /55-65
RR: 35-48

6. Toddlers (1-2 yrs old) Heart rate: 105-135 BP: 83-90/36-46 RR: 27-44
Temp:

7. Preschool (3-5 yrs old) Heart Rate: 90-118 BP: 87-96/45-55 RR: 21-28
Temp:

8. School-Aged 6-11 year olds 12-14 year olds Heart rate: 75-105
BP: 87-96/45-55
RR: 21-28
Temp:
12-14 year olds
Heart Rate: 65-90
BP: /61-65
RR: 14-20

9. Adolescent (13-18 years) Heart rate: 65-105 BP: 110-133/63-83
RR: 16-22
Temp:

10. Neurologic Assessment
Patient’s level of consciousness
Pupils
Level of sedation
Presence of pain
Sensory and motor function

11. Respiratory Assessment
Airway patency
Quality of breathing/bilateral breath sounds
Presence of artificial airway
Pulse oximetry
Ventilator settings (home vent-> have set up in PACU/MD)
If patient is on Bipap/Cpap at night, they need to bring it day of procedure/MD

12. Cardiovascular Abnormal cardiac rhythms
Presence and strength of pulses (apical/peripheral)
Skin color and general perfusion
Presence/patency of IV access
BP (upper & lower extremities to R/O cardiovascular abnormalities)
Presence of edema

13. Gastrointestinal Assessment
Presence of bowel sounds in all 4 quadrants
Inspect/palpate the abdomen
Determine NPO status
Genitourinary assessment
Presence of drains or catheters
Determine intake and output

14. Musculoskeletal Assessment
Assess extremities
Evaluate for presence of assistive devices, contractures and deformities
Identify casts, immobilizers or splints
Evaluate skin appearance, cap refill, distal pulses and sensation

15. Integumentary Assessment
Overall appearance, lesions, rashes
Identify and document presence of skin conditions, wounds, dressings, abrasions, bruises, redness, ulcerations, breakdown
Identify abnormal bruising that may indicate child abuse

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

17. Answers A E B C