Pediatric nursing reference: assessment, vital signs, and key conditions

Children are not small adults. That distinction drives every clinical decision in pediatric nursing – from vital sign interpretation to medication dosing to how you explain a procedure to a four-year-old. Organ systems are still maturing, physiologic reserves are narrower, and compensatory mechanisms fail faster than in adults. This reference covers what you need for your pediatric rotation: normal vital signs by age, growth and development stages, key assessment differences, common pediatric conditions with nursing priorities, weight-based dosing principles, pain assessment scales, and fluid management. Use it alongside vital signs by age and head-to-toe assessment for the most complete picture.

Quick reference: pediatric vital signs by age

Normal ranges below are based on PALS/AHA guidelines and standard pediatric references (PedsCases, Iowa Protocols). Heart rate, respiratory rate, and systolic BP follow the PALS provider manual tables, the same ranges used on our vital signs by age page. Heart rates are awake values; sleeping rates run lower (for example, 80–120 bpm in a sleeping toddler). Systolic ranges assume a child at the 50th percentile for height, and the newborn range spans the first 12 hours of life (60–76 mmHg at term) through day 4 (67–84 mmHg). Fever, pain, anxiety, and illness will shift all parameters.

Adolescent blood pressure: For adolescents 13 and older, the AAP 2017 guideline classifies a systolic of 120–129 mmHg as elevated and 130 mmHg or higher as stage 1 hypertension, so a reading near the top of the PALS adolescent range still warrants a repeat measurement.

PALS hypotension thresholds: Systolic BP below 60 mmHg in neonates, below 70 mmHg in infants, below 70 + (2 × age in years) mmHg for children 1–10 years, and below 90 mmHg from age 10 signals hypotension requiring immediate action.

Tachycardia red flags: In infants, HR above 180 bpm at rest is concerning. In school-age children, sustained HR above 150 bpm warrants investigation. SVT in children can present with HR as high as 220–300 bpm and abrupt onset.

Growth and development stages

Understanding developmental stage shapes every interaction – consent, teaching, pain assessment, and procedural preparation all depend on where the child is cognitively and emotionally. Erikson’s psychosocial theory provides useful clinical anchors.

Pediatric assessment: key differences from adults

The Pediatric Assessment Triangle (PAT)

The PAT is a rapid 30-second visual assessment used before touching the child. It has three components:

• Appearance: Tone, interactivity, consolability, look/gaze, speech/cry. A child who is limp, unresponsive to parents, or has a weak cry is critically ill until proven otherwise.
• Work of breathing: Nasal flaring, retractions (subcostal, intercostal, suprasternal), grunting, head bobbing, tripod positioning. Grunting is particularly ominous – it’s the child creating auto-PEEP to prevent alveolar collapse.
• Circulation to skin: Pallor, mottling, cyanosis. Central cyanosis (lips, mucous membranes) indicates severe hypoxia. Mottling beyond the knees is a sign of poor perfusion.

TICLS mnemonic for appearance

The T-I-C-L-S (Tickles) mnemonic gives you a systematic approach to assessing appearance:

• T – Tone: Is muscle tone normal? Does the child move spontaneously?
• I – Interactivity: Does the child interact with the environment, track objects, reach for toys?
• C – Consolability: Can the parent/caregiver calm the child?
• L – Look/gaze: Does the child make eye contact? Is the gaze glazed or vacant?
• S – Speech/cry: Is the cry strong and age-appropriate, or weak and high-pitched?

Head-to-toe assessment differences from adults

• Head: Assess fontanelles in infants. Anterior fontanelle closes by 12–18 months. A bulging fontanelle = increased ICP. A sunken fontanelle = dehydration.
• Airway: Children have a proportionally larger tongue, shorter trachea, and higher glottis (C3–C4 vs. C5–C6 in adults). The narrowest part of the pediatric airway is the subglottic area (cricoid ring), not the vocal cords.
• Chest: Breath sounds transmit easily across small chests – auscultation can be misleading. Always correlate with work of breathing.
• Abdomen: More rounded in toddlers; liver edge palpable 1–2 cm below the right costal margin is normal in young children.
• Neurological: Use the pediatric GCS modification for age. Verbal scoring for infants is based on cry quality rather than word production.

See head-to-toe assessment for the complete systematic approach.

Common pediatric conditions

RSV bronchiolitis

Who it affects: Infants and children under 2 years, peak season October–March.

Clinical picture: URI prodrome → wheeze → tachypnea → increased work of breathing. Hypoxia can develop rapidly in young infants.

Nursing priorities: Nasal suctioning before feeds and assessments (infants are obligate nose-breathers), small frequent feeds or NG feeds if tiring, close respiratory monitoring. The AAP clinical practice guideline sets the oxygen threshold at 90%: supplemental oxygen may be withheld in an otherwise well infant whose SpO2 stays at or above 90%, and targeting 94% leads to longer admissions without better outcomes. Many units start with standard low-flow oxygen and escalate to high-flow nasal cannula (HFNC) if it fails. In the PARIS trial (Franklin 2018, 1,472 infants treated outside the ICU), starting with high flow lowered escalation of care (12% vs 23%), but length of stay and oxygen duration did not differ, and 61% of infants who failed standard oxygen responded to rescue high flow.

Management is otherwise supportive. The AAP guideline recommends against routine bronchodilators, corticosteroids, chest physiotherapy, and antibiotics in uncomplicated bronchiolitis.

Watch for: SpO2 persistently below 90%, severe retractions, cyanosis, apnea (especially in infants under 2 months), dehydration from increased work of breathing.

Prevention: CDC recommends protecting every infant through either the maternal RSV vaccine (Abrysvo, given at 32–36 weeks of pregnancy during September through January in most of the US) or a long-acting monoclonal antibody (nirsevimab or clesrovimab) for infants younger than 8 months entering their first RSV season whose mother was not vaccinated. Some high-risk children aged 8–19 months receive nirsevimab before their second season. Ask about both at admission, since a protected infant can still be infected.

Croup (laryngotracheobronchitis)

Who it affects: Children 6 months to 3 years; caused predominantly by parainfluenza virus.

Clinical picture: Barking “seal-like” cough, stridor (inspiratory), hoarse voice, worse at night. Symptoms typically peak on days 2–3.

Nursing priorities: Keep child calm (agitation worsens stridor). Humidified air is a traditional comfort measure, but a Cochrane review found it probably does not improve croup scores, so it should never delay steroid treatment. Racemic epinephrine nebulization for moderate-severe croup, dexamethasone (0.6 mg/kg IM/PO, max 10 mg) reduces airway edema.

Watch for: Stridor at rest (severe), drooling, inability to swallow – these suggest epiglottitis, which requires a different approach entirely. Biphasic stridor indicates severe subglottic narrowing.

Epiglottitis

Who it affects: Historically children 2–6 years (Hib vaccine has drastically reduced incidence); now more common in unvaccinated or immunocompromised children and adults.

Clinical picture: The “4 Ds” – Dysphagia, Drooling, Dysphonia (muffled voice), and Distress – often with the child sitting in the tripod position. High fever and toxic appearance. Onset rapid (hours, not days).

Nursing priorities: Do NOT examine the throat with a tongue depressor – this can cause complete airway obstruction. Keep the child in the position of comfort, do not agitate, prepare for emergency airway management. Immediate senior/airway team notification. IV antibiotics (ceftriaxone) after airway is secured.

Watch for: Any patient who looks toxic, drools, and has stridor has epiglottitis until proven otherwise. This is an airway emergency.

Febrile seizures

Who it affects: Children 6 to 60 months. Occur in 2–5% of children. Strongly familial.

Clinical picture: Simple febrile seizure – generalized tonic-clonic, less than 15 minutes, single episode in 24 hours. Complex febrile seizure – focal, prolonged (>15 min), or recurrent within 24 hours.

Nursing priorities: Protect airway, position lateral, do not restrain. Time the seizure. Antipyretics after seizure resolves. Parent education is critical – high recurrence anxiety is common.

Watch for: Seizure lasting more than 5 minutes requires benzodiazepine intervention (diazepam rectal or IV lorazepam). Meningitis stays on the differential for any febrile child: the AAP says lumbar puncture should be performed when there are meningeal signs or other clinical concern, and is an option for infants 6–12 months with incomplete or unknown Hib or pneumococcal immunization and for children pretreated with antibiotics. Complex febrile seizures generally get a lower threshold for further workup.

Intussusception

Who it affects: Typically infants 6 months to 3 years; most common in the first year of life.

Clinical picture: Classic triad – episodic colicky abdominal pain (child draws up knees and cries, then appears well between episodes), vomiting, and “currant jelly” stool (blood and mucus, a late sign). Sausage-shaped mass may be palpable in the right upper quadrant.

Nursing priorities: IV access, fluid resuscitation, NPO, prepare for diagnostic ultrasound. Pneumatic or hydrostatic enema is the first-line treatment (diagnostic and therapeutic). Surgical consultation if enema fails or perforation suspected.

Watch for: Peritoneal signs, shock, altered mental status (a surprisingly ominous finding in intussusception – encephalopathy-like presentation occurs in some cases).

Pyloric stenosis

Who it affects: Male infants 2–8 weeks, peak at 3–5 weeks. Male:female ratio ~4:1.

Clinical picture: Projectile non-bilious vomiting immediately after feeds. Infant remains hungry and feeds eagerly despite vomiting. An olive-shaped pyloric mass may be palpable in the epigastrium (right of midline), though ultrasound is now the standard diagnostic test. Hypochloremic, hypokalemic metabolic alkalosis on labs.

Nursing priorities: Correct electrolytes before surgery (surgical repair – pyloromyotomy – is not emergent until metabolic abnormalities are corrected). Monitor weight and hydration closely. IV fluid replacement with isotonic saline, adding KCl once urine output is established.

Watch for: Dehydration progresses rapidly in neonates. Classic lab pattern: low Cl⁻, low K⁺, low Na⁺, high HCO₃⁻, alkaline pH.

Kawasaki disease

Who it affects: Children under 5 years; more common in Asian children; leading cause of acquired heart disease in children in developed countries.

Clinical picture – CRASH mnemonic:

• C – Conjunctivitis (bilateral, non-purulent)
• R – Rash (polymorphous, trunk)
• A – Adenopathy (cervical lymph node ≥1.5 cm)
• S – Strawberry tongue (also: red cracked lips, oral erythema)
• H – Hand/foot changes (erythema, edema acutely; desquamation in subacute phase)

Classic (complete) Kawasaki disease requires fever ≥5 days plus ≥4 of the above criteria. Incomplete Kawasaki disease, with fewer criteria plus supportive lab or echocardiogram findings, is common in infants, who also carry the highest aneurysm risk.

Nursing priorities: IV immunoglobulin (IVIG 2 g/kg as a single infusion over 8–12 hours) to reduce coronary artery aneurysm risk, plus aspirin during the acute phase, with echocardiogram monitoring. The 2024 AHA scientific statement gives moderate-dose (30–50 mg/kg/day) or high-dose (80–100 mg/kg/day) aspirin until the child is afebrile, then a low antiplatelet dose (3–5 mg/kg/day) until coronary imaging is normal at 4–6 weeks. The statement also notes real controversy over whether acute-phase aspirin dose affects coronary outcomes at all, so follow your institutional protocol.

Watch for: Coronary artery dilation/aneurysm is the feared complication. Children who receive IVIG within 10 days of fever onset have significantly reduced aneurysm risk. Irritability out of proportion to fever is a hallmark. Coronary involvement is now classified by body-surface-area-adjusted Z scores rather than raw vessel diameter.

Meningitis in children

Who it affects: Any age; neonates and infants are highest risk. Bacterial causes vary by age (GBS/E. coli in neonates; Neisseria meningitidis and Streptococcus pneumoniae in older children).

Clinical picture: Classic triad – fever, nuchal rigidity, altered mental status. Petechial or purpuric rash with meningococcemia indicates bacteremia and requires immediate escalation. Infants: Bulging fontanelle, high-pitched cry, irritability, poor feeding. Kernig’s and Brudzinski’s signs may be absent in infants.

Nursing priorities: Immediate blood cultures and LP (unless contraindicated by signs of raised ICP), IV antibiotics within 1 hour of presentation (do not delay for LP), isolation precautions for bacterial/meningococcal meningitis, ICP monitoring, seizure precautions, strict fluid management.

Watch for: Purpuric rash spreading rapidly = meningococcal septicemia, a life-threatening emergency. Waterhouse-Friderichsen syndrome (adrenal hemorrhage) can occur. Glucose should be checked simultaneously on blood and CSF – normal CSF glucose is about 60% of blood glucose, and a CSF glucose below 40 mg/dL or a CSF:blood ratio of 0.4 or less strongly suggests bacterial meningitis (a normal ratio does not rule it out).

Weight-based medication dosing

Pediatric dosing is weight-based. A dose that is appropriate for a 20 kg child will overdose a 10 kg child or underdose a 40 kg child. Dosing errors are one of the most common medication errors in pediatrics.

Core principles:

1. Always confirm weight in kilograms before calculating any dose. Pounds must be converted (divide by 2.2).
2. Use the Broselow tape for emergency weight estimation in children unable to be weighed.
3. Calculate mg/kg dose, then confirm the total does not exceed the adult maximum dose.
4. Double-check all calculated doses with pharmacy or a second nurse for high-alert medications.
5. Use weight-based infusion pumps (smart pumps with drug libraries) for IV medications.

Example pediatric dose ranges (reference only – always verify current institutional guidelines and pharmacy before administering):

See drug classifications for broader pharmacology reference.

Pediatric pain assessment scales

Pain assessment in children requires matching the scale to the child’s developmental stage and communication ability.

FLACC scale (for pre-verbal and non-verbal children, and children with cognitive impairment)

FLACC is validated for children aged 2 months to 7 years who cannot self-report pain. Each of the five categories is scored 0–2; total score ranges from 0–10. Observe for at least 2–5 minutes before scoring.

Score interpretation: 0 = relaxed/no pain; 1–3 = mild discomfort; 4–6 = moderate pain; 7–10 = severe pain or discomfort. Score greater than 3 requires intervention.

(FLACC scale originally developed by Merkel et al., 1997; published in Pediatric Nursing)

Wong-Baker FACES scale

Used for children aged 3 years and older who can point to a face. Shows six faces ranging from a smiling face (0 = no hurt) to a crying face (10 = hurts worst). The child points to the face that represents how they feel. Correlates reasonably well with NRS in children who can comprehend both.

CRIES scale (neonates)

CRIES (Krechel and Bildner, 1995) scores neonatal postoperative pain on 10 points, like the APGAR: Crying, Requires increased oxygen, Increased vital signs, Expression, and Sleeplessness. Use it in the NICU or newborn nursery, where FLACC’s age range does not apply.

Numeric rating scale (NRS)

Appropriate for children aged 8 and older, including adolescents, who are developmentally typical and who understand the concept of a numerical scale. “On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain you can imagine, what number is your pain right now?”

Fluid management in pediatrics

Holliday-Segar formula (maintenance fluid calculation)

The Holliday-Segar formula calculates maintenance IV fluid requirements:

Worked example: A 25 kg child requires: (4 × 10) + (2 × 10) + (1 × 5) = 40 + 20 + 5 = 65 mL/hour maintenance rate.

Standard maintenance fluid: The AAP 2018 clinical practice guideline recommends isotonic solutions with appropriate potassium chloride and dextrose (for example, D5NS with KCl) for most hospitalized children aged 28 days to 18 years, because hypotonic solutions significantly increase the risk of hospital-acquired hyponatremia. The guideline excludes some groups, including neonates under 28 days and children with neurosurgical disorders, cardiac or hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns.

Signs of dehydration in children

Mild gastroenteritis: For children 6–60 months with minimal dehydration, half-strength apple juice followed by preferred fluids led to fewer treatment failures than electrolyte maintenance solution (16.7% vs 25.0%) and less IV rehydration (2.5% vs 9.0%) in a randomized trial (Freedman 2016). Electrolyte solutions remain the choice once a child is clinically dehydrated.

Escalation threshold: Escalate if the child is unable to tolerate oral rehydration, has signs of moderate-severe dehydration, or if serum sodium is outside the range of 130–150 mEq/L. Rapid bolus rehydration: 20 mL/kg isotonic saline IV, reassess after each bolus.

Clinical applications: nursing considerations

Family-centered care

Parents and caregivers are essential members of the pediatric care team. Involving them reduces child anxiety, improves cooperation, and leads to better outcomes. Key principles:

• Include parents during assessments and procedures whenever possible (with the exception of procedures where parent presence increases their own distress – this requires individual assessment)
• Provide information clearly and at an appropriate literacy level
• Recognize that a distressed parent will make the child more distressed – supporting the parent is part of the intervention
• Use interpreters for families with limited English, not family members as informal interpreters (medical interpreter standard)

Atraumatic care

The goal is to eliminate or minimize the physical and psychological distress of procedures and hospitalization. Strategies include:

• Topical anesthetics (EMLA, LMX4) before IV placement or blood draws – applied 45–60 minutes in advance
• Child life specialist involvement for procedures, hospital preparation, and distraction
• Distraction techniques during procedures (bubbles, tablet videos, counting)
• Comfort positioning (sitting upright in parent’s lap rather than lying flat for venipuncture)
• Non-nutritive sucking and oral sucrose for neonates and young infants during painful procedures

Age-appropriate communication

• Infants/toddlers: Speak softly; minimize the number of strangers in the room; allow comfort objects; perform assessments from least to most invasive
• Preschoolers: Use concrete, simple language; avoid medical jargon; explain immediately before (not hours ahead); never say “it won’t hurt” if it will
• School-age: Give honest explanations; allow questions; let them participate in small decisions; maintain privacy
• Adolescents: Speak to them directly; address them before their parents; ensure confidentiality for sensitive topics (mental health, sexual health, substance use)

Related references

• Vital signs by age – complete adult and pediatric vital sign ranges
• Head-to-toe assessment – systematic physical assessment framework
• Nursing lab values – complete lab reference with critical values
• APGAR score – neonatal assessment at birth
• Glasgow Coma Scale – neurological assessment including pediatric GCS
• Drug classifications – pharmacology reference for common drug classes
• Nursing care plans – NANDA-based care planning framework

References

1. American Heart Association (AHA)/American Academy of Pediatrics (AAP). Pediatric Advanced Life Support (PALS) Provider Manual. 2025 ed. Dallas, TX: AHA; 2025. Reflects the 2025 AHA Guidelines for CPR and Emergency Cardiovascular Care. Source of the heart rate, respiratory rate, and systolic BP ranges in the vital signs table.

2. Dieckmann RA, Brownstein D, Gausche-Hill M. The pediatric assessment triangle: a novel approach for the rapid evaluation of children. Pediatr Emerg Care. 2010;26(4):312–315. doi:10.1097/PEC.0b013e3181d6db37

3. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23(3):293–297.

4. Wong DL, Baker CM. Pain in children: comparison of assessment scales. Pediatr Nurs. 1988;14(1):9–17.

5. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957;19(5):823–832.

6. Freedman SB, Willan AR, Boutis K, Stephens D. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966–1974. doi:10.1001/jama.2016.5352

7. Tenenbein M, Macias CG, Sharieff GQ, Yamamoto LG, eds; Schafermeyer R, editor emeritus. Strange and Schafermeyer’s Pediatric Emergency Medicine. 5th ed. New York, NY: McGraw-Hill; 2019.

8. Kliegman RM, St Geme JW III, Blum NJ, Tasker RC, Wilson KM, Schuh AM, Mack CL, eds. Nelson Textbook of Pediatrics. 22nd ed. Philadelphia, PA: Elsevier; 2025.

9. Subcommittee on Febrile Seizures, American Academy of Pediatrics. Febrile seizures: guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127(2):389–394. doi:10.1542/peds.2010-3318

10. Jone PN, Tremoulet A, Choueiter N, et al. Update on diagnosis and management of Kawasaki disease: a scientific statement from the American Heart Association. Circulation. 2024;150(23):e481–e500. doi:10.1161/CIR.0000000000001295

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13. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474–e1502. doi:10.1542/peds.2014-2742

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16. Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatr Anaesth. 1995;5(1):53–61. doi:10.1111/j.1460-9592.1995.tb00242.x

17. Feld LG, Neuspiel DR, Foster BA, et al. Clinical practice guideline: maintenance intravenous fluids in children. Pediatrics. 2018;142(6):e20183083. doi:10.1542/peds.2018-3083

18. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi:10.1542/peds.2017-1904

19. Franklin D, Babl FE, Schlapbach LJ, et al. A randomized trial of high-flow oxygen therapy in infants with bronchiolitis. N Engl J Med. 2018;378(12):1121–1131. doi:10.1056/NEJMoa1714855

20. Moore M, Little P. Humidified air inhalation for treating croup. Cochrane Database Syst Rev. 2011;(6):CD002870. doi:10.1002/14651858.CD002870.pub3

21. Moulia DL, Link-Gelles R, Chu HY, et al. Use of clesrovimab for prevention of severe respiratory syncytial virus-associated lower respiratory tract infections in infants: recommendations of the Advisory Committee on Immunization Practices – United States, 2025. MMWR Morb Mortal Wkly Rep. 2025;74(32):508–514. doi:10.15585/mmwr.mm7432a3

22. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964–e999. doi:10.1542/peds.2012-3488

23. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. NIH Publication No. 07-4051. Bethesda, MD: National Heart, Lung, and Blood Institute; 2007. (Acute exacerbation dosing table; not changed by the 2020 focused update.)

24. RxFiles. Amoxicillin 80 to 90 mg/kg/day: the dose may appear high but likely not a reason to call. Saskatoon, SK: RxFiles; 2024. https://www.rxfiles.ca/rxfiles/uploads/documents/Amoxicillin-HIGH-DOSE-Infographic.pdf (source of the usual 4 g/day pediatric maximum)