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

LS
By Lindsay Smith, AGPCNP
Updated April 5, 2026

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). Ranges represent awake resting values. Fever, pain, anxiety, and illness will shift all parameters.

Age group Heart rate (bpm) Respiratory rate (breaths/min) Systolic BP (mmHg) O2 saturation
Newborn (0–1 mo) 100–160 30–60 60–90 ≥95%
Infant (1–12 mo) 80–150 25–50 87–105 ≥95%
Toddler (1–3 yr) 70–110 20–30 95–105 ≥95%
Preschool (3–5 yr) 65–110 20–25 95–110 ≥95%
School-age (6–12 yr) 60–100 14–22 97–115 ≥95%
Adolescent (13–18 yr) 55–95 12–18 110–131 ≥95%

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

Stage Age range Erikson's task Key milestones Nursing considerations
Neonate 0–1 month Trust vs. mistrust Moro, rooting, sucking reflexes present; fixes gaze briefly Keep with parent/caregiver; minimize separation; skin-to-skin when possible
Infant 1–12 months Trust vs. mistrust Social smile by 2 mo; sits unsupported by 6–8 mo; stranger anxiety peaks 6–9 mo; pincer grasp by 9–12 mo Stranger anxiety is normal — involve parent in all care; use comfort objects; perform procedures quickly
Toddler 1–3 years Autonomy vs. shame/doubt Walks alone by 12–15 mo; 2-word phrases by 24 mo; parallel play; egocentric thinking Offer limited choices ("Which arm for the IV?"); never threaten; keep routines; expect resistance to procedures
Preschool 3–5 years Initiative vs. guilt Rides tricycle; 3–4 word sentences; magical thinking; fear of bodily harm and mutilation Explain procedures in simple, concrete terms immediately before; avoid saying "put you to sleep"; use play therapy
School-age 6–12 years Industry vs. inferiority Logical thinking; peer relationships important; understands cause and effect; fears loss of control Explain what will happen and why; involve child in decisions; allow questions; maintain privacy and dignity
Adolescent 13–18 years Identity vs. role confusion Abstract reasoning; peer influence dominant; developing adult identity; privacy concerns heightened Ensure confidentiality; respect autonomy; address body image concerns; speak directly to the teen, not just the parent

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), oxygen supplementation to maintain SpO2 ≥94%, small frequent feeds or NG feeds if tiring, close respiratory monitoring. High-flow nasal cannula (HFNC) is first-line respiratory support when standard O2 fails.

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

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), cool humidified air or cool night air can provide temporary relief, 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, Distress, and tripod positioning. High fever, muffled voice, 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 months to 5 years. Occur in 2–4% 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 must be ruled out in children with complex febrile seizures.

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. Olive-shaped pyloric mass palpable in epigastrium (right of midline) in 70–80% of cases. 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 normal saline + KCl supplementation.

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)

Diagnosis requires fever ≥5 days plus ≥4 of the above criteria.

Nursing priorities: IV immunoglobulin (IVIG 2 g/kg over 10–12 hours) to reduce coronary artery aneurysm risk, high-dose aspirin (anti-inflammatory phase), echocardiogram monitoring.

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.

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 — CSF glucose below 40 mg/dL (or CSF:blood glucose ratio below 0.6) is abnormal.

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):

Medication Indication Typical dose range Max dose Notes
Acetaminophen Pain/fever 10–15 mg/kg PO/PR q4–6h 75 mg/kg/day or 4 g/day (adult max) Hepatotoxic in overdose; check for acetaminophen in combination products
Ibuprofen Pain/fever 5–10 mg/kg PO q6–8h 40 mg/kg/day or 2.4 g/day Not for infants under 6 months; give with food; avoid in renal impairment or dehydration
Amoxicillin Otitis media, mild infections 80–90 mg/kg/day PO divided q8–12h (high-dose) 3 g/day High-dose recommended for resistant S. pneumoniae; confirm local resistance patterns
Albuterol (nebulized) Bronchospasm/asthma 0.15 mg/kg (min 2.5 mg) q20min × 3, then q1–4h 5 mg per dose Continuous nebulization used in severe exacerbations; monitor HR and K⁺

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.

Category Score 0 Score 1 Score 2
Face No particular expression or smile; relaxed Occasional grimace or frown; withdrawn; disinterested Frequent/constant frown, clenched jaw, quivering chin
Legs Normal position or relaxed Uneasy, restless, tense Kicking, drawn up, legs pulled tight to body
Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid, jerking
Cry No cry (awake or asleep) Moans or whimpers; occasional complaint Crying steadily, screams, sobs; frequent complaints
Consolability Content, relaxed Reassured by occasional touching, hugging, or talking to; distractible Difficult to console or comfort; inconsolable

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.

Numeric rating scale (NRS)

Appropriate for adolescents aged 8 and older and developmentally typical school-age children 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:

Weight rangeFluid rate
First 10 kg4 mL/kg/hour (or 100 mL/kg/day)
Next 10 kg (10–20 kg)Add 2 mL/kg/hour (or 50 mL/kg/day)
Each kg above 20 kgAdd 1 mL/kg/hour (or 20 mL/kg/day)

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

Standard maintenance fluid: Isotonic saline (0.9% NaCl) with 5% dextrose (D5NS) for most hospitalized children. Hypotonic solutions are associated with hyponatremia risk in ill children.

Signs of dehydration in children

Sign Mild (3–5%) Moderate (6–9%) Severe (≥10%)
Skin turgor Normal Decreased (tenting) Markedly decreased
Mucous membranes Normal to dry Dry Very dry, parched
Fontanelle (infants) Normal Slightly sunken Markedly sunken
Eyes Normal Slightly sunken Sunken, absent tears
Heart rate Normal to slightly elevated Elevated Tachycardia, possible bradycardia (late, ominous)
Urine output Mildly decreased Oliguria Anuria
Mental status Normal Irritable or lethargic Lethargic to unresponsive

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)