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Nursing

Code Blue

A Code Blue is called for an individual who is at immediate risk for respiratory and/or cardiac arrest with the exception of patients with a "no CPR" order. A Code Blue should be activated in any situation where the additional support and resources provided by the Code Blue Team is needed. 

Your assessment should include  Airway, Breathing, and Circulation.

Airway

Assess the patency of the airway by observing and checking:

  • air entry into the lungs
  • if the amount of air is adequate
  • the position of the head
  • for any signs of obstruction (stridor, hoarse voice dyspnea)

Breathing

Assess the effectiveness of ventilation and oxygenation by observing/checking:

  • chest expansion (e.g. equal and symmetrical)
  • adequate inspiration and expiration
  • ease of breathing, are there signs of increased work of breathing - head bobbing in infants, retractions, nasal flaring, gasping, grunting etc
  • audible breath sounds on auscultation - snoring, grunting, wheezing
  • oxygen saturation
  • colour (e.g. pink versus pale or cyanotic)

Circulation

Assess the effectiveness of circulation by observing/checking:

  • skin colour (pallor, mottling and cyanosis)
  • skin temperature - warm centrally, cool peripherally
  • heart rate - fast, slow or normal
  • presence of peripheral (radial and pedal) and central (carotid, femoral, bracheocephalic) pulses - weak or strong
  • blood pressure
  • capillary refill time - normal or prolonged
  • level of consciousness
  • irritability or lethargy
  • decreased response to pain
  • decreased response to surroundings
  • decreased muscle tone

Note: The above mentioned changes are very important and the emphasis should  be on detecting and treating at an early stage to prevent deterioration.