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Nursing

Code Blue

Nursing assessment includes the assessment of a child's ABCs: Airway, Breathing and Circulation.

Airway

Assess the patency of the airway by observing/checking:

  • if the infant/child is able to get air into the lungs
  • if the amount of air is adequate for the patient
  • the position of the head
  • for any signs of obstruction

Breathing

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

  • chest expansion (e.g. equal and symmetrical)
  • adequate inspiration and expiration for patient
  • colour (e.g. pink & well-perfused versus pale or cyanotic)
  • ease of breathing (Are there retractions or increased work of breathing?)
  • audible breath sounds on auscultation
  • oxygen saturation

Circulation

Assess the effectiveness of circulation by observing/checking:

  • skin colour
  • skin temperature
  • heart rate
  • presence of peripheral (radial and pedal) and central (carotid, femoral, bracheocephalic) pulses 
  • blood pressure
  • urine output (1ml/kg/hr @ minimum) 1-2 ml/kg/hr
  • level of consciousness
  • irritability or lethargy
  • decreased response to pain
  • decreased response to surroundings
  • decreased muscle tone
  • decreased response to parents

Note: The above mentioned changes are all ominous signs.