NR 305 Week 8 Discussion Topic, Rapid Assessment of a Client
Please choose one of the patient scenarios below. Next, complete a rapid assessment, and provide a
SBAR report to a classmate. Remember to include all concepts of patient safety, standard precautions,
and professional standards.
1. You are covering for a coworker who is off the floor for lunch, when you suddenly hear a
loud crash coming from a nearby patient room. You quickly run in and discover Mr. Johnson
who was admitted yesterday with a diagnosis of cerebral vascular accident (CVA)
unconscious on the floor between the bed and the bathroom.
2. You are called to the room of 2-year-old Jonah by his mother who states the child has
suddenly started breathing very loudly and does not look right. Upon entering the room you
quickly recognize that the child is in respiratory distress as his lips are cyanotic and the use
of accessory muscles is evident.
3. You are in the process of admitting Ashley, a 27 year old who is 28 weeks pregnant with her
first child, to the obstetric unit for complaints of headache, dizziness, and swelling of her
lower extremities when she suddenly begins seizing.
Professor Cox and Class,
Scenario Chosen:
You are called to the room of 2-year-old Jonah by his mother who states the child has suddenly started
breathing very loudly and does not look right. Upon entering the room you quickly recognize that the child is in
respiratory distress as his lips are cyanotic and the use of accessory muscles is evident.
Due to his loud breathing and cyanotic lips, I would immediately suspect Jonah has an upper airway
obstruction. Cyanosis is considered a late sign of respiratory distress and can lead to respiratory arrest. “A child
with marked tachypnea, significantly increased respiratory effort and changes in airway sounds, deterioration in
skin color, and changes in mental status is in severe respiratory distress”. (Pediatric Advanced Life Support,
2011, p.43). This can be caused by croup, foreign body airway obstruction and anaphylaxis. I would
immediately attempt to maintain his airway by using head tilt chin lift, assess his airway for a foreign body,
place him on a 100% NRB mask and call a Pediatric Code Blue. Signs of respirations distress include
tachypnea, nasal flaring, use of accessory muscles, and change in mental status.
Rapid Assessment would include Assessing:
Airway- maintain open airway check tongue mouth for redness or swelling
Breathing: assess for stridor, wheezing, grunting
Respirations – increased resp. effort- tachypnea, or decreased resp. effort -bradypnea or apnea
Circulation: check brachial pulse, note skin color and temp; pale cool skin- sign of respiratory distress.
V/S including pulse oximetry
Note if Jonah is crying or agitated
Check his LOC
Chest and abdomen- use of accessory muscles indicate an increase in resp effort
, NR 305 Week 8 Discussion Topic, Rapid Assessment of a Client
Auscultate lungs for adventitious or decreased breath sounds.
Note heart rate and rhythm; place him on a cardiac monitor/ pediatric code pads as soon as available. “Cardiac
arrests in children frequently result from respiratory failure”. (Springer, 2016, para.1).
While treating Jonah, I would ask his mother questions regarding his change in status including how
suddenly this came on and if Jonah was playing with anything that he may have put in his mouth. Did he
receive any recent immunizations or taken any recent medications including OTC medicines? Does Jonah
have any allergies or illnesses? Is Jonah up to date on immunizations?
I would obtain IV access if not already done or IO access if IV unobtainable. Draw bloods for ABG’s,
CBC, and chemistry. I would administer appropriate medications such as Racemic epinephrine via neb. and
Decadron IV . “Glucocorticoids (e.g., oral dexamethasone, oral prednisoLONE, and nebulized budesonide) will
decrease subglottal edema by decreasing local inflammation”. (Schub and Boling, 2016). Diagnostic test would
also include portable chest x-ray
Should Jonah’s condition continue to deteriorate, I would begin bag mask ventilate with supplemental
O2 and prepare for endotracheal intubation and transfer to the pediatric ICU.
If Jonah improved I would continue to monitor his respirations, skin color, LOC, and lungs sounds. Prepare
him for transfer home or pediatric ICU.
In this scenario Jonah has been stabilized but MD has admitted Jonah to the pediatric ICU for
continuous monitoring.
SBAR;
Situation:
This is Kathy; I am the nurse caring for Jonah, a 2-year-old male with sudden onset of severe
respiratory distress. A pediatric Code Blue was called and patient is presently stable. He will be transferred to
your unit for continued observation and monitoring.
Background: Mother stated patient had sudden onset of loud breathing. Cyanosis of lips and use of accessory
muscles noted upon initial assessment.
Time of incident: 0950
v/s : T. 101.8, 165, 54 So2=88% RA
Westley Croup Scale of 7
He was placed 100% NRB mask,
Meds:
1. Racemic epi 0.25ml (2.25%) in 3 ml NS via Neb @ 1000.
“Nebulized epinephrine is associated with clinically and statistically significant
transient reduction of symptoms of croup 30 minutes post-treatment”. (Bjornson, Russell,
Vandermeer, Klassen, and Johnson, 2013).
2. Decadron o.6mg/kg/ iv @ 1005
Please choose one of the patient scenarios below. Next, complete a rapid assessment, and provide a
SBAR report to a classmate. Remember to include all concepts of patient safety, standard precautions,
and professional standards.
1. You are covering for a coworker who is off the floor for lunch, when you suddenly hear a
loud crash coming from a nearby patient room. You quickly run in and discover Mr. Johnson
who was admitted yesterday with a diagnosis of cerebral vascular accident (CVA)
unconscious on the floor between the bed and the bathroom.
2. You are called to the room of 2-year-old Jonah by his mother who states the child has
suddenly started breathing very loudly and does not look right. Upon entering the room you
quickly recognize that the child is in respiratory distress as his lips are cyanotic and the use
of accessory muscles is evident.
3. You are in the process of admitting Ashley, a 27 year old who is 28 weeks pregnant with her
first child, to the obstetric unit for complaints of headache, dizziness, and swelling of her
lower extremities when she suddenly begins seizing.
Professor Cox and Class,
Scenario Chosen:
You are called to the room of 2-year-old Jonah by his mother who states the child has suddenly started
breathing very loudly and does not look right. Upon entering the room you quickly recognize that the child is in
respiratory distress as his lips are cyanotic and the use of accessory muscles is evident.
Due to his loud breathing and cyanotic lips, I would immediately suspect Jonah has an upper airway
obstruction. Cyanosis is considered a late sign of respiratory distress and can lead to respiratory arrest. “A child
with marked tachypnea, significantly increased respiratory effort and changes in airway sounds, deterioration in
skin color, and changes in mental status is in severe respiratory distress”. (Pediatric Advanced Life Support,
2011, p.43). This can be caused by croup, foreign body airway obstruction and anaphylaxis. I would
immediately attempt to maintain his airway by using head tilt chin lift, assess his airway for a foreign body,
place him on a 100% NRB mask and call a Pediatric Code Blue. Signs of respirations distress include
tachypnea, nasal flaring, use of accessory muscles, and change in mental status.
Rapid Assessment would include Assessing:
Airway- maintain open airway check tongue mouth for redness or swelling
Breathing: assess for stridor, wheezing, grunting
Respirations – increased resp. effort- tachypnea, or decreased resp. effort -bradypnea or apnea
Circulation: check brachial pulse, note skin color and temp; pale cool skin- sign of respiratory distress.
V/S including pulse oximetry
Note if Jonah is crying or agitated
Check his LOC
Chest and abdomen- use of accessory muscles indicate an increase in resp effort
, NR 305 Week 8 Discussion Topic, Rapid Assessment of a Client
Auscultate lungs for adventitious or decreased breath sounds.
Note heart rate and rhythm; place him on a cardiac monitor/ pediatric code pads as soon as available. “Cardiac
arrests in children frequently result from respiratory failure”. (Springer, 2016, para.1).
While treating Jonah, I would ask his mother questions regarding his change in status including how
suddenly this came on and if Jonah was playing with anything that he may have put in his mouth. Did he
receive any recent immunizations or taken any recent medications including OTC medicines? Does Jonah
have any allergies or illnesses? Is Jonah up to date on immunizations?
I would obtain IV access if not already done or IO access if IV unobtainable. Draw bloods for ABG’s,
CBC, and chemistry. I would administer appropriate medications such as Racemic epinephrine via neb. and
Decadron IV . “Glucocorticoids (e.g., oral dexamethasone, oral prednisoLONE, and nebulized budesonide) will
decrease subglottal edema by decreasing local inflammation”. (Schub and Boling, 2016). Diagnostic test would
also include portable chest x-ray
Should Jonah’s condition continue to deteriorate, I would begin bag mask ventilate with supplemental
O2 and prepare for endotracheal intubation and transfer to the pediatric ICU.
If Jonah improved I would continue to monitor his respirations, skin color, LOC, and lungs sounds. Prepare
him for transfer home or pediatric ICU.
In this scenario Jonah has been stabilized but MD has admitted Jonah to the pediatric ICU for
continuous monitoring.
SBAR;
Situation:
This is Kathy; I am the nurse caring for Jonah, a 2-year-old male with sudden onset of severe
respiratory distress. A pediatric Code Blue was called and patient is presently stable. He will be transferred to
your unit for continued observation and monitoring.
Background: Mother stated patient had sudden onset of loud breathing. Cyanosis of lips and use of accessory
muscles noted upon initial assessment.
Time of incident: 0950
v/s : T. 101.8, 165, 54 So2=88% RA
Westley Croup Scale of 7
He was placed 100% NRB mask,
Meds:
1. Racemic epi 0.25ml (2.25%) in 3 ml NS via Neb @ 1000.
“Nebulized epinephrine is associated with clinically and statistically significant
transient reduction of symptoms of croup 30 minutes post-treatment”. (Bjornson, Russell,
Vandermeer, Klassen, and Johnson, 2013).
2. Decadron o.6mg/kg/ iv @ 1005
