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Assessment
Pediatric GCS
Vital Signs
Respiratory Distress
Protocol
100
Patient in noticeable distress, initial assessment focuses on
What is airway, breathing, and circulation
100
A pediatric patient of any age who spontaneously opens his/her eyes receives what score on the pediatric glasgow coma scale
What is a 4
100
When assessing the pulse of a patient <1 year old, the caregiver should assess what pulse
What is brachial pulse
100
Nasal flaring, head bobbing, anxiety, lethargy, and retractions are considered
What is early signs of respiratory distress
100
When a change in patient status is noted, the nurse remains where
What is at the child's beside
200
When assessing a patient's breathing, you are assessing
What is rate and depth
200
A patient 0-23 months who smiles/coos appropriately receives what score for verbal response
What is a 5
200
When assessing the pulse of a patient >1 year old, the caregiver should assess what pulse
What is carotid pulse
200
Poor perfusion, bradycardia, expiratory grunting, and apnea are considered
What is late signs of respiratory distress
200
This number is called when an emergency situation is identified.
What is 911
300
The patient is using accessory muscles to breathe, this indicates
What is respiratory distress
300
When asking a patient to raise his or her arm during a GCS assessment, the nurse is assessing what
What is motor response
300
A heart rate of 120 bpm is considered normal for a 1 year old child. T or F
What is true
300
If patient is not breathing, the use of this will be required.
What is bag-valve-mask
300
This person provides delegation during an emergency situation.
Who is the charge nurse
400
The patient is tachycardic and has decreased peripheral perfusion, this is an early sign of
What is cardiovascular compromise
400
If a patient 2-5 years of age grunts, this is marked as a 2 in what GCS category
What is verbal response
400
A respiratory rate of 12-25 for a child 6-8 years old.
What is a normal respiratory rate
400
If respiratory distress is due to trach obstruction, the first step should be to
What is suction
400
This person is notified when an emergency situation has occurred.
Who is the Director of Nursing
500
This can create respiratory compromise in an infant who is a preferential nasal breather
What is nasal secretions
500
When a patient displays abnormal flexion, this is marked as a 2 in what category
What is motor response
500
Indicate patient's health status
What is vital signs
500
A patient experiencing respiratory distress may require this
What is oxygen
500
This person accompanies child needing transport to the ER.
Who is a caregiver