You are an emergency pediatric nurse. You

You are an emergency pediatric nurse. You receive this SBAR on a new patient:S: A 12 year old girl named Claire Smith who has had a general body rash for 3 days with intense pruritis. The reddish wheals vary in size from less than .5 to less than .25 mm. Claire states she doesn’t know what triggered this episode.B: Pt. has a history of multiple allergies. She also has asthma. She has a history of wheezing dyspnea and pruritis with exposure to peanuts, chickpeas and lentils. She awoke this morning feeling like she was “going crazy” scratching herself. She also c/o some difficulty breathing. The mother, Beth, says her daughter’s lips looked blue at that time.A: Anxious pale, pt. speaking in short sentences. Obvious raised rash over arms and face Temperature: 99.8 temporally Pulse: 112 apical Respirations: 40 breath/minute with audible expiratory wheeze Oxygen saturation: 85 in 21% B/P: 128/88 After receiving these vitals, what is the order of your next actions? – 1. 2. 3. 4. Gather complete medical history – 1. 2. 3. 4. allow patient to assume position that makes breathing easiest – 1. 2. 3. 4. Place on cardiac/respiratory monitor with continuous saturation readings – 1. 2. 3. 4. Place on nonrebreather bag with 100% oxygen and taper as able SCIENCE HEALTH SCIENCE NURSING NS 452

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