Difficult/Special Situations Flashcards
Signs of Abuse
- Verbally aggressive
- Tension between carer/pt
- Signs of stress
- Inconsistent accounts
- Defensive
- Disengaged
- Pt not left alone with staff
- Eveidence od psych disorder
- Evidence of intoxication
Exam features - concern elder abuse
- Poor sanitation
- Signs of trauma
- Unexplained bruising
- Unexplained fractures
- Untreated physical conditions i.e. infections / pressure sores
- Restraint marks
- Wt loss
- Dehydration
- Malnutrition
Advanced Care directive
- Situation where pt does not have capacity or abiltiy to communicate wishes
- Made when had capacity
- Signed and witnessed
- Applies to current siutation
- Clear and specific about treatments wanted or refused
Capacity
Capacity refers to an adult’s ability to make a
decision for him or herself.
Capacity is specific to the particular decision that
needs to be made.
Evidence of capcity:
* understand/believe the facts involved in making the decision
* understand the main choices
* weigh up the consequences of the choices
* understand how the consequences affect them
* make their decision freely and voluntarily
* communicate their decision
Bleeding in Jehovah’s witnesses
- Haemostatic control
a. IVF / IV colloid
b. TXA 1g IV stat
c. Desmopressin
d. Avoid coagulopathy, hypothermia, acidosis
e. Some products may be acceptable:
- Vitamin K
- Cryo
- Factor VIII - Surgical control
a. Cell salvage
b. Less invasive technique - laparoscopic
c. Tolerate less bleeding intra-op
d. - Stimulate RBC production
a. Fe Transfusion
b. EPO
c. B12 and folate
Care of the dying
- Acknowledge pt dying
- Share with patient and designated relatives
- Account for pt wishes / beliefs / faith / values
- Anticipatory prescribing for symptom control
- All further interventions reviewed in interest of patient
- Nutritional needs assessed
- Regular assessments
- Care of patient immediately after death dignified
Drug Seeker
- Dvp rapport
- Ensure no new organic pathology
- Treat genuine pain
- Onced rug seeking established -set clear limitations regarding meds sought
- Consider open discussion w/ pt regarding their behaviour
- Refer to D+A for ongoing Mx
- Dvp Mx protocols for future attendances or agressive behaviours
Frequent attender
- Humane approach
- Medical care follow standard procedures
- Access to PMHx and community services involved in pt care
- Dvp individ acute care plan to streamline assessment and Mx
- MDT approach
- Do not divert care away from ED - no benefit to pt
Cultural Safety and competence
Cultural competence = set of behaviours + attitudes, skills and knowledge that allows an indivuidual to interect effectively in cross-cultural situation.
Respects and considers the patient’s cultural background, cultural beliefs and their values and appropriately tailors the way health
care is delivered to that individual.
Cultural safety = a way of practicing; recognising the impact of culture on professional practice
Measured from the patient’s perspective.
Unsafe cultural practice = any action that diminishes,
demeans or disempowers the cultural identity and well-being of an individual.
Non Accidental Injury - Kids
History
No Hx / Inconsistent / Changing history
Inconsistent with child’s dvpt stage
Non-ambulatory Infant
Unwitnessed Trauma
Delay in seeking medical attention
Parental Factors - DV, young maternal age, Substance abuse, Mental Health Isuses, Known to DCJ, Previous Hx of abuse
Examination
Bruising
Any bruising < 4months
Bruising to trunk, ears, neck
Bruises to frenulum, auricular, cheek, eyes, sclera
Patterned bruising - linear, identifiable implement
Fracture Patterns
Metaphyseal lesion (bucket handle or corner #)
Ribs -post > lateral
Femoral fracture - non- ambulance child
Humeral - proximal / shaft < 3 years
Scapula, sternal and spinous process
Multiple fractures at various stage of healing
Complex skull fractures
Mulptiple presentations for fractures
Other
Eye - Retinal haemorrhages, SC haemorrhage, eye lid laceration
Burns - soles of feet, buttocks, back of hands
GI - visceral injury, duodenal haematoma, viscous perforation, pancreatitis with no explanation
Genitalia - injury, FGM, hymen perforation
DDx
True accidental injury
Osteogenesis imperfecta
Osteopaenia or rickets of prematurity
Metabolic - Scurvy, Copper deficiency
Chronic disease - liver/renal
Rashes - phytodermatitis, dermal melanocytes is, bulbous impetigo
Mx
Skeletal survey / CT head
Mandatory reporting
ID other children at risk
Admit - Paeds, Child protection, SW input
Documentation
Elements of Verbal De-escalation
Safe Place
Safe space
- Remove agitated pts from waiting room
- Triage to be seen quickly
Posture
- Non-confrontational
Listen carefully
Acknowledge
- note frustration
Clarify limits and offer choices
- no violence tolerated
Exit strategy
