Emergency Care Flashcards
From APN Celine's lecture
Scope of practice of an ED nurse
- Triage
- Administer treatment and implement interventions
- Evaluate response
- Communicate with pts, fam, multidisciplinary team
- Coordinate discharges and referrals
- Patient advocate in end of life issues
- Crisis intervention
Other roles of ED nurses
- Pandemic, hazmat and disaster preparedness planning
- Research
- Education
Role of the observation medicine and clinical decision unit in ED
provides evaluation and management of selected pts who require further hospital care following ED visit
Which grps of patients does the observation and clinical decision unit cater to?
- Diagnosis unclear after initial ED evaluation
- Selected emergency conditions requiring additional period of treatment or observation
Definition of disaster
Disruption of the functioning of a community, which exceeds the ability of the society to cope using its own resources.
An event which overwhelms local capacity, necessitating external assistance.
Disaster triage in Singapore (P0-P3)
P0: Unlikely to survive given the severity of injuries and require palliative care
P1: Require immediate intervention and transport to hospital due to compromise in A/B/C
P2: Can afford delayed transport to the hospital, have life threatening injuries but is not expected to deteriorate significantly over the next few hrs
P3: Victims with minor injuries that is unlikely to deteriorate over days
Principles of triage
- rapid collection of relevant subjective and objective data
- complex complaint-based process of sorting patients
- Intended to identify the most seriously ill patients with time dependent conditions to ensure that they receive rapid care
- Accurate triage is the key to efficient operation of ED, to increase chance of survival for critically ill patients
Process of triage
Visual assessment –> History Taking with VS –> POCT & PAC status
- Visual assessment (begins when pt first step into ED, assess using sight, hearing and smell)
- Obtain subjective data (presenting complaint using PQRST/OLDCARTS/SOCRATES framework)
- Obtain objective data (VS, pertinent physical findings)
- Past medical history
- Drug history and allergies
- Fall risk/clinical fragility scale
Point of care testing (POCT) purpose
Enables more rapid clinical decision making in the process of diagnosis (rule-in or rule-out), treatment choice and management
Examples of POCTs
- Capillary blood glucose
- Urinalysis (urine dipstick)
- Urine pregnancy test (Urine HCG)
- Visual acuity test
- 12 lead ECG
- Covid ART
How many Patient Acuity Categories (PAC) are there?
PAC 1-4
Role of an effective triage nurse
- Able to estimate conditions from a short clinical history taking, VS and physical examination
- Comprehensive knowledge of pathological presentations
- Intuition developed through long-time experiences
PAC 1
Critically ill and require resuscitation:
- state of cardiovascular collapse
- imminent danger of collapse , require immediate attention
e.g. Cardiac arrest, seizure, shock, acute stroke, poly trauma
PAC 2
Major emergency:
- ill and non ambulant
- In severe distress
- Not in imminent collapse
- Requires early attention, if not likely early deterioration
e.g. Asthma, chest pain, pregnant with PV bleeding (vaginal), testicular pain, burns
PAC 3
Minor emergency:
- Ambulant
- Acute mild to moderate symptoms
- Requires acute treatment which will result in resolution of symptoms over time
e.g. Laceration, sore throat, sprains, diarrhoea
PAC 4
No emergency:
- NON emergency
- Should NOT be presenting to ED
- Pls go home
e.g. Flu symptoms, unspecific aches and chronic pain
Identify the PAC score for the following scenario:
Graham is a 55-year-old man who presents to the ED accompanied by his partner. He states that he has been ‘bleeding from the back-passage’ since the previous night. He is very anxious about the bleeding and reports that it was ‘bright’ in colour and ‘filled the toilet bowl on two occasions. His blood pressure is 155/100 mmHg, heart rate is 102 beats per minute and his respiratory rate is 20 breaths per minute.
PAC2
Only PAC3 if haemorrhoidal bleeding (will NOT fill the ENTIRE toilet bowl)
Identify the PAC score for the following scenario:
Louisa is a 24-year-old woman who presents to the ED with her friend after ‘fainting’ in the toilet at home. She is reporting left sided abdominal pain, which she has had ‘on and off’ for several months. She previously attended the ED two weeks ago for the same problem. An abdominal ultrasound was performed at that time but identified no abnormalities. She rates her pain as 6/10. Her respiratory rate is 18 breaths per minute, heart rate is 82 beats per minute and her blood pressure is 112/64 mmHg. Her skin is cool and dry. She looks pale and uncomfortable.
PAC2 (considering she is cold, dry, pale), unless pt has chronic anemia
Identify the PAC score for the following scenario:
Fred, an 84-year-old man, presents to triage reporting palpitations and central chest pain. He has a history of ischemic heart disease, coronary artery by-pass grafts and atrial fibrillation. He takes his anti-arrhythmic medications regularly and normally manages well at home. Today his skin is pale, cool and moist. His respiratory rate is 26 breaths per minute, heart rate is 142 beats per minute and irregular and he reports chest pain of 4/10.
PAC 2: Chest pain
Identify the PAC score for the following scenario:
Rae, a 24-year-old university student, comes to the ED with a friend. She has a four-hour history of generalised abdominal pain, now localised to the right iliac fossa. She has vomited twice and had one episode of diarrhoea about two hours ago. Her respiratory rate is 24 breaths per minute, heart rate is 92 beats per minute, blood pressure is 128/72 mmHg and her temperature is 38.2 °C. She rates her pain as 6/10
PAC3 (looks relatively well, hemodynamically stable + she has friend beside her who can alert HCPs if she suddenly unwell)
PAC2 if appendix already ruptured
PAC1 if compromised V/S + severe abdominal pain
Identify the PAC score for the following scenario:
Sarai is a 38-year-old woman with a history of asthma. She has required two admissions to the intensive care unit for her asthma in the past 18 months. She presents to triage at 8.30pm following a 22-hour history of wheeze and shortness of breath. She has been self-administering salbutamol at home but has had a minimal response to this despite three nebulisers in the past hour. On arrival her respiratory rate is 26 breaths per minute, she is speaking in three-word sentences and has an audible wheeze. Her oxygen saturation is 91% on room air
PAC1 (has been trying salbutamol w no improvement, Spo2 is 91% - may deteriorate)
Might be PAC2 if pt speaking in phrases, has not had such extensive treatment like this patient can suddenly deteriorate very fast
Identify the PAC score for the following scenario:
A restless 24-year-old man is shouting in the ED waiting area. He says, ‘God says everyone here is a sinner’. He stands up and kicks the seats, his fists are clenched, he is red in the face and breathing hard. He turns to face the waiting patients with his fists raised aggressively.
PAC2 (area is away from everyone else), bc PAC3 has the rest of the pts there. Security guards present at
PAC2 incase he harms himself. It’s the only way to control him/allow him to calm down. Give him anxiolytics (which have sedative effects which cannot be observed in PAC3)
Identify the PAC score for the following scenario:
Vinh is a 74-year-old man who is brought to the ED by paramedics at 5.10am. He has acute shortness of breath and a history of left ventricular failure. His respiratory rate is 30 breaths per minute, with accessory muscle use. His Sp02 is 89%, but the pulse oximetry display is giving a poor trace. Oxygen is being administered at 100% via bag-valve-mask. His heart rate is 112 beats per minute and irregular, and his blood pressure is 180/100 mmHg. Vinh is trying to remove the oxygen mask and is very agitated.
PAC1; possible CVS collapse
Information to gather upon arrival of the ambulance
AT MIST
A: Age of patient
T: Time of incident
M: Mechanism of injury
I: Injuries sustained/suspected
S: Signs and symptoms
T: Treatment/interventions performed
