Patient Assessment - Deep trouble - page 2
The aim of this "game" is to look at critical indicators in assessment. Some of the patients in the following scenario are in "deep trouble" but some may not be. Can you identify the ones in... Read More
Jun 8, '03I was leaning toward a foreign body occlusion, croup or epigottitis...but did not feel there was enough info. A chile with tachycardia is a sign of impending arrest. Kids just decompensate so damn fast. I just did not say anything more than what I did cause you said not to give away the one in trouble
Jun 9, '03gwenith,
Thanks for starting this thread. It was not only fun, but a good chance for all of us to review our assessment A-B-C's! Keep posting more of these when you have some time.
Jun 9, '03We play this game at work all the time. My boss is also the regional ACLS & PALS instructor, and people come from all over to take her classes.
I was going to ask a few more questions, like cap refill about the child....but in all situations, the child would usually be the hot patient in the ER, right?
Re Patient A, you mentioned the pt was on 4 liters O2, so he isn't really satting that great on his own, right?
For pt C...do we know what drug was ingested?
Jun 9, '03Patient A)
A: Want an ABG. If procedure of obtaining a radial gas, is explained beforehand, chest pain may suddenly subside. I have seen this miracle of Jesus before.
Pain cannot be objectively measured, but one would think it would cause an increase in H/R and BP, especially with all the thrashing and such.
Other than that you are stuck giving the possible drugseeker what he wants. Rule of thumb.......For every drugseeker there are ten liberal lawyers.
O2 via cannula can be difficult to rely on in the restless-take-it-off-every-5 min-type The fact that he is full of CO would also skew your Sao2 reading of a false o2 sat.
Kudos to whomever managed an ECG.
No mention of R/R
Is he on any meds that would skew your
normal? What "door prizes" did you find in his pockets? How does he present on visual inspection of say, looking for retractions, tracheal deviation, asymetrical thoracic cavity. What are B/S like in this 25 year smoker? Are there any visible signs of blunt force trauma.
Pts with pneumothorax can present this way. Blood gas could give a false sense of security from reading CO saturation. I would expect SOB to also be present though. Can't rely on skin appearence either since CO poisoning presents with nice pink flush.
Geeze I'm late again.
Jun 10, '03Patient C
What are resp?
ABGs should be drawn in order to assess ventillation. Since gag reflex is missing, aspiration is a real possibility. Sao2 is not a reliable indicator for the same reason it isn't for pt A.
As for pt B, drooling and asymetrical jawline are halmarks of epiglottitis. I haven't been trained in peds, so I don't know squat about a differential. Ascultation of the airway and visualization should confirm the need for the epi neb
Poor RT is going to be filling all these orders.
Jun 10, '03Thank- you all for responding - as I have said before it is not about me teaching you but us learning form each other. WE live in slightly different worlds i.e. we do not have respiratory techs. We do, in some hospitals, have anaesthetic techs who maintain the circuits on vents etc. but are unable to give meds. Also some of our drug names are different i.e. Epi = adrenalin. So sometimes writing these becomes a little difficult.
Peeps McCarthur - great responses! I keep coming back to assessment without laboratory support as THIS is the first line. This is one of the reasons I don't give many lab results.
One of the things I am exploring here is primary assessment not as it is described in many assessment texts but as nurses acutally do it. i.e. differentiating between chst pain of cardiac origin and non- cardiac sources of reported discomfort. One day this may even help plug that darn theory-pracitce gap.
Jun 10, '03OK...looks like a really fun game...and learning too...
Here are my two kids that present in emerg:
A: kiddie 4 yrs old 3day Hx malaise and cough, dehyrated, temp 38.8
B: kiddie 4 years old on Tx for ALL temp 38.3 no other Sx.
who ya gonna send past triage first?
Jun 11, '03gonna send B first- if antipyrexials havent brought the temp down then you are potentially in trouble!
Jun 11, '03The 8 year-old seems in the deepest trouble, obstructed airway, tachycardia=resp.distress, probable upcoming pediatric code?
Jun 11, '03Okay turnabout is fair play Canadian
I'm not really Paeds nor ED but I would choose the first child. Being from a hot country we can get some severly ill dehydrations.
Ooooh! This IS fun!!!