ESI practice thread

~Mi Vida Loca~RN, ASN, RN · Jun 1, 2017

Here's a question: do you (any of you) make all of your psych patients an ESI level 2?

Our hospital protocol was that we had to unless they were coming in for med refill or something unrelated. But anything with a complaint of SI or an acute pysch issue was automatically a 2 and protocol put in place.

amzyRN · Jun 1, 2017

I have another one. A 58-year-old male found down on the kitchen floor at home by his wife for an unknown length of time. Pt was soaked in urine when he came in, did not follow commands but was reaching out with his left arm. He could move all extremities but his left side was stronger than the right. He had bruising and swelling over his right eye and right hip. He had a history of alcoholism, HTN and high cholesterol. His vitals were stable, with mild hypertension 160s/90s, pulse and oxygen sat within normal limits. He was afibrile. He was breathing spontaneously. His finger stick was also within normal limits. What would you designate his esi?

Party_of_five, BSN · Jun 1, 2017

2? I'm a new grad but it sounds like maybe a stroke.

I used this as a guide: https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/esi/esihandbk.pdf

It said he isn't following commands so that means a 2 but I could also see it being a 3 since we don't know the LKN.

Editorial Team / Moderator · Jun 1, 2017

I have another one. A 58-year-old male found down on the kitchen floor at home by his wife for an unknown length of time. Pt was soaked in urine when he came in, did not follow commands but was reaching out with his left arm. He could move all extremities but his left side was stronger than the right. He had bruising and swelling over his right eye and right hip. He had a history of alcoholism, HTN and high cholesterol. His vitals were stable, with mild hypertension 160s/90s, pulse and oxygen sat within normal limits. He was afibrile. He was breathing spontaneously. His finger stick was also within normal limits. What would you designate his esi?

I'd make him a 2 and get him to CT immediately! If it's an ischemic stroke he wouldn't qualify for TPA, but could be a bleed of some kind, trauma-related or otherwise. If his GCS met our criteria I would actually make him a trauma alert â€” found down is trauma until proven otherwise, and we all know about ETOH and head injuries!

NurseHeart&Soul, MSN · Jun 2, 2017

Here's a question: do you (any of you) make all of your psych patients an ESI level 2?

Yes, level 2 and immediate continuous observation put into place.

JKL33 · Jun 2, 2017

I have another one. A 58-year-old male found down on the kitchen floor at home by his wife for an unknown length of time. Pt was soaked in urine when he came in, did not follow commands but was reaching out with his left arm. He could move all extremities but his left side was stronger than the right. He had bruising and swelling over his right eye and right hip. He had a history of alcoholism, HTN and high cholesterol. His vitals were stable, with mild hypertension 160s/90s, pulse and oxygen sat within normal limits. He was afibrile. He was breathing spontaneously. His finger stick was also within normal limits. What would you designate his esi?

ESI 2

NurseHeart&Soul, MSN · Jun 2, 2017

I have another one. A 58-year-old male found down on the kitchen floor at home by his wife for an unknown length of time. Pt was soaked in urine when he came in, did not follow commands but was reaching out with his left arm. He could move all extremities but his left side was stronger than the right. He had bruising and swelling over his right eye and right hip. He had a history of alcoholism, HTN and high cholesterol. His vitals were stable, with mild hypertension 160s/90s, pulse and oxygen sat within normal limits. He was afibrile. He was breathing spontaneously. His finger stick was also within normal limits. What would you designate his esi?

Great cases Amy! Keep them coming! I'd make him level 2. Stat CT scan needed for sure. He meets the ESI criteria Decision point B for high risk situation and confusion.

~Mi Vida Loca~RN, ASN, RN · Jun 2, 2017

I would love to know if he was drunk at the time. I agree with the 2 though since he had already "come to" by the time EMS arrived.

NurseHeart&Soul, MSN · Jun 2, 2017

I am starting this tread for people to post scenarios (easy or hard) and for others to say how they would triage this patient according to ESI and their rationale for doing so. I think we can learn a lot from each other. Especially newer ER nurses learning from those more experienced.
Does anyone want to start?
It can be based off real patient scenarios.

AWESOME idea for a thread!!

Lev, MSN, RN, NP · Jun 2, 2017

Male patient 39 years old comes in with complaints of swollen cheeks and lip swelling. Pt says also has been having sore throat, cough, and fatigue. Pt comes in with his son who also has a cough and sore throat and wants to be seen. Pt is very obese has puffy cheeks and swollen lips but not our of proportion to rest of his body. Pt says he has a little more puffiness than usual in his face. Pt speaks in full sentances, denies swelling in tongue or throat. Vitals are stable, no swelling noted in mouth or uvula. Pt denies taking any medications that might have caused an allergy but states that he has had some type of cold or flu-like illness that both he and his son has had and though he should come in due to the swelling in his face. Assign an ESI.

My first thought was an ESI 2 for angioedema. Any potential allergic reaction should be at least a 3 but if it involves the face that makes it airway and potentially high risk.

Lev, MSN, RN, NP · Jun 2, 2017

I have another one. A 58-year-old male found down on the kitchen floor at home by his wife for an unknown length of time. Pt was soaked in urine when he came in, did not follow commands but was reaching out with his left arm. He could move all extremities but his left side was stronger than the right. He had bruising and swelling over his right eye and right hip. He had a history of alcoholism, HTN and high cholesterol. His vitals were stable, with mild hypertension 160s/90s, pulse and oxygen sat within normal limits. He was afibrile. He was breathing spontaneously. His finger stick was also within normal limits. What would you designate his esi?

He would be a 2. Sounds like he is out of the window for TPA.

Lev, MSN, RN, NP · Jun 2, 2017

Here's a question: do you (any of you) make all of your psych patients an ESI level 2?

Either 2 or 3. The more high risk ones (attempted suicide, violent, suicidal ideation with a plan, absolutely hysterical - they are triaged as ESI 2s).