Patient Assessment - Deep trouble

gwenith, BSN, RN · Jun 9, 2003

Thank-you all for responding!

Yes B was the worst and yes KUDOS++++ to those who picked the epiglottitis because that was what I was trying to describe. They get sick fast and they can lose an airway fast.

C is also a big potential trouble for although they are saturating well the very fact that they are tolerating a guedel airway means they have lost at least one of the three main protective mechanisms of the airway - the gag reflex. (The other two mechanisms are swallow and cough) It depends on how long ago the pateint took the OD and whether or not the GCS is mproving but it would be probable this patient would be tubed. Studies have actually proven that there is no correlation between GCS and gag so we would need to keep a VERY close watch on this patient.

A) Yes would have you worried but as a GENERAL rule ( and believe ME there are exceptions) Cardiac patients who are expereincing true 10/10 chest pain are usually envervated. They have little or no energy.

Still - all chest pain is guilty of being cardiac until proven otherwise.

We had an interesting case recently with admission of central chest pain relieved by anginine tablets SL. ECG showed tall "t" waves. No troponin rise no CK change. Past ECG showed this pattern is normal for him.

Talk about it while I think up a few more. Disagree with me if you like. Anyone who has had recent experience with epiglottitis please feel free to come in and talk about the latest management as my experience is a couple of years old.

nowplayingEDRN · Jun 9, 2003

I 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

bestblondRN · Jun 9, 2003

gwenith,

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.

ScarlettRN · Jun 9, 2003

We 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?

LPNtoBSNstudent, BSN, RN · Jun 9, 2003

I love these posts!!! Keep them coming, please?

Mkue · Jun 9, 2003

that was great Gwenith, thank you:)

Peeps Mcarthur · Jun 9, 2003

Patient 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.

Differential DX:

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.

Anyhoo,

Geeze I'm late again.

Buhbye.

dosamigos76, RN · Jun 9, 2003

Thank you so much for posting these Gwenith!

Cheryl

Peeps Mcarthur · Jun 10, 2003

Patient C

Oversdose Vital signs within normal parameters. Monitor - sinus rhythm. Sao2 99% on 100% O2 GCS 6/14 eye opening to painful stimuli.verbal respons - nil and Motor response 3 - flexing. When you see the patient tehy are in a lateral position with a guedel airway in place (oropharyngeal airway)

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.

gwenith, BSN, RN · Jun 11, 2003

Thank- 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.

canadian · Jun 11, 2003

OK...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?

who

karenG · Jun 11, 2003

gonna send B first- if antipyrexials havent brought the temp down then you are potentially in trouble!

karen