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Discussion

Triage question

Hi, so I have a long question about a pt I triaged the other night and was hoping to get some insight from some experienced nurses. On a side note, I've been an ER nurse for almost 2 years, only been doing triage for the past few weeks. I have a doctor at work who is very hard on me, so when I was triaging this particular pt, I heard his voice in my ear. A 20 year old male came in c/o chest pain x2 days. Denied SOB, nausea, vomiting, pain going down left arm or up his chin/neck,said pain 5/10. when I asked him where his pain was he pointed straight to his epigastric region, right under his sternum. I asked him several different ways, the pain was not in his chest, not on the left side of his chest, right in the epigastric. He had dusky colored fingers, when I asked him about this he said his hands were always cold and looked like this in the winter. Because of this I was not able to get a SPO2, but I palpated a pule of about 70. He had no complaints of his hands, because as he put it this was normal. I put chief complaint as "abd pain" and put him at ESI of 3. I wrote in my initial note that pt was c/o of "chest pain" but that he pointed to his epigastric region, that it was ongoing for 2 days, and denied other symptoms. I told the charge nurse, it was change of shift, and then told the oncoming dr what was going on. The pt waited longer than I guess the mother thought he should have given that he said chest pain, she though he should've had a ECG immediately. When the other nurse told her that he was put down as abd pain she was angry that he was not in as chest pain. Now this would have been the case had I put chest pain down at the complaint, but I did not think it really was. So my question, is would you have put chest pain down because that's what the pt said, or when I did my assessment and thought it was abd, would you have put that down? Also would the raynauds have had any play, and that I didn't get an SPO2 initially? The doctor that was oncoming gave me a problem on a previous night because I put down chest pain because that was what the pt said, when it was really epigastric pain. I'm still learning and looking for input.

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    If that was me, i would put it down as abd pain, esi 3. A quick ekg would most likely get ordered anyway so a normal ekg would just further back up an abd pain. Romi would probably get ordered anyway just to make sure, but hell most likely get treated with the gi cocktail instead of cardiac

    You need to be able to anticipate exactly what will get ordered, and document your symptom findings to accompany your nursing "diagnosis"

    Imo, if you can backup your triage decisions then you should be fine.

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    I would have done abd pain as well but still ordered an EKG. Just to CYA.

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    • Author

    Thank you nurses for your feedback!!! Just curious if either of you would have thought twice about the raynauds??

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    • Experts

    Please don't think I'm trying to second guess you because I'm not. I always put the chief complaint as what the patient, or in the case of pediatrics, what the parent, says it is. As my assessment unfolds I list others areas of complaint as necessary but the chief complaint remains as how they presented it upon arrival.

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    A 20 year old with epigastric pain, no other associated symptoms, and stable VS? A 3 and out to the waiting room.

    A 87 year old with epigastric pain? They are a 2 and EKG in triage.

    Age matters.

    To make everyone happy, you could have just written epigastric pain. Not chest and not abdominal.

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    I would have used the stated complaint or epigastric pain. I agree with the assignment of ESI Level 3 based on the info presented, however it's not really acceptable to just say "I can't get an spo2." Get an ear probe, a forehead probe, something. The spo2 level with a decent wave form may change your acuity of another pt in the future.

    I do EKG's according to policy...I don't feel like this kid needed a STAT but have worked in ED's that require one to be done as soon as the words "chest pain" escape their lips...even peds. :cautious:

    Sounds like he was fine to be in the waiting room...Mom can get over it. "Chest Pain" shouldn't be the magic words without age, risk factors or CHD.

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    Exactly...I've seen far too many patients say chest pain to just skip the line....I'm guessing there was a time this worked, but now it's so common that we can't just accept it as the standard. I had a girl of approx age 20 try to skip the line or so 10 people deep and claim chest pain cheerfully to me and I pointed her to the back of the line.m she was so offended and started throwing a fit. In that line I had at least 3 elderly patients, one bleeding from the head and one who looked unwell who I was about to pull. I simply told her, "your chest pain does not supersede these elderly patients. I'll get my charge nurse for you to complain to later." She got her EKG, s doc ordered a cxr and she was discharged from the waiting room. One of my elderly patients went to ICU....and there ya go. We start triage with our eyes and go from there.

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    Any complaint has to be put into the context in which it is given. Lots of reasons for your patient's complaint, and the most worrisome would be cardiac, which is why we're all even talking about this.

    Once you assess the PQRST etc., you've got to consider risk factors for cardiac ischemia. Age? Smoker? Diabetic? HTN? Obese? Other vascular disease like peripheral vascular problems, carotid disease, aortic aneurysm? What's his exercise tolerance?

    You're trying to match the complaint with the likelihood of cardiac ischemia, and you can't do that without considering co-morbidities and risk factors. If they don't match up, they don't get priority.

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    • Experts

    Just curious and want further information. If I, a 40 something diabetic came in with chest pain, I would be treated after a 70 year old with chest pain due to age?

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    • Experts
    Any complaint has to be put into the context in which it is given. Lots of reasons for your patient's complaint, and the most worrisome would be cardiac, which is why we're all even talking about this.

    Once you assess the PQRST etc., you've got to consider risk factors for cardiac ischemia. Age? Smoker? Diabetic? HTN? Obese? Other vascular disease like peripheral vascular problems, carotid disease, aortic aneurysm? What's his exercise tolerance?

    You're trying to match the complaint with the likelihood of cardiac ischemia, and you can't do that without considering co-morbidities and risk factors. If they don't match up, they don't get priority.

    I think we're all on the same page. I list the chief complaint just to "check the box" and continue as my assessment indicates further...this has nothing to do with my assessment of acuity.

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    Just curious and want further information. If I a 40 something diabetic came in with chest pain, I would be treated after a 70 year old with chest pain due to age?[/quote']

    For me that would depend on EKG, vital signs and clinical presentation.

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