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.
Not a nurse but based off what I see the nurses at work do, I would have put epigastric pain. If that's where the patient pointed to and said the pain was, why put chest pain? And for him to be so young and to not have chest pain, lightheadedness, dizziness, sob, etc, there's literally no reason to have an EKG done.
Quick tip for the future when you have patients with dark nail polish or blue nailbeds that interfere with SpO2 collecion:
Turn the probe 90 degrees and re-apply to the finger (so it is looking at the finger tip through the sides). Doesn't always work (especially if the fingers are cold/cyanotic) but when you're in a pinch... ;-)
Great points by everyone!! I think I'm doing ok but there is usually one case where I'm going back and thinking what I should have done differently so I can be better. I wasn't necessarily trying to tailor my triage to a cranky dr, but just trying to do it the best and most accurate way. Epigastric pain would have been the best chief complaint, but honestly I'm not sure that it is listed, I'll have to check. Next time I'm having difficulty getting a. SPO2 I will definitely be putting a sensor on the forehead. Thanks again for helping a new nurse think it through.
Thanks. I've only been in this er for about 3 months. This particular dr is very much into pointing out EVERYTHING that you did or didn't do.... If you take initiative and do something it's why didn't you wait for orders, if you don't do something it's why are you waiting? I feel the more I try not to screw up around him, the more I am.
it might take a little while, but you definitely need to develop a relationship with your doc to show that they can trust your judgement
Thanks. I've only been in this er for about 3 months. This particular dr is very much into pointing out EVERYTHING that you did or didn't do.... If you take initiative and do something it's why didn't you wait for orders, if you don't do something it's why are you waiting? I feel the more I try not to screw up around him, the more I am.
I feel if you "err" on the side of the patient, you can't go wrong. I will often get EKGs on patients presenting with epigastric pain or left shoulder pain, especially if they are older or have any kind of history (or they have NO history, meaning they haven't seen a doc in decades). I have picked up some surprise STEMIs this way.
Neonate/infant pulse ox sensors also work well on earlobes. :)
For me, if they say chest pain, I put chest pain. The chief complaint is theirs to declare. That said, he's not a high-risk patient so he doesn't warrant an ESI 2. He's an easy 3, gets a quick EKG and basic labs by protocol (including the TnI) and then sits out in the waiting room for several hours waiting for the higher acuity patients to clear.
I don't want to be the nurse that translates his complaint of chest pain into abdominal pain only to later learn that he had a congential defect that was just declaring itself or a PE. Admittedly, he's at low risk for either event but low risk doesn't mean no risk and that's what the work-up is for. A quick EKG and an iStat troponin, along with chemistry, cbc, and belly labs will shed a lot of light on the situation.
At some facilities, the chief complaint isn't even entered by a nurse; it's entered by a registration clerk before the patient even gets to triage.
I'll also echo Pixie's suggestion of the earlobe and add the webbing between the thumb and forefinger or possibly the toes (which may be a bit warmer). In a pinch, slapping a heel warmer on 'em right away might be enough to give you a reading. It really depends how the line and reassess stack are looking to determine how much effort I'd put into the SpO2 for someone with clear lung sounds and no complaint of SOB... not much, generally.
He would have been epigastric pain with recent hx of n/v with. Notations to where the pain has radiated. EKG in triage Bc we are a chest pain facility and to CYA. A 3, and back to the waiting room. Screw the doctor. You're out in triage and as long as you can stand by what and why you did it, that's what counts.
I had a 63 year old, well dressed lady check in at 0240 am for c/o a toothache.
Now I've had toothaches (just had 2 out of my 7 impacted molars removed last week!). But something about her story just didn't add up.
Vitals were normal.
No other complaints. No real Hx other than HTN.
Something in the back of my mind was bothering me - Who the heck checks in for a tootache at 3 in the morning? On a hunch, I ordered the tech to do an EKG and caught the STEMI.
It is easy to second guess the Triage nurse - especially when you've had the chance to perform a more thorough assessment, ask more than 5 questions and have the leisure of being able to actually observe the patient.
All I have upfront is a Dynamap and 2 minutes to triage someone! Especially now, they're trying to change it by limiting triage vitals to just a pulse ox and heart rate!!!
The most common sites of pain in an inferior wall MI is the epigastric and RUQ's, which is why every ED I've worked uses epigastric and upper abdominal pain as equal indications for a 12-lead compared to sites of pain that fit the anatomical definition of "chest" sites. When screening for possible MI in triage I think nurses and physicians often confuse the anatomical definitions of the "chest" with the actual purpose, which is to look for symptoms frequently associated with an MI.
I took care of a 19 year old male with chest pain (in ICU). He had had a massive MI, due to a previously undiagnosed clotting disorder. Age certainly matters, but even a young person can get in real trouble.
mindofmidwifery, ADN
1,419 Posts
Not a nurse but based off what I see the nurses at work do, I would have put epigastric pain. If that's where the patient pointed to and said the pain was, why put chest pain? And for him to be so young and to not have chest pain, lightheadedness, dizziness, sob, etc, there's literally no reason to have an EKG done.