[Music]
Facilitator 2 (FA2): Okay, we're gonna do something a little bit different. We're going to actually watch
a patient scenario here and then kind of talk about it as a group.
Sound like a plan? See if I can turn on this video.
These are some videos of some patient scenarios that are actually real scenarios here.
Nurse (N): Linda Boggs?
Patient (P): That's me.
N: Have a seat, Linda. My name is Nikki, I'm one of the nurses.
I need to ask you a few questions about what brought you
here today. You're having some belly pain and bleeding?
P: Yeah, it's not really pain,
it's like cramping up on me, like I have my period.
I thought maybe I was pregnant because I skipped a period.
N: Okay, how long have you had this cramping?
P: It started about two hours ago.
I was sitting watching TV and it just came on kind of sudden.
N: Okay, on a scale of 0 to 10, with 10 being the worst pain you could
imagine, how do you rate this cramping?
P: About a five.
N: Alright, and you're bleeding?
P: It started spotting in the morning and now it's like a heavy period.
N: Have you passed any clots?
P: No.
N: When was your last normal menstrual period?
P: It's been a while... Let me see, maybe seven or eight weeks ago?
N: Have you ever been pregnant? P: No.
N: Okay, any dizziness? P: No.
N: Okay, good. How old are you? P: 23.
N: Any medical problems you see doctor regularly for?
P: No, I'm real healthy.
N: Alright, do you take any medications?
P: Nope. N: Any allergies to any medications?
P: No N: Alright, I just need to take your blood
pressure and then put this thing on your finger.
[Camera goes to dinemap and shows vital signs.]
[Then goes to nurses note. Nurse marks ESI 3 note needs to say skin warm and dry]
FA2: Lower abdominal pain with vaginal bleeding is a common chief complaint in
women of childbearing age. The cause can range from an ectopic pregnancy to a
spontaneous abortion to an irregular menses. In order to decide the acuity
level, it is important to look at the patient. This healthy,
23 year old female does not require immediate life-saving interventions, so
she does not meet criteria for ESI Level 1. The question becomes does she meet
criteria for ESI level 2, and the answer is no. She is awake, alert, oriented her
pain is 5 over 10, and her abdominal cramping is generalized lower abdominal
pain. Her skin is warm and dry and she has experienced no dizziness.
No indication that she has an ectopic pregnancy. The triage nurse feels
comfortable that she is stable to wait in the waiting room.
So, moving on to resources.
This patient will consume a number of resources. She will need labs,
an IV with fluids, an ultrasound and perhaps IV pain medication.
Two or more resources, so she will be assigned ESI Level 3.
After the nurse looks at the patient's vital signs and notes they are within
normal limits. If the patient's vital signs fell
outside the accepted parameter for this age, in this case a heart rate (HR) greater than
100 or a respiratory rate (RR) greater than 20, she could uptriage her to
ESI Level 2. If she was hypotensive or significantly tachycardic or had
impaired mental status or was hemorrhaging that necessitated the need
for immediate hemodynamic interventions, like fluid resuscitation or blood, she
would meet criteria for ESI Level 1. This is a good time to talk about the patient
who presents with abdominal pain. Most patients with abdominal pain will be at
least ESI Level 3, consume many resources, labs, IV with fluids, IV medications and a
cat-scan. The elderly,
patients in severe pain or
abnormal vital signs would meet ESI Level 2 criteria.
The need for hemodynamic interventions would make an abdominal pain ESI Level 1,
requiring immediate life-saving interventions.
Okay so let's stop and
talk about that for a little bit. Do you guys have any questions about this scenario?
[Video continues playing] Oops, I didn't quite get that off. Any questions about that one?
What do you think? FA1: Pretty straightforward?
Registered Nurse 3 (RN3): Yeah, I thought it was pretty typical of the
patients that present in our ED and the types of things you assess, the types of
common interventions. Registered Nurse 1 (RN): And her color looked good. She was fairly animated, she even
smiled in conversation with the nurse, and she didn't have any unilateral pain
or anything indicative of an ectopic, so I'd feel comfortable that even if she's
pregnant, she's relatively stable.
FA2: We get a lot of patients asking about that
ectopic, or a lot of nurses asking about that, they want to make that that
complaint a Level 2 because of an ectopic, but she really doesn't. I think
you said - go ahead.
RN3: Right, I was going to say she looked too good. I mean, her pain
level was low, she interacted well, her color was good.
FA1: And her vital signs were certainly appropriate.
FA2: Yep, generalized abdominal pain, as you said,
not localized abdominal pain. Good.
FA1: Sounds like you guys got it.
RN1: Yeah, we agree that it was a Level 3.
FA2: Oh, good.