ED1- Intro to ED & Patient History

Mid-level Provider

licensed nurse practitioner (NP) or PA

Charge Nurse

manages ED patient flow

Nurse

record medical history, symptoms, monitor patients, start IVs, administrate medication, and assist with procedures

Tech

help nurse/provider and assist with procedures

Respiratory Therapist(RT)

administrates breathing techniques and assist with managing patient airways

Unit Secretary

answers calls, pages other specialists/doctors, organize patients paperwork

First Step to ED Flow

Check-in & Triage:

chief complaint(CC): main reason pt came in

. vitals taken: bpm, respiratory rate(RR), temperature, SaO2= oxygen saturation

level activity: 1(high)-5(low)

Second Step to ED Flow

History & Physical:

nurse assessment: confirm CC, brief medical history, current medications, allergies

Physician: History & Patient history(H&P): history of patient illness(HPI), review of systems(ROS), Past History: past medications, past surgeries, family history, social history, Physical Exam

Third Step of ED Flow

Differential Diagnosis(DDx):

based on H&P evaluate possible causes, doctor orders to "rule out"

Fourth Step of ED Flow

Orders & Treatments:

physician: lab studie- blood work, urinalysis, microscopy, cultures

imaging studies- EKG, X-ray, CT, ultrasound

procedures- sutures, join reduction, splints

meds- antiemetics, analgesics, vasodilators, diuretics, antibiotics

Fifth Step of ED Flow

Medical Decision-Making(MDM):

physician- considers lab results and medications, consults specialists

Sixth Step of ED Flow

Disposition:

discharged home, discharge to nursing facility, admitted, transferred, left against medical advice, expired(died)

Subjective Complaints

what the pt describes they feel

Objective Complaints

what the doctor can use his five senses to identify as fact

Diagnosis(Dx) & Disposition

final diagnosis and where patient will go

PMHx

Past Medical History

High Blood Pressure

Hypertension (HTN)

High Cholesterol

Hyperlipidemia(HLD)

Diabetes

diabetes mellitus(DM)

"I only take pills for diabetes"

non-insulin dependent diabetes mellitus(type 2 diabetes)(NIDDM)

"I take shots(insulin) for diabetes

insulin dependent diabetes mellitus(type 1)(IDDM)

Heart Disease

coronary artery disease (CAD)

heart attack

myocardial infarction(MI + CAD)

Heart Failure

congestive heart failure(CHF)

Irregular Heartbeat

arrhythmia

Asthma

asthma

emphysema or chronic bronchitis

chronic obstructive pulmonary disease (COPD)

blood clot in lung

pulmonary embolism(PE)

Pneumonia

pneumonia (PNA)

Reflux

Gastroesophageal Reflux Disease (GERD)

ulcers

Gastric Ulcer or Peptic Ulcer Disease (PUD)

pancreatitis

pancreatitis

hepatitis

hepatitis

irritable bowel

irritable bowel syndrome(IBS)

bladder infection

Urinary Tract Infection (UTI)

kidney infection

pyelonephritis

kidney stones

renal calculi

"I'm on dialysis"

chronic kidney disease on dialysis(CKD)

enlarged prostate

Benign prostatic hyperplasia (BPH)

Gynecological: GPA

Gravida: # of pregnancies(include current)

Para: # of pregnancies w/ viable results

Abortus: # of miscarriages & abortions

Stroke

Cerebrovascular Accident (CVA)

blockage of brain

Ischemic CVA

brain bleed

Hemorrhagic CVA

mini stroke

Transient Ischemic Attack (TIA)

"blood clot in my leg"

deep vein thrombosis (DVT)

"bulge in my aorta"

aortic aneurysm

"bad blood flow in my legs"

Peripheral Vascular Disease (PVD)

tonsil removed

tonsillectomy

adenoids removed

adeniodectomy

ear tubes

pressure equalizer tubes(P.E)

"ballon in my head"

angioplasty(PMHx CAD)

"stents in my heart"

coronary stents(PMHx CAD)

heart bypass

Coronary Artery Bypass Graft (CABG) --> PMHx CAD

breast removal

mastectomy

part of my lung removed

Partial lobectomy

appendix removed

appendectomy

gall bladder removal

cholecystectomy

part of my colon removed

Partial colectomy

spleen removed

splenectomy

kidney removed

nephrectomy

uterus removed

hysterectomy

ovary removed

oophorectomy

ovary & fallopian tube removed

Salpingo-oophorectomy

prostate removed

prostatectomy

Family History(Hx)

. medical conditions in pt's blood relative

. age of onset important, earlier=more genetic risk

Social History(Hx)

. tobacco/vaping: pack per day(PPD)

. alcohol use: how often

. drug use: what substance?, method of use?, route of administration?, last used?

. occupation: what they do? stress, night shifts, manual labor

. living circumstances: alone, family, nursing, hospice, homeless

Medication & Allergies

. nurse or MA

. only rash, itching, swelling, or difficulty breathing indicate allergies