Do this if you suspect life-threatening condition
As soon as the triage nurse suspects life-threatening pneumonia, the ED nurse stops his or her assessment, moves the patient to a treatment room, and notifies the ED physician, says Amanda Person, RN, an ED nurse at Methodist North Hospital in Memphis, TN. She gives the following example: Mr. J. is a 76-year-old male who presents to ED triage with his wife.
Chief complaint. "I've been short of breath for three days."
History of the present illness. Dyspnea for three days, gradual onset. Dyspnea on exertion initially, but now the patient is short of breath at rest. Has used albuterol inhaler from a previous episode of bronchitis six months ago, but without relief. Admits to pain in the right, middle, posterior chest, dull, non-radiating, 6/10. Also admits to productive cough with moderate amounts of thick, yellow sputum. Denies fever, but admits chills and diaphoresis.
Primary survey.
General: Presents in wheelchair, sitting in tripod position; occasional cough noted.
Vital signs: Heart rate 120. Blood pressure 90/45. Respiratory rate 30. Oxygen saturation 90% on room air. Temperature 38.9.
Airway: Speech is clear, but patient is unable to speak more than a few words without gasping for air. No excessive oral secretions.
Breathing: Tachypneic and labored. Rhonchi and diminished breath sounds over the right middle lobe.
Circulation: Capillary refill of five seconds. Skin clammy and mottled. Peripheral pulses thread.
Disability: Lethargic. Oriented to person, place, time, and situation.At this point, the ED nurse should realize that this patient's condition is potentially life-threatening and is likely related to pneumonia. "This warrants cessation of triage, immediate bed placement, and notification of the ED physician on the patient and his condition," says Person.
As soon as the triage nurse suspects life-threatening pneumonia, the ED nurse stops his or her assessment, moves the patient to a treatment room, and notifies the ED physician, says Amanda Person, RN, an ED nurse at Methodist North Hospital in Memphis, TN.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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