ESI Acuity
A 33-year-old male with chest discomfort and med non-compliance is what ESI acuity?
ESI 2: high risk situation; potentially unstable condition, even if vitals are normal (ACS risk)
BIPAP is considered falls under what ESI acuity?
An ESI 1 considered lifesaving resource
When should standing orders be implemented?
When a provider is unavailable (should be within 10 minutes)
EMTALA requires hospitals to provide what to anyone who presents to the ED?
A medical screening exam and stabilizing treatment
What is the quickest way to determine physiologic stability?
Utilizing the basic assessment techniques- inspect, auscultate, and palpate is t quickest way to assess for physiologic stability vs waiting on a set of vital signs
Ankle deformity after a fall >10 feet is what ESI acuity?
ESI 2: High risk trauma (mechanism of injury)
fluid resuscitation or blood products fall under what ESI acuity?
ESI 1 considered lifesaving resources
ESI acuity resources are based on what?
Standing orders
The family of your patient states they are having chest pain. EMTALA requires the nurse to do what?
Encourage the patient to check in for evaluation
C-SSRS screening is completed on which patients?
All patients 12 years of age or older. 12 and younger if BH related complaint
A 6-month-old infant with fever, tachycardia, and congestion. VS: Temp. 103F, HR 176, RR 28, BP 84/56, O2 Sat 96%. What ESI acuity are they?
ESI 2: Consider ESI level 2 for T>102.2, or incomplete immunizations, or no obvious source of fever
A PRN adapter falls under is what ESI acuity?
ESI 5; Saline or heparin lock is not considered an ESI resource
If there isn't a standing order for a chief complaint, the nurse should?
consult with the provider
If EMS has a delayed arrival for transfer, the provider must do what?
Reassess the patient and sign the form within 1 hour
When are Police contacted without patient consent?
A criminal activity has occurred (i.e. stabbing, GSW, etc.) or minors with inconsistent bruising unrelated to the injury.
A patient who is nonverbal and not following commands acutely is what ESI acuity?
ESI 1; unresponsiveness is defined as a patient who either is nonverbal and not following commands (acutely) OR requires noxious stimulus (P or U on AVPU scale)
Crutches and slings fall under what ESI acuity?
ESI 5; crutches, slings, and pre-made splints are not considered an ESI resource
Entering an individual order vs standing order is permitted when?
scope of practice only permits nurses to enter standing orders, unless provided with a verbal order from the provider
A patient at Ballantyne is transferred to CMC. Why is an EMTALA form required for this patient vs. if they were to go to Pineville?
CMC has a different facility license
What is STAMP?
Aggression screening tool.
S: staring and eye contact
T: tone and volume of voice
A: anxiety
M: mumbling
P: pacing
These questions screen for ESI 2 criteria?
High-risk situation OR
Confused/lethargic/disoriented? OR
Severe pain/distress?
How many resources is required for a patient presenting for an STD check?
2 resources; lab and IM injection. Prophylactically treat for STDs but don't test for all of them, therefore IM injection and lab (either swab or urine).
When signing standing orders, which communication type from the drop down is selected?
Standing: cosign required
A minor (<18) can self-consent when?
treatment for:
pregnancy, STD, substance use disorder, emotion disturbance
A person presents to the ED informing the team they need detox. What is an example of non-stigmatizing language that should be used in triage documentation?
Person with substance use disorder, person in recovery are examples of non-stigmatizing language that should be documented vs abuse or addict