The Emergency Department Of A County Hospital

A 68 year old male presented to the emergency department at 0800 hours via ambulance after experiencing chest discomfort and intermittent palpitations since 0500 hours. Prior to presentation, the patient stated he

When focusing on the Centers for Medicare and Medicaid Systems strategies for improvement with unnecessary emergency room visits, a major key area is accessibility to health care at the appropriate health care setting. For many years, there has been the perception that the emergency department is the only place for someone who is uninsured or underinsured can go to receive the needed and appropriate health care, and in some situations that may be the case. (Rhodes et al, 2013, p.394) Due to the decreases in reimbursements for the publicly funded, more and more physicians are opting out to treating these patients, thus leading to an increase in emergency department utilization. According to a study conducted by Rhodes, Bisgaier, Lawson, Soglen, Krug, and Haitsma, this is becoming a greater concern for the

History of Present Illness: Mr. Olson is a very pleasant 57-year-old gentleman with multiple medical problems to include severe COPD, who is here today for an initial consultation for his shortness of breath. He is followed by a pulmonologist Dr. William Goodman, at the Veteran Affairs Administration. His last evaluation there was in February 2015. Mr. Olson states he has had ongoing dyspnea on exertion over the last two years. He complains of minimal cough. He does note some sinus problems for which he is on Flovent. In the past, he has had pulmonary function testing that did demonstrate reversible airflow obstruction, therefore he likely has some component of asthma overlay. He states that occasionally has chest tightness and chest heaviness. He has gained about 25 pounds over the last year. He is currently using Spiriva, albuterol as needed as well as Symbicort. He is also using supplemental oxygen at 2.5L per minute at night as well as on an as needed basis during the day. Mr. Olson admits to continued tobacco use with about a half pack to a pack a day. He states that when he is feeling depressed, he will smoke more.

S (situation): Hi, my name Kelsey and I am a nurse in the emergency department. I am calling about Shannon O’Reilly’s most recent laboratory results.

The patient did have black soot around his nose and mouth. Thats when first responders started manual ventilation's via BVM and 02 at 15 LPM. At this time Medic 1 assumed patient care. Medic 1 assigned first responders to obtaining vitals signs that are stated in the vital section of the report. It was at this time that Medic 1 applied a OPA after first measuring on what size to use. First responders also applied fast patches to the patients right upper chest and left midaxillary line At this time Medic 1 assigned first responders to start chest compressions a 15:2 ratio. Medic 1 at this time started a IO in the patients plateau region of the right leg. The Plateau region is inferior and lateral to the knee cap. At this time Normal Saline bolus was started with a 60 drop per ML set. Medic 1 found the patient to be in a sinus rhythm At this time miscommunication with Medic 1 and first responders happen with chest comparisons started. We then secured the patient on the cot via 4 straps and transported a code red patient to the nearest hospital. While enroute to hospital radio report was given with chief compliant and treatments listed in the appropriate category of the report. Vitals was continued to be taken every 5

Patient “DD” is a 56-year-old woman who was admitted to a nearby hospital for respiratory failure. With the only previous medical history being chronic bronchitis, she was diagnosed upon admission with COPD, anemia, hypoxia, moderate anxiety, and dyspnea.

Any patient brought into the Emergency Department, is first signed in at ED receptionist desk and triaged by a triage nurse, prioritized and brought to patient room by a charged nurse either by wheelchair or stretcher or walking by the patient depending on patient’s illness. A nurse is assigned to the patient. Emergency Doctor comes in and if the patient illness is life threatening it is stabilized and the Doctor orders test such as blood work and x-ray if necessary to be conducted. Based on the test result the patient is either discharged or admitted. Certain times the emergency department is filled with a lot of patient that there is no place to sit and patients keep coming in and creating

History of Present Illness: Mr. Magnuson is a very pleasant 77-year-old gentleman who was previously seen in this office by Elvira Aguila, MD for COPD and hypoxic respiratory failure. He is here today for routine followed up. He was last evaluated in January 2015. Since that time, he states that his dyspnea is worse. He feels that it is related to the weather. He does state that he works around the house, although he does have significant functional limitations because of shortness of breath. His wife also confirms that he is able to do less and less. He has a stable, minimal cough. He is using 4L of oxygen at night as well as, as needed throughout the day. He continues to smoke three to four cigarettes on

Admitted through the Emergency Room at 4 PM to a semi-private room is Maggie P., a 78-year-old retired Registered Nurse with end-stage Chronic Obstructive Pulmonary Disease (COPD). Her temperature is 98.7, B/P 130/92, heart rate 124 and respirations are labored and irregular at 37 per minute. She appears frail and weighs 89 pounds. She is pale with a bluish hue to her lips and nail beds. Oxygen at 3 liters per minute is applied via nasal cannula. She is alert and oriented to time, place, and person. She coughs intermittently, expectorating copious amount of thick gray, blood-tinged sputum. She complains of back and rib pain and 5mg of Morphine Sulfate in administered intramuscularly. On assessment the nurse lists, between

“The patient is Adam Rudd, a 78 y/o white male with a history of hypertension. He has been diagnosed with hypertension past 15 years and is on anti-hypertensive medications and aspirin. He is very weak and short of breath. He is accompanied with his longtime friend Jennifer, who reports that Rudd was looking very weak and was complaining of severe headache and blurred vision before coming to the hospital. He is 5’9” and weighs 270 lb. Vital signs recorded were: oral temperature 98.20 F, BP 224/120 mm Hg with a heart rate of 102 beats/minute and respiration of 24 breaths per minute. The pulse oximetry reading was 94% on room air. He is complaining of severe headache and blurred vision. Rudd said that he did not take his antihypertensive medication or aspirin since he ran out of pills. He has not been taking his medication for past 15 days. He reports no known allergies to any medications or other substances.”

c. 34 years old male who complained of shortness of breath. He was obese and had a history of COPD. He was on two liters nasal cannula. After admitting at the ER, he was tranfered to med-surge floor for further evaluation.

The primary nursing diagnosis for this patient is impaired gas exchange, related to abnormal ventilation and perfusion ratio, as evidenced by restlessness, irritability, anxiety, decreased level of consciousness, abnormal arterial blood gases, and abnormal skin color (Gulanick & Myers, 2014, p. 82). A.C. has an endotracheal tube (ETT), and there is a note for the next day to have surgery to put in a tracheostomy. She is currently a smoker, her C02 is 74.6mEq/L which is high, her pH is low at 7.19, and the bicarbonate is 28.6mEq/L which is high. Her oxygen saturation is maintaining at 90%. Her PA02 is 56mm Hg and FI02 is 0.60. The patient is very anxious and restless in the bed, despite sedation and pain medication, and her skin is pale in color and she is diaphoretic.

While working in the emergency department for my clinical this week I could see the staff members that help in the emergency department. There are RNs, EMTs that have different certifications like BLS or ALS, a nurse practitioner, and doctors. In the emergency department, they have staff members from different parts of the hospital to assess the patients. Radiology comes down to get X-rays on the patients for a closer look at their heart. The patients who come into the ER with shortness of air, chest pains, numbness in the extremities and dizziness with signs of fatigue are ordered an X-ray. The lab can come to draw the patient's blood or the nurse will draw up the patient's blood and then send it to the lab. More patients come in with chest pains or shortness of air while in the ER,

A: Janie is a 60 year old Female with PMH of A-Fib, COPD, Hypothyroidism, HTN, Lung Cancer and recently diagnosed Pulmonary Embolism. Janie presents to ER for evaluation on SOB, cough with greenish sputum, sore thoart, hoarseness and generalized weakness. Janie lives at home with her husband, use to smoke ½ pack per week, but quit many years ago, denies alcohol or drugs. Family history is non-contributory. Allergies: NKDA. Differential diagnosis includes worsening Lung Ca, PE, COPD and CHF. Janie uses home O2 at 4 L/NC. V/S: T=98.7, HR=89, R=16, B/P=132/56, O2 sats=100% on 4L/NC, Pain=6/10. Labs: WBC=7.6, H&H=8.5/27, Na=141, Troponin=0.08/0.06, BNP=495, INR=4.2, UA=3+ protein, 1+ blood and 6-10 RBC. CXR: Impression:1). COPD with nonspecific coarsening of the basilar interstitium. 2). Mild cardiomegaly with borderline cardiac compensation. 3). Right

Patient is a 45 yo male; 5’7”, 221 lbs who entered the emergency room at 6:30 am on 9/7/14 with severe chest pain (onset at 6:00 am) radiating to his arm, L arm numbness and nausea and vomiting. Past medical history reported by wife includes peptic ulcer, tobacco use (1-2ppd for 27 years), elevated blood pressure (controlled by lopressor). Wife did not know of any family history but reports patient’s father is deceased, died at 42 in his sleep. Mother alive and with high blood pressure.