Day 1: ED Flow/PMHx/PSHx Flashcards
(123 cards)
Main components of ED flow:
Chief complaint (CC), Physician Assessment (H&P), Objective Orders, Results & Medical Decision Making, Disposition
Chief complaint is comprised of:
the reason the patient came to the ED
Physician Assessment is comprised of:
Initial subjective complaints (HPI, ROS), and objective facts (PE), DDx
Objective orders is comprised of:
tests are ordered for each DDx to determine if the disease is present
Results and Medical Decision Making is comprised of :
reviewing the lab/test results to rule out unlikely DDx, and arrives at a final diagnosis
Disposition can be:
admit, discharge, transfer
Five triage vital signs
HR, BP, T, SaO2, RR (respiratory rate)
Covered during nurse assessment
- confirm chief complaint
- review allergies
- brief PMHx
Covered during H&P
Subjective, Hx, Objective
Covered during subjective
HIP, ROS
Covered during Hx
PMHx, PSHx, FHx, SHx
Covered during objective:
PE
The doctor places orders to ____ each differential diagnosis
rule out (r/o)
Types of physician orders
labs, imaging, procedures, medications
Charge nurse:
manages ED patient flow
LNP, PA:
works under supervision of physician
ED Nurse
records MHx, symptoms, monitors patient, starts IVs, administers meds, assists w/procedures
Respiratory Therapist (RT)
admins breathing treatments, manages patient’s airway
ED tech
helps nurse, assists w/procedures
Unit secretary
places docs orders, answers phone, pages docs, organizes pt paperwork
Pain vs. tenderness
pt’s feeling vs physicians assessment
distress
docs judgement of discomfort (none, mild, moderate, severe)
baseline
individuals normal state of being
inpatient
admitted to the hospital overnight
