Exam (elaborations)
EMERGENCY SEVERITY INDEX (ESI) EXAM 2024/2025 QUESTIONS WITH COMPLETED & VERIFIED SOLUTIONS.
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EMERGENCY SEVERITY INDEX (ESI) EXAM 2024/2025 QUESTIONS WITH COMPLETED & VERIFIED SOLUTIONS.
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EMERGENCY SEVERITY INDEX (ESI)questions to consider when determining if the level 2 patient can wait to be seen: - ANS -would I
use my last bed for this patient?
-should I make a hallway bed for appropriate intervention?
-Is this a high risk situation?
-Is the patient experiencing new onset confusion, lethargy, or disorientation?
-is the patient experiencing severe pain or distress?
to Identify a high risk situation: - ANS an experienced nurse will always assess the patient's
chief complaint, presenting signs and symptoms, demographics, and medical history.
a good source is the emergency nursing core curriculum***
significance of VS in triage: - ANS -a patient with a fever and productive cough may have a
respiratory rate of 32 and SPO2 90%, this patient probably has pneumonia and is at high risk for
oxygen desaturation.
when is abdominal pain a level 2? - ANS -if there is tachycardia, respiratory distress, pallor,
bloating, bleeding, hypotension, (think shock)
-the elderly often experience bowel obstruction, GI bleed, and other problems that place them at
higher risks than younger patients.
-ask yourself: how long has the patient had the pain?, how does the pt describe the pain?, what
made them come to the ED today?, have they had severy nausea, vomiting, or diarrhea?, have
they had fever or loss of apetite? are they dehydrated?
-pt with severe "ripping" abd pain radiating to the back are at high risk for an Abdominal aortic
aneurysm (AAA) -they often describe the pain as severe, constant, and sudden in onset and
may have a hx of high blood pressure. other conditions masquerade as an AAA, the high risk of
this defines this presentation as an ESI level 2
difference in age and how it affects the decision for a level 2 - ANS -vomiting blood for a chief
complaint or blood per rectum should be considered as per vital signs- a 30 YO with bright red
blood per rectum and normal vital signs is appropriately and emergency but does not warrant
and ESI level 2. however, the elderly patient who called the ambulance because he started
vomiting blood and has a heart rate of 117 beats per min. and a rr of 24, is high risk and meets
ESI level 2
chest pain criteria - ANS patients who c/o chest pain with an episode of epigastric discomfort
with or without accompanying symptoms usually will need an ECG to determine the presence of
ACS and need a level 2
-the 54 YO obese female who presents with epigastric pain and fatigue is at risk for ACS.
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