September 19, 2019
Emergency Severity Index Pt.2: Practice Cases – 16 Hypertension

Emergency Severity Index Pt.2: Practice Cases – 16 Hypertension

[Music] Facilitator 2 (FA2): Okay, next case. We have a 33 year old that
comes to triage from her doctor’s office. She complains of a severe frontal
headache, 10/10, for about four days. She went to her eye doctor’s
office because she thought she needed glasses. The ophthalmologist performed an
eye exam and sent her directly to the emergency department for further
evaluation. She’s alert oriented times three (A&Ox3), her blood pressure (BP)
is 260/160, her heart rate is 82, and her respirations (RR) are 16, SpO2 and her temperature are fine. So, what do you not like the most about this case? Registered Nurse 1 (RN1): Well, the
blood pressure is off the charts. Registered Nurse 2 (RN2): So, how
does this work if the blood pressure isn’t part of the vital
signs criteria for the ESI? FA2: That’s a good question. All patients probably should
get vitals, especially adults who are going to go to the waiting room. This is
a perfect case that demonstrates the need for vitals. Facilitator 1 (FA1): While it’s true that
vitals are usually not helpful, a patient with a headache or a nosebleed are really
two examples when you need to take the blood pressure.
Make sure you check it. So, let’s go back to this case. What do you think the ophthalmologist saw and why did he refer her to the emergency department? RN2: Well, maybe she had papilledema and then I guess he checked her blood pressure. FA2: Great. So, what triage level is this patient? RN1: Well, she’s tolerated this pressure for
four days, so I would make her a Level 2. She is high-risk. RN2: Could she be a Level 1? FA2: Well, does she require immediate life-saving interventions? I would err on
the cautious side with this case. She is going to require immediate access
for medication administration to start lowering that blood pressure. While it is
true she may have had this elevated blood pressure for four days, you don’t
know that for sure. It may have just started today. It’s really hard to tell. FA1: Well, I would make her an ESI Level 1 and get her care going. 260/160 is
really high. She is symptomatic and you can bet she has papilledema. She has the potential for a stroke.
What if she was, you know, symptom free and this was a
“by chance” blood pressure? You know, she came in for a minor, unrelated complaint. RN1: I guess you can make her a Level 2 or a Level 3. RN2: I wouldn’t make her a Level
3 though. She’s too high-risk with that high of a blood pressure,
even if she is stable. FA1: Agreed. Okay, time to move on.

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