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INTRODUCTION

The Wheatbelt Nurses Guidelines (WNG) contain information about the 25 most common presentations to emergency departments of the 16 Hospitals throughout
the Wheatbelt. The guidelines were developed to assist nurses in the assessment and management of such patients, when a doctor is not available.

NOTE:
Clarification of DOCTOR AVAILABILITY will be determined by the Director of Nursing and the doctor for each specific Emergency Department

The development of the Wheatbelt Nurses Guidelines has been a project of the Wheatbelt GP Network in conjunction with the Implementing Quality Initiatives in the
State’s Public Hospitals and Health Services Program.

The Wheatbelt Nurses Guidelines were developed through:
 An in-depth study of existing practices and protocols in the 16 Emergency Departments of hospitals in the Wheatbelt
 Analysis of the patients who attended those Emergency Departments from July 2000 to June 2001, and
 Extensive consultation with Nurses, Directors of Nursing and Visiting Medical Officers
th th
The Wheatbelt Nurses Guidelines, 4 Edition 2007 incorporates appropriate sections of the Remote Area Nursing Emergency Guidelines (HDWA, 4 Edition, 2005),
RAN GUIDELINES. Where necessary these sections have been edited by the WNG development team.

The WNG directs users to the RAN Guidelines for guidelines relating to URGENT, Triage 1 and 2 presentations.

NOTE:
Nurses can use either the WNG or the RAN GUIDELINES but CAN NOT proceed with interventions for which they do not have legal cover

Authorisation was obtained in June, 2004 from the Wheatbelt Health Services for the use by nurses of these Wheatbelt Nurses Guidelines.

WHEATBELT NURSES GUIDELINES Page 3
WHEATBELT NURSES GUIDELINES
Page 4
CONTENTS
Emergency Numbers .................................................................Error! Bookmark not defined. Alcohol intoxication ................................................................... Error! Bookmark not defined.
Focussed assessment .......................................................... Error! Bookmark not defined.
INTRODUCTION .......................................................................................................................1
Alcohol intoxication (intervention for all patients, including children) ... Error! Bookmark not
How to use these guidelines ......................................................Error! Bookmark not defined.
defined.
Consultation flowchart ...............................................................Error! Bookmark not defined.
Delirium Tremens ................................................................. Error! Bookmark not defined.
Information for the doctor ..........................................................Error! Bookmark not defined.
Asthma ...................................................................................................................................... 8
Nurse initiated pain relief ...........................................................Error! Bookmark not defined.
Children (see paediatric asthma p92) ................................................................................... 8
Tetanus vaccination status ........................................................Error! Bookmark not defined.
Focussed and Intervention ................................................................................................... 8
Discharge home plan .................................................................Error! Bookmark not defined.
Mild attack, Moderate attack, Serious - life threatening attack ...................................... 35
Discharge assessment ..........................................................Error! Bookmark not defined.
Bronchodilator delivered via spacer (adults and children) .................................................... 8
Discharge home advice .........................................................Error! Bookmark not defined.
Back pain .................................................................................................................................. 8
Patient travel to doctor ...............................................................Error! Bookmark not defined.
Assessment all conditions .................................................... Error! Bookmark not defined.
SECTION ONE: ASSESSMENTS.............................................Error! Bookmark not defined. Urgent conditions (focussed assessment and intervention) . Error! Bookmark not defined.
Universal assessment process ..................................................Error! Bookmark not defined. Non- Urgent conditions (focussed assessment) ................... Error! Bookmark not defined.
Rapid Primary assessment ........................................................Error! Bookmark not defined. Non- Urgent conditions (intervention) ................................... Error! Bookmark not defined.
Initial assessment ......................................................................................................................7 Bites and Stings ........................................................................ Error! Bookmark not defined.
Focussed assessment ...............................................................................................................7 Bee Stings ............................................................................ Error! Bookmark not defined.
Neurological assessment ..........................................................Error! Bookmark not defined. Blue Ringed Octopus and Cone Shell envenomation ........... Error! Bookmark not defined.
AVPU.....................................................................................Error! Bookmark not defined. Centipede bite ....................................................................... Error! Bookmark not defined.
Pupil assessment ..................................................................Error! Bookmark not defined. Scorpion sting ....................................................................... Error! Bookmark not defined.
Glasgow Coma Scale ............................................................Error! Bookmark not defined. Redback Spider bite ............................................................. Error! Bookmark not defined.
Adult Glasgow Coma Scale ...................................................Error! Bookmark not defined. Fish stings (Stonefish, Stingray) ........................................... Error! Bookmark not defined.
Paediatric Glasgow Coma Scale ...........................................Error! Bookmark not defined. Snake bite (land and sea) ..................................................... Error! Bookmark not defined.
Neurovascular assessment .......................................................Error! Bookmark not defined. Burns ......................................................................................... Error! Bookmark not defined.
Pain assessment .......................................................................Error! Bookmark not defined. First aid ................................................................................. Error! Bookmark not defined.
Focussed assessment .......................................................... Error! Bookmark not defined.
SECTION TWO: EMERGENCY INTERVENTIONS ......................Error! Bookmark not defined.
Further assessment .............................................................. Error! Bookmark not defined.
Resuscitation information chart .................................................Error! Bookmark not defined.
Depth of burns ...................................................................... Error! Bookmark not defined.
Basic Life Support .....................................................................Error! Bookmark not defined.
Burns intervention ................................................................. Error! Bookmark not defined.
Abdominal pain ..........................................................................Error! Bookmark not defined.
Calculating % of burn ............................................................ Error! Bookmark not defined.
Focussed assessment ...........................................................Error! Bookmark not defined.
Patients requiring transfer to a burns unit ............................. Error! Bookmark not defined.
Potential problems, conditions to consider ............................Error! Bookmark not defined.
Cardiac irregularity (arrythmias) ................................................ Error! Bookmark not defined.
Abdominal pain assessment related to anatomical regions ..Error! Bookmark not defined.
Urgent conditions .................................................................. Error! Bookmark not defined.
Abdominal pain (intervention) ................................................Error! Bookmark not defined.
Other conditions to consider ................................................. Error! Bookmark not defined.
Urinary retention ....................................................................Error! Bookmark not defined.
Non urgent conditions ........................................................... Error! Bookmark not defined.
Specific discharge instructions ..............................................Error! Bookmark not defined.
Chest pain .................................................................................Error! Bookmark not defined. Red Eye (intervention) .......................................................... Error! Bookmark not defined.
Chest pain (focussed assessment) .......................................Error! Bookmark not defined. Other eye emergencies ........................................................ Error! Bookmark not defined.
Differential diagnosis .............................................................Error! Bookmark not defined. Golden rules ......................................................................... Error! Bookmark not defined.
Features of ischaemic chest pain ..........................................Error! Bookmark not defined. Transport (penetrating / perforating eye injuries).................. Error! Bookmark not defined.
Chest pain (intervention) .......................................................Error! Bookmark not defined. Fever ......................................................................................... Error! Bookmark not defined.
Choking .....................................................................................Error! Bookmark not defined. Fever (focused assessment) ................................................ Error! Bookmark not defined.
Infant (under 1 year) ..............................................................Error! Bookmark not defined. Fever (intervention)............................................................... Error! Bookmark not defined.
Adult / child (over 1 year) ......................................................Error! Bookmark not defined. Conditions considered to identify cause of the fever ............ Error! Bookmark not defined.
Needle Cricothyroidotomy .........................................................Error! Bookmark not defined. Fractures and dislocaTIons ....................................................... Error! Bookmark not defined.
Collapse (loss of consciousness) ..............................................Error! Bookmark not defined. Dislocated elbow................................................................... Error! Bookmark not defined.
Focussed assessment...........................................................Error! Bookmark not defined. Dislocated finger, toe, hand and foot .................................... Error! Bookmark not defined.
Head to toe assessment........................................................Error! Bookmark not defined. Intervention (all fractures and dislocations) .......................... Error! Bookmark not defined.
Common causes of collapse .................................................Error! Bookmark not defined. Headaches ................................................................................ Error! Bookmark not defined.
Collapse intervention .............................................................Error! Bookmark not defined. Conditions to consider .......................................................... Error! Bookmark not defined.
Faint ......................................................................................Error! Bookmark not defined. Headache (assessment) ....................................................... Error! Bookmark not defined.
Transient Ischemic Attack .....................................................Error! Bookmark not defined. Headache (intervention) ....................................................... Error! Bookmark not defined.
Cough ........................................................................................Error! Bookmark not defined. Migraine (intervention) .......................................................... Error! Bookmark not defined.
Focussed assessment...........................................................Error! Bookmark not defined. Hit to head (loss of consciousness for a short time) ................. Error! Bookmark not defined.
Other conditions to consider..................................................Error! Bookmark not defined. Focussed assessment .......................................................... Error! Bookmark not defined.
Intervention............................................................................Error! Bookmark not defined. Intervention ........................................................................... Error! Bookmark not defined.
Cuts and abrasions (wounds) ....................................................Error! Bookmark not defined. Specific discharge instructions ............................................. Error! Bookmark not defined.
Intervention............................................................................Error! Bookmark not defined. Infection of skin and wounds ..................................................... Error! Bookmark not defined.
Diarrhoea / Gastroenteritis........................................................Error! Bookmark not defined. Focussed assessment .......................................................... Error! Bookmark not defined.
Adult (urgent).........................................................................Error! Bookmark not defined. Intervention ........................................................................... Error! Bookmark not defined.
Adult (non-urgent) .................................................................Error! Bookmark not defined. Limb injury ................................................................................. Error! Bookmark not defined.
Children (urgent) ...................................................................Error! Bookmark not defined. Focussed assessment .......................................................... Error! Bookmark not defined.
Children (non-urgent) ............................................................Error! Bookmark not defined. Lower extremities.................................................................. Error! Bookmark not defined.
Ear and Earache ........................................................................Error! Bookmark not defined. Upper extremities.................................................................. Error! Bookmark not defined.
Focused assessment ............................................................Error! Bookmark not defined. Meningitis Bacterial - Meningococcal Disease .......................... Error! Bookmark not defined.
Acute Otitis Externa ...............................................................Error! Bookmark not defined. Signs and symptoms adults and older children .................... Error! Bookmark not defined.
Acute Otitis Media .................................................................Error! Bookmark not defined. Septiceamia versus Meningitis ............................................. Error! Bookmark not defined.
Differentiation between: Otitis Externa and Otitis Media .......Error! Bookmark not defined. Meningococcal Disease (children) ........................................ Error! Bookmark not defined.
Cleaning ears ........................................................................Error! Bookmark not defined. Paediatrics / sick child ............................................................... Error! Bookmark not defined.
Other common conditions .....................................................Error! Bookmark not defined. Most common signs of serious illness in a child under the age of six months.............. Error!
Eye injury and red eye ...............................................................Error! Bookmark not defined. Bookmark not defined.
Eye Injury (intervention) ........................................................Error! Bookmark not defined. Paediatric vital signs ............................................................. Error! Bookmark not defined.
Red Eye (conditions to consider) ..........................................Error! Bookmark not defined. Focussed assessment of the sick child ................................ Error! Bookmark not defined.
Red Eye (focussed assessment) ...........................................Error! Bookmark not defined. Paediatric severe dehydration or shock................................ Error! Bookmark not defined.
Red Eye (alternate assessment strategy) .............................Error! Bookmark not defined. Intussusception ..................................................................... Error! Bookmark not defined.

WHEATBELT NURSES GUIDELINES
Page 5
WHEATBELT NURSES GUIDELINES

Infectious diseases ............................................................... Error! Bookmark not defined.
Page 6
Paediatric respiratory distress (general) ....................................Error! Bookmark not defined. Skin rashes, itches and allergic reactions ............................. Error! Bookmark not defined.
Urgent action .........................................................................Error! Bookmark not defined. Sprains, strains and bruises ...................................................... Error! Bookmark not defined.
Focussed assessment...........................................................Error! Bookmark not defined. Sprains (injuries to ligaments supporting a joint) .................. Error! Bookmark not defined.
Pneumonia ............................................................................Error! Bookmark not defined. Strains (Injuries to muscles and tendons) ............................. Error! Bookmark not defined.
Bronchiolitis ...........................................................................Error! Bookmark not defined. Bruises .................................................................................. Error! Bookmark not defined.
Croup and Epiglottitis ............................................................Error! Bookmark not defined. Tetanus vaccination status........................................................ Error! Bookmark not defined.
Epiglottitis ..............................................................................Error! Bookmark not defined. Throat, mouth and nose pain .................................................... Error! Bookmark not defined.
Mild Croup .............................................................................Error! Bookmark not defined. Pharyngitis (sore throat) ....................................................... Error! Bookmark not defined.
Moderate to severe Croup.....................................................Error! Bookmark not defined. Tonsillitis ............................................................................... Error! Bookmark not defined.
Paediatric Asthma .....................................................................Error! Bookmark not defined. Heart attack (angina, myocardial infarction) ......................... Error! Bookmark not defined.
Assessment and intervention ..............................................................................................92 Heartburn .............................................................................. Error! Bookmark not defined.
Mild attack, Moderate attack, Serious - life threatening attack ............................................92 Nose bleed (epistaxis) .......................................................... Error! Bookmark not defined.
Respiratory distress (severe) .....................................................Error! Bookmark not defined. Mouth ulcers ......................................................................... Error! Bookmark not defined.
Conditions to consider (ALL ARE URGENT)...............................Error! Bookmark not defined. Thrush (oral candidosis) ....................................................... Error! Bookmark not defined.
Assessment in all cases ........................................................Error! Bookmark not defined. Urine - pain on passing urine (dysuria) ..................................... Error! Bookmark not defined.
Intervention............................................................................Error! Bookmark not defined. Focussed assessment .......................................................... Error! Bookmark not defined.
Focussed assessment...........................................................Error! Bookmark not defined. Urinary tract infections (UTI) ................................................. Error! Bookmark not defined.
Gross upper airway obstruction.............................................Error! Bookmark not defined. Urinary retention ................................................................... Error! Bookmark not defined.
Severe pulmonary oedema / left ventricular failure ..............Error! Bookmark not defined. Other conditions to consider ................................................. Error! Bookmark not defined.
Other conditions to consider ..................................................Error! Bookmark not defined. Vomiting, diarrhoea, and dehydration ..................................................................................... 10
Respiratory tract infection (lower) ..............................................Error! Bookmark not defined. Focussed assessment ........................................................................................................ 10
Conditions to consider ...........................................................Error! Bookmark not defined. Conditions to consider ........................................................................................................ 11
Bronchitis...............................................................................Error! Bookmark not defined. Assessment of severity of dehydration ............................................................................... 11
Whooping cough ...................................................................Error! Bookmark not defined. Intervention (adults and children) ....................................................................................... 11
Respiratory tract infection (upper) .............................................Error! Bookmark not defined. Fluid replacement for mild - moderate dehydration ............................................................ 12
URTI (focussed assessment) ................................................Error! Bookmark not defined. Specific instructions ............................................................................................................ 12
URTI (intervention) ................................................................Error! Bookmark not defined. Wheeze with shortness of breath ............................................................................................ 13
Tonsillitis (or Streptococcal infection) focussed assessment Error! Bookmark not defined. Conditions to consider (all are urgent) ................................................................................ 13
Tonsillitis (or Streptococcal infection) intervention ................Error! Bookmark not defined.
Streptococcal infection ..........................................................Error! Bookmark not defined. SECTION THREE: MEDICATIONS.............................................. Error! Bookmark not defined.
Other conditions to consider..................................................Error! Bookmark not defined. Aspirin (e.g. Dispirin, Solprin, Cardoprin) ....................... Error! Bookmark not defined.
Seizures / convulsion .................................................................Error! Bookmark not defined. Ibuprofen (e.g. Nurofen, Advil, Brufen) ........................... Error! Bookmark not defined.
Conditions to consider ...........................................................Error! Bookmark not defined. Paracetamol (e.g. Panadol, Panamax, Dymadon) ......... Error! Bookmark not defined.
Shock .........................................................................................Error! Bookmark not defined.
Common causes of hypovolaemia ........................................Error! Bookmark not defined. RESOURCES .............................................................................. Error! Bookmark not defined.
Assessment (indicators of inadequate tissue perfusion) .......Error! Bookmark not defined. Research data ...................................................................... Error! Bookmark not defined.
Shock (intervention) ..............................................................Error! Bookmark not defined. Formulation of the 25 guidelines........................................... Error! Bookmark not defined.
Skin rashes, itches and allergic reactions .................................Error! Bookmark not defined. Patient education material .................................................... Error! Bookmark not defined.
Urgent....................................................................................Error! Bookmark not defined.
Itch: with or without a rash (non urgent) ................................Error! Bookmark not defined. INDEX ........................................................................................... Error! Bookmark not defined.
INITIAL ASSESSMENT
Following the RAPID PRIMARY ASSESSMENT continue with the following

 Vital signs
 temperature
 BP
 pulse
 respirations
 oxygen saturation if oximetre available

 Ask about:
 chief complaint (symptom)
 associated symptom/s (onset and duration)
 precipitating cause
 mechanism of injury (events) (severity of injury will indicate potential problems)
 pain score
 note body language and facial expressions (e.g. grimacing)
 for Women (date of Last Menstrual Period and normal or abnormal menses)
 time of last food / fluid intake

During the Initial Assessment ALWAYS REMEMBER TO:
 EXPOSE your patient when necessary to conduct your assessment
 Keep the patient WARM
 Get a set of BASE LINE VITAL SIGNS
 Take a full HISTORY (AMPLE = Allergies, Medications, Past history Last ate or drank , Events prior to presentation
 Don’t forget to INSPECT THE PATIENT’S BACK when appropriate. If there is a possibility of spinal injuries log roll the patient

FOCUSSED ASSESSMENT
 Once you have completed the RAPID PRIMARY and INITIAL ASSESSMENTS go on to the FOCUSSED ASSESSMENT, which may include Key Assessment
Points, Subjective and Objective Assessments, and Head-To-Toe Assessments
 You will find the FOCUSSED ASSESSMENT for each of the presenting complaints in the BLUE section of these guidelines

For patients with complex INJURIES, you can refer to TRAUMA ASSESSMENT in the RAN Guidelines RAN 176-182

Section One: Assessments WHEATBELT NURSES GUIDELINES Page 19
ASTHMA
Conduct RAPID PRIMARY ASSESSMENT p 17 and INITIAL p 19 Carry out BASIC LIFE SUPPORT if required p 28 Follow CONSULTATION p8
ASSESSMENT FLOWCHART
CHILDREN see Paediatric Asthma p 89

FOCUSSED ASSESSMENT
MILD ATTACK MODERATE ATTACK SERIOUS-LIFE THREATENING ATTACK
 SaO2, usually > 95 %  SaO2, usually 92-95 %  SaO2, usually < 92 %
 Sounds wheezy  Use of accessory muscles  Patient may have no audible wheeze
 Use of accessory muscles  Moderate to loud wheeze  Use of accessory muscles ++
 Patient can speak normally  Patient can speak short sentences  Inability to speak
 Respiration < 25 / minute  Respiration < 25 / minute  Patient exhausted
 Heart rate < 120 / minute  Heart rate 100-120 / minute  Decreased level of consciousness
 Peak flow >150  Peak flow >150  Respiration > 25 / minute
 Patient gets relief from their own  Patient gets short lived relief from  may suffer respiratory arrest
treatment their own treatment  Heart rate >120 / minute
 bradycardia < 60 / minute when respiratory arrest is imminent
 Peak flow < 150 (may be unable to perform a reading)
 Cyanosis of lips and pale

INTERVENTION
MILD ATTACK MODERATE ATTACK SERIOUS-LIFE THREATENING ATTACK
 Contact doctor on call to authorise  If SaO2 < 95% administer oxygen 8-14  If SaO2 < 95% administer oxygen 8-14 litres / minute to
nebulised bronchodilator treatment litres to ensure saturation is > 95% ensure saturation is > 95%
(Salbutamol 5mg) OR  Contact doctor on call to authorise  If SaO2 still < 92% increase oxygen flow with Hudson or non
 bronchodilator treatment medication including: rebreathing mask
(Salbutamol) via a spacer see  nebulised bronchodilator treatment  Contact doctor on call to authorise medication including:
p 36 (Salbutamol 5mg) OR  nebulised bronchodilator treatment (Salbutamol 5mg), etc
 Monitor SaO2  bronchodilator treatment  Monitor vital signs and SaO2 ¼ hourly
 Monitor vital signs ¼ hourly (Salbutamol) via a spacer, see p 36  Patient will need hospital admission
 Observe over 1 hour and can go  Monitor vital signs and SaO2 ¼ hourly
home  Admit to hospital or discharge home on
 Discharge home plan p 12 advice of the doctor
 Discharge home plan p 12

Section Two: Emergency Interventions WHEATBELT NURSES GUIDELINES Page 35
Section Two: Emergency Interventions WHEATBELT NURSES GUIDELINES Page 36

BRONCHODILATOR DELIVERED VIA SPACER (adults and children)
1. Sit the patient in an upright position
2. Place the spacer mouthpiece between the patient’s teeth and the lips with a good seal
 use a small spacer for children < 5 years
 use a spacer with a mask for children < 3 years
3. Dispense 1 puff from the reliever spray Salbutamol (Ventolin) into the spacer
4. Instruct adult patient to take 1 deep slow breath from the spacer and hold it for 5-10 seconds
 Instruct Children to take 1 slow deep breath and hold it for 5-10 seconds or five (5) normal breaths
5. Repeat steps 3 and 4 according to chart below
6. Breath in and out 5 times between each puff

ADULT CHILD
MILD MILD
 Contact the doctor for authorisation of bronchodilator  Contact the doctor for authorisation of bronchodilator

 Up to 8-12 puffs of Salbutamol (1 puff in spacer at a time)  Up to 6 puffs =/< 6 years (1 puff in spacer at a time)
 Review in 20 minutes  Up to 12 puffs > 6 years according to age (1 puff in spacer at a time)
 If symptoms of Asthma persist then treat as for Moderate  Review in 20 minutes
 If no symptoms or signs of Asthma, the patient can be discharged with  If symptoms of Asthma persist then treat as for Moderate
arrangements to be reviewed by the doctor  If no symptoms or signs of Asthma, the patient can be discharged home
 Discharge home plan p 12 after discussion with the doctor
 Discharge home plan p 12

MODERATE MODERATE
 Contact the doctor for authorisation of medication including bronchodilator  Contact the doctor for authorisation of medication including bronchodilator

 8-12 puffs of bronchodilator (1 puff in spacer at a time)  6 puffs =/< 6 years (1 puff in spacer at a time)
 Review in 20 minutes  12 puffs > 6 years (1 puff in spacer at a time)
 Further management according to authorisation by the doctor  Review in 20 minutes
 Further management according to authorisation by the doctor

NOTE: 8-12 puffs of Salbutamol (Ventolin), are equivalent to 5mg of Salbutamol for nebulisation
Section Two: Emergency Interventions WHEATBELT NURSES GUIDELINES Page 110
VOMITING, DIARRHOEA, and DEHYDRATION
Conduct RAPID PRIMARY ASSESSMENT p 17 and INITIAL ASSESSMENT p 19 Carry out BASIC LIFE SUPPORT if required p 28 Follow CONSULTATION FLOWCHART p8

See Shock Assessment p 97 See Paediatric, Severe Dehydration or Shock p 84

FOCUSSED ASSESSMENT
KEY ASSESSMENT POINTS Determination of severity of dehydration
 Frequency and volume of vomits PAEDIATRICS
 Frequency and volume of urine output Pinch Test
 Pinch skin of abdomen
 Skin recoils instantly = normal
 1 to 2 seconds = mild to moderate dehydration
 > 2 seconds = severe dehydration

SUBJECTIVE ASSESSMENT OBJECTIVE ASSESSMENT
 History  Temperature, pulse, blood pressure
 Vomiting see Vital Signs (Paediatric) p 82
 duration see Paediatric Assessment of the Sick Child p 83
 frequency  Urine output
 volume  has there been reduction?
 Diarrhoea: appearance, watery, any blood  is urine a darker colour?
 Urine  Test urine (ward test)
 frequency  Assess for signs of dehydration:
 decrease or increase in volume  inspect mucous membranes, the tongue and gums (? dry or moist)
 Is patient thirsty?  skin turgor (see Pinch test above)
 Trauma to abdomen or head  presence of tears and appearance of eyes
 Possibility of ingesting  pulse rate
 poison  capillary refill (test by squeezing nail bed of thumb)
 plants (it should be around 2 seconds or less, at normal environmental temperature)
 drugs  Temperature of skin, extremities and body (are they pale and cold?)
 allergenic material  Alert or lethargic especially in children
 infected food  Assess abdomen See Abdominal Pain Assessment p 30
 Difficult to rouse, lethargic
 Headache or migraine
CONDITIONS TO CONSIDER
  
o
Most common cause of diarrhoea and High Fever, if temp > 40 this could be a serious bacterial Pregnancy
vomiting is gastroenteritis, the majority are infection  Poisoning e.g. plants drugs, alcohol
viral infections which are usually self limiting See Meningitis Meningococcal Disease (Adult) p 80
see Gastroenteritis p 61 See Meningitis Meningococcal Disease (Paediatric) p 81  see Urinary tract infection p 108
 Abdominal condition e.g. Appendicitis and  Motion sickness  see Head injury (Hit to Head) p 75
Intussusception  Food poisoning  see Headache, migraine p 74
see Intussusception p 84  Medication induced nausea and vomiting
 Vestibular disturbances

ASSESSMENT OF SEVERITY OF DEHYDRATION
History of diarrhoea and vomiting losing a fluid volume of more than the fluid intake
If an accurate pre-illness weight is available, the degree of dehydration can be calculated from weight loss

NO DEHYDRATION MILD-MODERATE DEHYDRATION SEVERE DEHYDRATION
(<3% weight loss) (3-8% weight loss) (>9% weight loss)
 Urine frequency decreased  Urine amount reduced  Increase in the signs from the mild to
slightly  Urine darker as it’s more concentrated moderate group
 Urine slightly darker  Mouth and tongue dry (be wary of the mouth breather)  Capillary refill >2 seconds (after pinching
 Tongue normal moisture  Skin soft when pinched, diminished turgor (pinch test 1 to 2 seconds) the nail bed of thumb)
 Anterior fontanel normal (in  Anterior fontanel normal or slightly depressed (in children)  Marked reduction in urine output (Anuria)
children)  Altered neurological state, Irritability or drowsiness, see  Hypotension
 Skin turgor normal when pinched Neurological Assessment p 20-22  Circulatory collapse – pale and cold
p 110  Deep breathing (acidotic breathing)

INTERVENTION (Adults and Children)
No dehydration - MILD MODERATE (4%) DEHYDRATION OF 5% or >5%
 Can be treated at home  Contact doctor on call
 Give small frequent drinks of fluid, which can be:  Can be treated at home with oral rehydration solutions, CONTACT DOCTOR ON CALL
 water or oral rehydration fluids e.g. Hydrolyte or Gastrolyte
 Adults (> 13 years) can try Imodium, 1 tab, 4 hourly or  Give patient or carer a time for review with hospital or  5% dehydration or more
Kaomagma for diarrhoea with doctor should be hospitalised
NOTE:  May need to be hospitalised if mother cannot cope
 Continued vomiting is not a reason to stop fluids,
water and / or oral rehydration
 Continuing observations and assessment is essential

Section Two: Emergency Interventions WHEATBELT NURSES GUIDELINES Page 111
Section Two: Emergency Interventions WHEATBELT NURSES GUIDELINES Page 112

FLUID REPLACEMENT FOR MILD - MODERATE DEHYDRATION
PAEDIATRIC ADULT
 Weight is used to calculate volume of fluid needed  Can use oral rehydration solution e.g. Gastrolyte and hydrolyte
 Comparing weight of child pre illness and during illness is a good measure of  A useful guide for diluting drinks at home with water is to make
dehydration the fluid taste slightly sweet, for example:
 Fluid requirement for 24 hours consists of:  commercial cordial: 1 part to 16 parts of water (no diet
 maintenance fluid cordial)
 rehydration to replace fluid already lost  fruit juice: 1 part to 4 parts of water
 must also add fluid equal to any further loss as vomit or diarrhoea  carbonated drinks: 1 part to 6 parts of water
 Volume of fluid required can be discussed with doctor on call Do NOT use sports drinks for rehydration fluids
 Give fluids in small frequent amounts, water if tolerated
 USE oral rehydration fluids at home such as Gastrolyte, Hydrolyte
 DO NOT USE home made mixtures of water, fruit juice or cordials with sugar or salt
and sugar or sports drinks as there may be too much salt and sugar
 Breast feeding should continue
 if breast feeding, can also supplement with rehydration fluid
 MUST pass urine within 8 hrs or 4 times a day
 If child is getting worse MUST return immediately
 If no improvement in 6 hrs 0-2yrs or 8hrs > 2yrs must be seen again
 If inadequate parenting, the child may need admission to hospital
NOTE for ADULT and PAEDIATRIC
 Antibiotics are of no benefit in viral infections and often increase diarrhoea
 For adults, do not rely on antidiarrhoeals such as Lomotil or Kaolin which DO NOT help to prevent dehydration and sometimes can have adverse effects
 Do not use Lomotil or Kaolin for children < 12 years
 Anti-emetics: Stemetil and Maxalon may cause severe toxic effects to children

SPECIFIC INSTRUCTIONS
 Important signs to watch for in babies, children and adults:
 dryness of the lips and tongue
 the number of times urine is passed (must be at least 4 times in a day)
 patient becoming listless and difficult to awaken

Follow Discharge Home Plan p 12
WHEEZE WITH SHORTNESS OF BREATH
Conduct RAPID PRIMARY ASSESSMENT p 17 and INITIAL ASSESSMENT p 19 Carry out BASIC LIFE SUPPORT if required p 28 Follow CONSULTATION FLOWCHART p8

 Respiratory Distress (Severe) Intervention for all cases p 90
 Focused Assessment for Severe Respiratory Distress p 91

REMEMBER: there are patients with a wheeze who do not have asthma

CONDITIONS TO CONSIDER (ALL ARE URGENT)

 Pulmonary oedema: Congestive Cardiac Failure (CCF) or Left Ventricular Failure (LVF) p 92
 Asthma (Adult): serious or life threatening p 35
 Asthma (Child) p 89
Must ring doctor on call
 Paediatric Respiratory Distress p 85
for all patients
 Choking, Foreign Body Inhalation p 54-55
 Croup and Epiglottitis p 87-88

Section Two: Emergency Interventions WHEATBELT NURSES GUIDELINES Page 113