Respiratory Type Illness Nurse Management Guidelines

Red Flag Exclusion Criteria

• Child at risk of significant harm

• Suspected non-accidental injury

• Unplanned repeat ED presentation

• Infant ≤ 3 months

• Chest pain

• Recent overseas travel

• Leg pain

• Increased respiratory effort including increased rate

• Meets case definition criteria for Pandemic Influenza(1)

• Recent infectious disease contact / communicable disease

• History of severe asthma

• History of Chronic Obstructive Pulmonary Disease (COPD)

• Paediatric patients:

  • Decreased ability, or inability to feed due to tiring

  • Respiratory distress assessed as mild, moderate or severe as per Respiratory Distress Table in the Standard Paediatric Observation Chart (ED SPOC)

• History of workplace injury

• Patient brought in by Police or Corrective Services

• Yellow or Red Zones observations or additional criteria outlined in the NSW Health Standard Between the Flags Observation Charts

Additional Observations

1. Assess work of breathing

• Audible breath sounds (grunting, wheeze etc.)

• Respiratory effort

• Use of accessory muscles

• Nasal flaring

2. Auscultate lung fields for normal and abnormal breath sounds and air entry symmetry

Additional History

Events surrounding current illness (e.g. onset and duration of symptoms)

Management Principles

• Provide analgesia as indicated by pain scale. Refer to Pain NMG.

• Encouraged increased oral intake

• Document assessment findings, interventions and outcomes

References / Further Resources

1. NSW Health (2016) NSW Health Influenza Pandemic Plan NSW Ministry of Health, Sydney

2. NSW Department of Health (2011) Recognition of a Sick Baby or Child in the Emergency Department Clinical Practice Guidelines (2^nd Ed.) NSW Department of Health, Sydney