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:

  • 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

(1) NSW Ministry of Health Pandemic Influenza case definitions are dynamic throughout an influenza season. Refer to specific LHD notifications for the most current Pandemic Influenza definitions.

Additional Observations

  1. Assess work of breathing

  • Audible breath sounds (grunting, wheeze etc.)

  • Respiratory effort

  • Use of accessory muscles

  • Nasal flaring

  1. 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 (2nd Ed.) NSW Department of Health, Sydney

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