Telephone Triage Protocols for Nurses » (3rd Edition)

Briggs, Julie K., RN, BSN, MHA (Good Samaritan Community Healthcare, Puyallup, WA)

The contributors represent the specialty of emergency nursing. All are from Good Samaritan Community Healthcare in Puyallup, Washington.

This quick-reference manual presents over 200 triage protocols for evaluating patients' symptoms over the telephone. Each symptom entry lists questions, grouped by urgency level, to determine whether the caller should seek emergency care now, seek medical care the same day, call back for appointment, or follow home care instructions. Detailed home care instructions are then provided.

This edition features fourteen new protocols: avian influenza; congestive heart failure; electrical burns; hand/wrist problems; hip pain/injury; influenza; neurological symptoms; newborn problems; pertussis; severe acute respiratory syndrome; sickle cell disease problems; substance abuse; West Nile virus; and wound care: sutures or staples. New appendices include difficult caller practice scenarios; acetaminophen and ibuprofen dosage charts; infant feeding guide; and causes and characteristics of abdominal pain, chest pain, and headache.

Introduction     1
Abdominal Pain, Adult     4
Abdominal Pain, Child     7
Abdominal Swelling     10
Abrasions     13
Alcohol, Hangover     15
Alcohol Withdrawal     17
Allergic Reaction     19
Altered Level of Consciousness     21
Ankle Injury     24
Ankle Problems     26
Anxiety     29
Appetite Loss, Adult     32
Appetite Loss, Child     34
Arm or Hand Problems     37
Asthma     40
Avian Influenza ("Bird Flu")     42
Back/Neck Injury     45
Back Pain     47
Bad Breath     50
Bed-Wetting     52
Bee Stings     54
Bites, Animal/Human     57
Bites, Insect     60
Bites, Marine Animal     64
Bites, Snake     66
Bites, Tick     68
Black or Bloody Stools     70
Bleeding, Severe     73
Blood/Body Fluid Exposure     75
Body Piercing Problems     77
Bone, Joint, and Tissue Injury     80
Breast-Feeding Problems     83
Breast Problems     88
Breathing Problems     90
Bruising     93
Burns, Chemical     95
Burns, Electrical     98
Burns, Thermal     101
Car Sickness     104
Cast/Splint Problems     106
Chest Pain     108
Chest Trauma     112
Chickenpox     114
Child Abuse     117
Choking     119
Choking Emergency Procedure     121
Circumcision Care     128
Common Cold Symptoms     130
Confusion     133
Congestion     136
Congestive Heart Failure (CHF)     140
Constipation     143
Contact Lens Problems     146
Cough     148
Croup     151
Crying, Excessive, In Infants     153
Dehydration     155
Depression     157
Diabetes Problems     160
Diaper Rash     163
Diarrhea, Adult     165
Diarrhea, Child     168
Dizziness     172
Domestic Abuse     175
Drug and Alcohol Problems      177
Earache, Drainage     180
Ear Injury, Foreign Body     183
Ear Ringing     185
Electric Shock     187
Extremity Injury     190
Eye Injury     193
Eye Problems     195
Facial Pain     198
Facial Skin Problems     200
Fainting     202
Falls     205
Fatigue     208
Feeding Tube Problems     211
Fever, Adult     213
Fever, Child     216
Finger and Toe Problems     219
Food Allergy     221
Food Poisoning, Suspected     223
Foot Problems     225
Foreign Body, Eye     228
Foreign Body, Inhaled     230
Foreign Body, Nose     233
Foreign Body, Rectum     235
Foreign Body, Skin     237
Foreign Body, Swallowing of     239
Foreign Body, Vagina     241
Frostbite     243
Gas/Belching     245
Gas/Flatulence     247
Genital Lesions     249
Genital Problems, Male     252
Glands, Swollen or Tender     254
Hair Loss      256
Hand/Wrist Problems     258
Hay Fever Problems     261
Headache     264
Head Injury     267
Hearing Loss     270
Heartbeat, Rapid     272
Heartbeat, Slow     274
Heartburn     276
Heat Exhaustion     279
Heat Stroke     281
Hemorrhoids     283
Hepatitis     285
Hiccups     288
Hip Pain/Injury     290
Hives     292
HIV Exposure     295
Hoarseness     297
Hospice Problems     299
Hypertension     301
Hyperventilation     304
Hypotension     306
Hypothermia     309
Immunization After Injury     311
Immunization Reactions     314
Impetigo     316
Incontinence, Stool     318
Incontinence, Urine     320
Indigestion     322
Influenza     326
Insomnia     329
Intravenous Therapy Problems     331
Itching     335
Jaundice     337
Jaw Pain      339
Joint Pain/Swelling     342
Knee Pain/Swelling/Injury     345
Laceration     347
Leg Pain/Swelling     350
Lice     353
Menstrual Problems     356
Mouth Problems     359
Mumps     362
Muscle Cramps     364
Nausea/Vomiting, Adult     366
Nausea/Vomiting, Child     369
Near Drowning     372
Neck Pain     374
Neurological Symptoms     377
Newborn Problems     380
Nosebleed     383
Nose Injury     386
Numbness and Tingling     389
Ostomy Problems     392
Overdose     395
Pertussis     398
Pink Eye     401
Pinworms     404
Poisoning, Suspected     406
Postoperative Problems     409
Postpartum Problems     412
Pregnancy, Cold Symptoms     416
Pregnancy, Fetal Movement Problems     419
Pregnancy, Hypertension     422
Pregnancy, Leaking Vaginal Fluid     425
Pregnancy, Nausea and Vomiting     428
Pregnancy Problems      431
Pregnancy, Suspected Labor     435
Pregnancy, Suspected Labor < 36 Weeks     438
Pregnancy, Urination Problems     441
Pregnancy, Vaginal Bleeding     443
Puncture Wound     446
Rash, Adult     449
Rash, Child     453
Rectal Problems     457
Reye's Syndrome, Suspected     459
Roseola     461
Rubella (German Measles)     463
Rubeola (Measles)     465
Scabies     467
Scrotal Problems     469
Seizure     471
Seizure, Febrile     473
Severe Acute Respiratory Syndrome (SARS)     475
Sexual Assault     478
Sexually Transmitted Disease (STD)     480
Shock, Suspected     482
Shoulder Pain/Injury     484
Sickle Cell Disease Problems     486
Sinus Problems     489
Skin Lesions     491
Sleep Apnea, Adult     493
Sleep Apnea, Infant     495
Sore Throat     497
Speaking Difficulty     500
Spitting Up, Infant     503
Stools, Abnormal     506
Stye      509
Substance Abuse, Use, or Exposure     511
Suicide Attempt, Threat     514
Sunburn     516
Swallowing Difficulty     518
Sweating, Excessive     520
Swelling     523
Teething     526
Tongue Problems     528
Toothache     530
Tooth Injury     532
Umbilical Cord Care     534
Urinary Catheter/Nephrostomy Tube Problems     536
Urination, Difficult     538
Urination, Excessive     540
Urination, Painful     542
Urine, Abnormal Color     545
Vaginal Bleeding     547
Vaginal Discharge/Pain/Itching     550
Vision Problems     552
Weakness     555
West Nile Virus     558
Wheezing     561
Wound Care: Sutures or Staples     564
Wound Healing and Infection     567
Abbreviations     570
Sample Telephone Triage Protocol Form     571
Community Resources Telephone List     573
Telephone Triage Quality Improvement Survey     574
Telephone Triage Documentation Form     575
Telephone Triage "Call Back" Log      576
Consulting Nurse Call Tape Review     577
Consulting Nurse Call Documentation Review     578
Telephone Triage Training Outline     579
Guidelines for Scenario Practice     580
Difficult Caller Practice Scenario     584
Mystery Caller Practice Session     586
Communicable Diseases     588
Sexually Transmitted Diseases     593
Typical Immunization Schedule     597
Temperature Conversion Chart     598
Weight Conversion Chart     599
Acetaminophen Dosage Chart     600
Ibuprofen Dosage Chart     601
Infant Feeding Guide     602
Teaching Self-Assessment     603
Abdominal Pain Causes and Characteristics     605
Chest Pain Causes and Characteristics     607
Headache Causes and Characteristics     610
Resources     612
Bibliography     614
Quick Reference Protocol Index     618