Back to the Basics: Reviewing the nurse telephone triage process, guideline selection, and standard assessment skills

Transcription

1 Back to the Basics: Reviewing the nurse telephone triage process, guideline selection, and standard assessment skills Andrew Hertz, MD Vice-President and Medical Director UH Rainbow Care Connection 1

2 Disclaimer I receive royalties from the American Academy of Pediatrics for the book I authored, Pediatric Nurse Telephone Triage. Views expressed are mine, inherent with my experience and biases. 2

3 Objectives 1. Describe the parts and order of the standard pediatric nurse telephone triage call 2. Document a pediatric telephone triage call using suggested assessment processes to assist in conveying the content of the call. 3. Quickly determine the best pediatric telephone triage guideline to use for common complaints. 3

4 Agenda 1. Why standardize the telephone triage process, assessment and documentation 2. One approach to a standard nurse telephone triage call 3. Suggested standard telephone assessment tools 4. Common chief complaints and guideline selection decision trees 5. Questions and Answers 4

5 Occasionally BEWARE Cameo appearances by your co-workers 5

6 Who are we? Me You 6

7 Why? 1. Clinical 2. Communication 3. Patient experience 4. Productivity, business model 5. Risk management, scope of practice 7

8 Dissection of a Telephone Triage Call 1. Introduction 2. Confirmation of Demographics 3. Past Medical History 4. Assessment and Guideline Selection 5. Triage 6. Education and Advice 7. Contract and Closure 8

9 Nurse Telephone Triage Nursing Process 1. Assessment 2. Identify problem/symptom 3. Planning 4. Implementation 5. Evaluation Telephone Triage Process 1. Assessment 2. Guideline selection 3. Triage 4. Education and Advice 5. Contract and Closure 9

10 Dissection of a Telephone Triage Call 1. Introduction 2. Confirmation of Demographics 3. Past Medical History 4. Assessment and Guideline Selection 5. Triage 6. Education and Advice 7. Contract and Closure 10

11 Match Up 1. Introduction 2. Confirmation of Demographics 3. Past Medical History 4. Assessment and Guideline Selection 5. Triage 6. Education and Advice 7. Contract and Closure 1. Clinical 2. Communication 3. Patient experience 4. Productivity, business model 5. Risk management, scope of practice 11

12 Are you kidding me! Diarrhea how many times? 12

13 Seeing Over the Phone 1. Size of objects 2. Respiratory distress 3. Hydration 4. Pain 5. Activity level 6. Rashes 13 13

14 Basic Assessment Onset Duration Severity Relevant associated signs, symptoms and history (presence of fever, hydration status, presence of respiratory symptoms) 14

15 Assessing Size of Rashes, Cuts, Lumps Pin Point tiny Pea ¼ inch Dime ¾ inch Quarter 1 inch Golf Ball 1 ½ inches Tennis Ball 2 ½ inches 15

16 Assessing Respiratory Distress MILD RESPIRATORY DISTRESS Rapid respiratory rate (tachypnea) <2 months > months > years > years >30 over 12 years >20 Mild wheezing and chest tightness may also be present -From Barton Schmitt, MD 16 16

17 Assessing Respiratory Distress MODERATE RESPIRATORY DISTRESS Labored breathing (working harder to breath) Some retractions Trouble talking in full sentences without stopping to breath, trouble sucking on the breast, bottle or pacifier Nasal flaring Wheezing, if present, is now audible, tight and persistent (i.e. can hear over the telephone) -From Barton Schmitt, MD 17

18 Assessing Respiratory Distress SEVERE RESPIRATORY DISTRESS Marked respiratory effort (struggling to breathe) Severe retractions, head bobbing, paradoxical abdominal breathing Cyanosis may occur Breathing may stop (apnea) The other extreme is the slow, weak breathing (agonal breathing) that precedes apnea. -From Barton Schmitt, MD 18

19 I should be getting back to work now, the queue is getting long 19

20 Assessing Hydration Any urine out every 8 hours is adequate Reassure this assures kidneys are getting enough fluid Color and odor of urine does not matter Moist mouth, NOT LIPS Eating does not matter, only hydration 20 20

21 Hydration Status MILD DEHYDRATION: 3-5% weight loss Urine Production: slightly decreased Mucous Membranes: normal Tears: present Anterior Fontanelle: normal Mental Status: normal -From Barton Schmitt, MD 21

22 Hydration Status MODERATE DEHYDRATION: 5-10% weight loss Urine Production: none for > 8 hrs. for infants, > 12 hrs. for older children Mucous Membranes: dry inside of mouth Tears: decreased Anterior Fontanelle: normal to sunken Mental Status: irritable -From Barton Schmitt, MD 22

23 Hydration Status SEVERE DEHYDRATION: >10% weight loss Urine Production: very decreased or absent Mucous Membranes: very dry inside of mouth Tears: absent, sunken eyes Anterior Fontanelle: sunken Mental Status: very irritable to lethargic -From Barton Schmitt, MD 23

24 Assessing Pain MILD: doesn't interfere with normal activities (pain scale 0-3) MODERATE: interferes with normal activities or awakens from sleep (pain scale 4-7) SEVERE: excruciating pain, unable to do any normal activities, doesn't want to move, incapacitated (pain scale 8-10) -From Barton Schmitt, MD 24

25 Assessing Pain - Baby MILD: Active, not crying at time of call (or transient brief periods of crying), will play, doesn t awaken from sleep MODERATE: Intermittent crying, takes longer to console, doesn t want to play, prefers to be held, irritable or fussy, overall, awakening from sleep frequently SEVERE: Unable to do normal activities, unable to sleep or will only fall asleep briefly, miserable, incapacitated, excessive or constant crying, difficult or impossible to console. -From Barton Schmitt, MD 25

26 Assessing Activity, General Appearance Awake Status Level of Distress Interaction or responsiveness Appropriateness of behavior 26

27 Assessing Activity Level Baby Eating well, sucking well Alert Moving all extremities Toddler Walking well Appropriate complaining/toddler frustration Playing with toys Child/Teen Watching TV complains if TV turned off Walks to bathroom Walks to kitchen for drink/food 27 27

28 Assessing Activity Level Nurses are experts at assessment Believe in yourself Document with standard phrases demonstrating you did your job 28

29 Standardizing Activity Assessment Awake, no distress, interactive and acting appropriately (ANDIA) Asleep but arousable, when awake no distress, interactive and acting appropriately (AsANDIA) 29

30 Just one more call and my shift is over 30

31 Didn t make it to the end of shift AsANDIA 31

32 Assessing Rashes 1. Location 2. Size 3. Macular vs Papular 4. Color 5. Blanching vs Non-Blanching 6. Shape 7. Appearance 32

33 Rash Location Local Rash (Focal) Rash is located on just one body part Patchy Rash Rash is located on multiple body parts, but has skip areas of normal skin Diffuse Rash (Generalized) Rash is present on multiple body parts, but not necessarily everywhere 33

34 Types of Rashes Macule (macular) Can not feel the rash, it is not raised Papule (papular) Rash can be felt, it is raised Vesicle (vesicular) Papule with clear fluid Pustule (pustular) Papule with cloudy, purulent fluid Blister Large vesicles 34

35 Color Erythematous (red or pink) Blue or purple Flesh colored Hyperpigmented (darker) Hypopigmented (lighter) 35

36 Blanching vs Non-Blanching Push on rash, depress the skin forcing the blood out of blood vessels (or preventing filling of blood vessels) Blanching rash become skin colored BRIEFLY, then returns to rash color Non-Blanching rash remains discolored even with pressure 36

37 Shape Annular (circular) Linear (in a line) Serpentiginous irregular borders Confluent without breaks Patchy with breaks 37

38 Appearance Weeping Dry Scaly Crusty 38

39 This mom is crazy! 39

40 Documentation Do and Don t Activity Level Don t Asleep, watching TV Do Asleep now, was nl Asleep now, was decreased activity but approp Watching TV, tired, approp Interactive or simply ANDIA AsANDIA 40 40

41 Documentation Do and Don t Don t Chief Complaint Multiple complaints, detail Do Major complaint, general

42 Documentation Do and Don t Fever Level Don t Add value or interpret level Do Document level and how taken 42 42

43 Hey, this mom actually thinks a fever can cause brain damage 43

44 Documentation Do and Don t Time References Don t Use specific dates, times, days of weeks At 10:00, on Tuesday, on the 14 th Do Use reference to time of call 6 hours ago or for 6 hours mean different things 3 days ago or for 3 days mean different things 44 44

45 Documentation Do and Don t Pattern Don t Use continuous or non-stop unless meant Do Recurrent Paroxysms Spasms Episodic Intermittent 45 45

46 Mrs. Smith again!, your turn 46

47 Glad I could help, call back anytime, we re here all night 47

48 Guideline Selection Asthma Wheezing Cough Croup Cold 48

49 Guideline Selection Respiratory Symptoms Rashes Pink Eye Vomiting vs Diarrhea Spitting vs Vomiting Newborn 49

50 Respiratory Symptoms Determine Main Concern Chief Complaint: Cough, wheeze, congestion, runny nose, asthma, croup, trouble breathing, cold, etc. Cough Wheezing Neither Hx of Wheeze Hx of Wheeze no yes yes no Bark, stridor, hoarse yes no Croup Cough Asthma Wheezing Cold

51 Rash Guideline Selection To be used with Pediatric Telephone Protocols by Barton Schmitt, MD Localized Presence of Fever No Location of Rash Yes Generalized Consider having all patients with fever and rash be seen Evaluate for petichiae or pupura (BE SEEN) Chicken Pox Scarlet Fever Rash Localized, Cause Unknown (If triager or caller has an inclination as to the cause, go to that guideline first and see if the description fits) Athlete s Foot Bee or Yellow Jacket Sting Diaper Rash Hand, Foot, Mouth Impetigo Insect Bites (may be generalized) Cold sores Poison Ivy, Oak or Sumac Ringworm Spider Bite Sunburn Tick Bite Rash Widespread, Cause Unknown (If triager or caller has an inclination as to the cause, go to that guideline first and see if the description fits) Fifth Disease Hives Newborn Rashes No On Medication No Rash Widespread, On Medication Yes Amoxicillin (including Augmentin) Yes Amoxicillin Rash 51 Andrew Hertz, MD 2008

52 Pink Eye Pus Eyes crusted shut Recurrent drainage More than sleep yes no Eye red, no pus Eye red, with pus 52

53 Vomiting vs Diarrhea yes Vomit in last 2 hrs. no yes Vomit >1 no Vomiting Diarrhea 53

54 Spitting vs Vomiting Spitting Effortless No discomfort Nose sometimes No worries Vomiting Effort Abdominal muscles Upset Amount does not matter Projectile does not matter 54

55 Vomiting vs Coughing First question with vomiting calls..is their coughing too? Post-tussive emesis is very common in babies, toddlers 55

56 Another constipation call! 56

57 See mom, I could do your job! 57

58 Mental, this one 58

59 That s it, I quit! 59

60 Discussion Questions & Answers 60