Triage for Practice Nurses

Why didnt they just go to the hospital, dont they know theyre sick?

What is TRIAGE?

A French noun derived from the verb trier, which means to sift or sort. Has contemporary usage in agriculture, mining and the railways, and was imported into the English language in the 18th century to describe the sorting of wool and coffee.

Triage

In medicine, triage literally means the sorting of patients, on the basis of their illness and other factors, into categories that determine the urgency and extent if medical care required.

The Australasian National Triage Scale (NTS)

Triage for General Practice

Telephone Triage Face to face - make appointment - see urgently that day what is urgent ? - get Doctor now to see pt - ring an ambulance and start first aid

Chest Pain

Difficult to differentiate between cardiac and non-cardiac origin Dont be distracted by repeat attendees, histrionics, other family members or hangers on Focus on the patient at presentation

Chest Pain Assessment

Triage Assessment ABC Skin colour, cyanosis, pallor Respiratory status, quality of respiration, unusual chest movement Any other obvious problems General appearance, age

Chest Pain Assessment

The simple mnemonic PQRST offers a reliable approach to the assessment of chest pain of any origin

Chest Pain Assessment

P PROVOKES

aggravating factors, alleviating factors What caused the current condition? What were you doing when it began? Does anything make it better or worse? (i.e., deep inspiration, movement etc.)

Chest Pain Assessment

Q Quality

What does it feel like? Ask to describe in own words what the discomfort is like ( sharp, stabbing, burning, crushing). Does any thing change the pain? deep inspiration, cough and movement

Chest Pain Assessment

R

- Radiation / Region

Where is it located? Does it go any where else? Ask the patient to point to where the pain is at its worst

Chest Pain Assessment S Severity

How bad is the current condition? Severity of an individuals condition is difficult to assess and is highly subjective Ask patient to rate any pain sensation on a scale of 1 to 10 If patient has had ischaemic pain before, determine if it is greater or lesser severity than usual

Chest Pain Assessment

T Time / Onset/ Duration

Do you have any discomfort now? When did this episode of pain start? How long did it last? Is it constant or does it come and go? Did it come on suddenly or gradually over a period of time?

Chest Pain Assessment

History taking MUST NOT delay interventions or definitive care

Chest Pain Assessment

Associated symptoms - nausea and vomiting - shortness of breath - diaphoresis - cough, productive or non-productive - fever - racing heart, palpitations

Chest Pain Assessment

Measures taken to relieve pain at rest - Anginine - GTN sprays - antacids - oxygen

Chest Pain Assessment

Past Medical History - previous myocardial infarction, cardiac surgery, angina - medications in particular: Digoxin, diuretics, beta blockers, ACE inhibitors - risk factors *smoking *hypertension *diabetes *+ve family history *obesity * hyperlipidaemia Recent stress, illness or exertion

Differential Diagnosis Chest Pain

Cardiovascular
-

Typical angina Prinzmetal or variant angina Unstable or accelerating angina Acute myocardial infarction Aortic dissection Mitral valve prolapse Pericarditis Dresslers Syndrome

Differential Diagnosis Chest Pain

Pulmonary
-

Pleuritic chest pain Pneumonia Pulmonary embolism Pulmonary hypertension Spontaneous pneumothorax

Differential Diagnosis Chest Pain

Gastrointestinal
-

Reflux oesophagitis Oesophageal spasm Peptic ulcer Pancreatitis Cholecystitis Cholelithiasis

Differential Diagnosis Chest Pain

Musculoskeletal disorders
-

Costochondritis Tietzes Syndrome Rib fracture or trauma Cancer metastasis Sternoclavicular arthritis Painful xiphoid syndrome Fibromyalgia Traumatic muscle pain Shoulder arthritis/bursitis Cervicothoracic nerve root compression

Differential Diagnosis Chest Pain

Miscellaneous
-

Herpes zoster Anxiety/depressive disorder Panic disorder

Telephone Triage

Telephone Triage is the practice of conducting a verbal interview to assess a patients health status and to offer recommendations for treatment and referral

Telephone Triage

The goal of Telephone Triage is appropriate patient referral to the appropriate level of care within an appropriate period of time

Telephone Triage

It is helpful to those calling, however: It may be time consuming and it is often difficult to determine the needs of the person calling for advice. The nurse may be asked to make a diagnosis or to provide an opinion of what she thinks may be wrong.

Telephone Triage

There are legal implications if an opinion is offered which is incorrect, and nurses are able to be held liable for the information given. Other risks associated with telephone triage are offering the wrong advice, incorrect assessment, incomplete collection of data, caller mistrust or misunderstanding and poor documentation

Telephone Triage

Remember You are not making a diagnosis over the phone. Decisions are made on acuity of signs and symptoms.

Telephone Triage
The process of telephone triage has 5 main components: Introduction of self and opening communication channels Performing the assessment via interview Making the triage decision Offer advice according to protocol or established guideline for care incorporating follow up plans Document the call.

Telephone Triage
Step 1: Introduce self and open communication Give your name and title so that your patient feels he/she is getting information from a knowledgeable person, allowing for trust and openness Caring attitude non judgemental manner, thus improving the amount and detail of information revealed

Telephone Triage
Step 2: Perform the interview Establish if the call is an emergency to life or limb by the use of five questions. - symptoms - age - sex - breathing sounds - level of consciousness

Telephone Triage
Step 2: cont Information gained must include demographic data (name, age etc), baseline health information and current signs and symptoms Listen to what is not said as well as what is said Use experienced staff, so that nursing knowledge and intuition is used

Telephone Triage
Step 2: cont. Listen for non verbal cues sentence structure pauses, breathing patterns, crying etc. Background noise may indicate further what pressures the caller is under. If not talking to the patient, bringing them to the phone to listen to breathing, coughing etc will help

Telephone Triage
Step 2: cont Remember the greater the amount of information collected the more accurate our nursing diagnosis will be Use open ended questions try not to lead the caller Ask the person to describe his/her symptoms, not to diagnose the cause of the symptoms.

Telephone Triage
Step 3: Making a triage decision. Nursing diagnosis: establishes priorities of care based on the patients signs and symptoms Medical diagnosis: establishes the cause of the patients signs and symptoms. Do not attempt to provide a medical diagnosis.

Telephone Triage
Step 3: cont Use of protocols and guidelines will help make sure you do not miss information and helps you make decisions more quickly How well steps one and two are done will determine how well we do this step; keep this in mind when gathering data, so it is in an organised fashion.

Telephone Triage
Step 4: Offer advice Based on acuity of the signs and symptoms Disposition of the call may include - calling an ambulance - observe at home - see GP when convenient - transfer call to GP or other health care provider, as appropriate - self treatment at home

Telephone Triage
Step 4: cont Ensure that the caller clearly understands the advice by having the caller repeat the information back to you Encourage caller to call back if the condition worsens, or if they have a further issue In all cases caller should be advised to go to the emergency department or attend their own doctor if there was no improvement in their condition, if their condition worsened or if they are still worried

Telephone Triage
Step 5: Document the call Be precise Reflect advice given by the protocol followed Include all data and as much information as possible to give a complete patient scenario

Telephone Triage - Tips

Avoid stereotyping callers or problems Avoid second guessing the caller Do not try to be an expert on everything Avoid absorbing patient/caller anxiety Make a nursing diagnosis, not a medical diagnosis

Respiratory Distress Asthma Assessment

Visual Assessment: Skin colour: pallor, cyanosis Level of consciousness Respiratory status - ability to speak - ability to cough - ability to move air Chest shape and movement

Respiratory Distress Assessment - Asthma

Subjective Assessment History of present episode Treat while assessing - how long have the current symptoms been present? What were you doing when they occurred? - precipitating factors such as exposure to toxins, allergies, anxiety, URTI - is the patient becoming fatigued ? - reason for acute exacerbation?

Respiratory Distress Assessment - Asthma

Subjective Assessment cont. Associated symptoms - cough (describe any sputum) - wheezing - chest pain - pleuritic: sharp pain on inspiration - cardiac: crushing central chest pain - presence of orthopnoea or paroxysmal nocturnal dyspneoa usually indicates cardiac origin - fever, chills - ankle oedema - voice changes - degree of anxiety

Respiratory Distress Assessment - Asthma

Subjective Assessment cont. Measures taken to relieve symptoms, such as aspirin, nebuliser, medications Past medical history - lung or cardiac disease - usual level of activity - history of smoking - medication including PRN meds - allergies history of hay fever/asthma - hospitalisations, especially for respiratory disease - any other previous illness - trauma history - family history of asthma and allergies Recent stress, emotional event or illness Beware of oversimplifying diagnosis!!

Respiratory Distress Assessment - Asthma

Objective Assessment Vital signs - respiratory rate: greater than 18-20 min or 25-60 in children. Check rate, rhythm and quality of respirations. Note also accessory muscle use and intercostal and sternal retractions - pulse: tachycardia (bradycardia with children) may indicate hypoxia

Respiratory Distress Assessment - Asthma

Vital signs cont. -blood pressure: note pulsus paradoxus - temperature: may need rectal temp if respiratory rate increased - peak flows: if patient distressed leave until later

Respiratory Distress Assessment - Asthma

Objective Assessment Respiratory Effort - skin colour: cyanosis or pallor of lips or nail beds. Note diaphoresis - breathing pattern such as prolonged expiratory phase, use of accessory muscles - stridor or audible wheeze - tracheal deviation - increased AP diameter (barrel chest) - distended neck veins

Respiratory Distress Assessment - Asthma

Objective Assessment Breath sounds - bilateral comparisons - presence or absence of crackles, wheezes - palpation: note crepitus

Respiratory Distress Assessment - Asthma

Objective assessment Neurological status may be diminished because of hypoxia; look for signs of change, such as lethargy, agitation, increased anxiety, confusion or irritability Signs of external trauma

Adult Asthma Severity

MILD ATTACK - Respirations <25 per min - Heart rate <120 bpm - Peak flow >150 - Dyspnoea + - Wheeze + - Accessory muscles not used - Patient able to converse

Adult Asthma Severity

SEVERE ATTACK - Respirations > 25 per min - Heart rate > 120 bpm - Peak flow <150 - Dyspnoea ++ - Wheeze ++/silent - Accessory muscles used - Patient exhausted unable to speak

Adult Asthma Severity

LIFE THREATENING - Decreased level of consciousness - Inability to speak - Cyanosis of lips/mouth - Bradycardia <60/min - Respiratory arrest

Paediatric Asthma
Wheeze Score (WS) 0 = no wheeze 1 = wheeze on terminal expiration heard with a stethoscope 2 = wheeze heard on inspiration and expiration 3 = wheeze heard without stethoscope, or silent chest

Paediatric Asthma
Accessory Muscle Score (AMS) 0 = no accessory muscle usage 1 = subtle but definite use of accessory muscles 2 = obvious use of accessory muscles 3 = maximal use of accessory muscles

Paediatric Asthma Severity

Mild - Child who is not distressed - WS = 0,1 - AMS = 0 or 1 - o2sat = >95% in air

Paediatric Asthma Severity

Moderate - a distressed child with obvious wheeze, tachypnoea, tachycardia - WS = 2 or 3 - AMS = 2 - o2sat = 91%-95%

Paediatric Asthma Severity

Severe - Marked distress, tachycardia, tachypnoea, marked reduction in volume of breath sounds - WS = 3 - AMS = 3 - o2sat = < 90%

Headache

Headache

Most headaches seen in general practice are simple or an associated symptom of the patient's problem. However, we need to be vigilant for headaches that are clues to dangerous problems because although headache is a nearly universal part of the human experience, it is unusual for "the average person" to go to the GP with an "ordinary" headache.

Headache

Doing so (with the cost, inconvenience, and discomfort of a GP visit) should be a marker for concern. The reason the patient comes will be because of what seems unusual or frustrating: i.e., -"I never have a headache" or "worst headache of my life", - persistence ("It just won't go away"), - associated symptoms or interference with activities of daily living (nausea/vomiting, fever, "I can't sleep"), - or fears of worse possibilities ("we thought she might be having a stroke").

Headache
A good mnemonic would be PQRST: P: Provocative-Palliative factors; "what makes it worse or better?" Q: Qualitative: "Is it sharp, dull, aching, stabbing, burning, etc.? R: Radiation-Regional: "Where does your headache sit?, "does it go anywhere else?" e.g., hemicranial, sinus pressure or tenderness, jaw or ear pain. S: Severity: "How bad does it feel?" 0-10 scale, or "faces" scale, "has it kept you from working?" T: Temporal factors: "When did it start?", "Was it sudden or gradual?" Is it always the same, goes away for a while entirely, or always there but gets worse in waves?" Is there a pattern or association to the occurrence? e.g., recurring waking headache of brain tumour, or activity related exposures to toxins.

Headache

Questions regarding PMH may elicit hypertension, cancer which may be metastatic, TIAs, URTI or allergy symptoms, sinus or cranial surgery, ventriculoperitoneal shunting of CSF from hydrocephalus. Occupation may suggest a toxin, environmental problems, or exposure to pathogens (childcare worker, or foreign travel). Habits such as alcohol or intravenous drug abuse which increase risk.

Headache

Neurologic signs and symptoms such as lethargy, any loss of consciousness, disorientation or confusion, dysarthria, visual changes such as photophobia, blurring, diplopia, halos around lights, speckles or jagged streaks, ataxia or gait disturbance, clumsy use of extremities, nausea or vomiting may be significant and should be repeatedly sought. These should have high priority.

General Practice Triage Protocols

General Practice Triage