Exam & Evaluation (Telephone Triage)
Questions: Please respond to following statements.
A protocol is a detailed, official scientific plan of nursing assessment which may recommend a specific plan of care to the caller.
Open-ended questions allow the patient to respond in a more creative, spontaneous, and accurate manner. Leading questions can normally be answered with a "yes" or a "no".
Being able to show compassion, practice mercy, and listen well are essential skills of the quality telephone nurse.
For security reasons, nurses MUST NOT identify themselves when speaking with a patient over the telephone.
Essential to accurate documentation, the nurse must include where the patient is calling from, what type of insurance they have, their typical compliance with nursing instruction, and how many times they have called the service that day.
When dealing with a caller in crisis who may seem hostile, aggravated, or rude, the nurse has the right to hang up immediately if the caller uses profanity.
Quality improvement is an optional portion of any telephone triage program.
The design of the work station used by the telephone triage nurse should be ergonomically correct to avoid repetitive injuries for the staff.
Risk factors that increase the acuity of patients with fever are:
immunosuppression, as in patients with AIDS or medicated with corticosteroids
Pregnancy in the 3rd trimester
It is important to see immediately:
Any patient with fever ongoing over 72 hours
Any patient with persistent cough with fever
Any patient with fever and stiff neck
Home care advice for children with fever includes administration of antipyretics such as Tylenol, ibuprofen and aspirin.
The main cause of wheezing in children over 3 years of age is asthma.
The telephone triage nurse should advise that a child should be seen within 4 hours who:
is having difficulty breathing.
has respirations over 60/minute for infants less than 12 months.
has a fever for over 3 days.
has a constant cough, non-responsive to mist
With abdominal pain, the triage nurse should assess whether the patient also has chest pain.
A risk factor that increases the acuity of abdominal pain symptoms is diabetes.
A child should be seen immediately if experiencing:
Severe nausea, vomiting and diarrhea.
Pain lasting longer than 24 hrs.
Pain localized to the lower left abdomen for the last one and a half hours.
For the purpose of triage advice, treatment differs according to whether the chemical in the eye was a HARMFUL or HARMLESS substance. Check the following list, choosing the HARMFUL substances only.
toilet bowl cleaner
Secretaries may begin the telephone triage process by taking down the caller's name, phone number and history of their complaints.
Disease management allows nurses and doctors to check up on their patient's compliance with home care instructions and report them to their insurance carrier if they are non-compliant.
It is legal for a nurse with a license in her own state to advise patients calling from another state, providing both states have signed the Nurse Licensure Compact into law.
The nurse bases their triage decision on the diagnosis made by the patient regarding their symptoms.
At the beginning of a call, it is safe for the nurse to tell the caller: "Oh, don't worry. The vomiting bug is going around."
Obtaining the weight is only important on patients with a history of CHF.
According to Sara Courson's article, What is Telephone Triage Nursing?, there is no difference between health advice telephone lines and telephone triage lines.
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