What is My Patient's Problem TODAY???

So many times I see nurses having difficulty discerning what the main focus of the call is, and therefore it impedes their advice ability as well as productivity. This is especially true when the patient has multiple complaints or many chronic illnesses.
Sometimes the caller has difficulty expressing what their main concerns are or reason for the call, and you simply have to just ask, "So what concerns you that made you call TODAY?" That will usually get the answer you are looking for so that you can determine the chief complaint, and find the correct protocol.
Focus on what the current symptoms are, and not symptoms they had last week that are no longer an issue such as, the patient now has a fever for 3 days, but diarrhea a week ago. The protocol used should be fever, and if the patient is now having normal BMs, why would you even ask any questions about the diarrhea?
One good way to determine if you have done a thorough assessment of the complaint is by remembering
*P Problem/Chief Complaint
*H (How are you feeling?)
*O Onset
*S Associated Symptoms
*H Pertinent History
*P Precipitated by
*A Aggravated or Alleviated by
*T Timing
*E Etiology (Have I overlooked anything?)

Problem- Listen to decide what the chief complaint is. Ask for all adjectives used to describe this problem. If not able to determine the complaint, ask the appropriate questions to draw out the information, like "What is bothering you the most?"

Onset- Did it come on suddenly or gradually? When did the symptoms start?

Associated symptoms- What else is bothering them? Use caution to "not put words in the patient's mouth".

Pertinent history- Have you been ill or seen the doctor recently? Have they had this problem before, and if so, what was it? Who said? How was the decision made?

Precipitated by- Is there anything they do that brings it on? Is there any way they can predict it's recurrence?

Aggravated or Alleviated by- What makes it better? What makes it worse?

Timing- Is there any time of the day, week or month that you notice this problem more?

Etiology- Have I overlooked anything? Did I consider all the pertinent findings?

Following this will ensure an accurate and complete assessment, will keep the call in focus and productivity at it's best. 

(Carol Rutenberg2012)

This Takes Skill

It is time for telephone triage nursing to be recognized as a true skill. Maybe it is just me, but it gets frustrating when you attempt to explain to others, including nurses, what it is that you do, and they either just look at you or say " I am afraid I would lose my skills". This growing area of nursing IS A SKILL! Not just any nurse can do it.

I have seen a great number think this is a eat bon-bon, watch a movie, and throw a party in between calls, kind of job. That fairy tale would be a dream if it were true, but that is all it is, a fairy tale. Having been a nurse for over 20 years, and worked in many different areas of nursing, this is the most mentally challenging of them all by far. Not even managing a 150 bed skilled facility or working a 12 hour shift in an ICU can leave you as exhausted. Sure, you don't do venipunctures, start IVs or treat wounds, but if you miss one vital piece of information, you do cause un-do harm or worse yet, death to the patient you are talking to.
True triage is not just asking a few questions, and then giving advice. You are trying to come to the best solution in the shortest amount of time. You have to be a quick thinker, a good reasoner, an excellent multi-tasker, and a polite, well rounded person to be the most successful. There is nothing like trying to calm an anxious first time mom with a 3 year old crouper, listen for warning signs that may say the child needs to be seen in the ED tonight, while the other line has a physician beeping in about a medication call you paged him about 30 minutes ago. You have to be able to change courses quickly, place the current call on hold, handle the medication call, go back, finish the croup call, and then call the patient back about their medication. Don't forget, finishing your documentation falls in there, along with your co-worker asking your opinion on how to handle the newborn jaundice call they are dealing with. And, that my friends is not a skill?
I may be a little rusty on trying to start an IV right now, but I can guarantee you I can advise you on how to handle your child's bicycle accident in 5 minutes or less, and at the same time be a resource to my co-workers, speak to a physician and call a pharmacy.
Having done this job for years, I find it changes the way I problem solve day to day as well. I find I am always looking for the shortest way to reach my goals in the quickest amount of time, and I love it. I don't think I will ever look a situations any differently again.
Yes, this is a skill to be proud of, and it does not make me any less a nurse. We all have areas that we are good at, and that is what makes nursing unique. If we all liked or wanted to work in the same areas, patient needs would not be met. After all, isn't that why we chose nursing? To be a patient advocate and to care for them to the best of our ability.

Identifying High Risk Callers

It is so easy to become like a robot, taking one call after another and going through the motions...reciting protocol after protocol. There are, however, a select group of calls that should stand out as high risk.
Extremes of age: The very young, as in newborns, and the old (those above age 65) are at higher risk of developing complications. They are also physically less tolerant of symptoms such as fevers.
Comorbidities: Those with diabetes, post-op patients, immunosuppressed.
Repeat Callers: (Repeat calls for the same problems) Maybe the caller is not understanding instructions given? Are the patient's symptoms worsening, and the caller does not understand how to communicate this? Is there a high level of anxiety?
Frequent Flyers: Are they anxious? Is there a lack of caregiving in the home? Is the caller difficult to educate?
Patients with Multiple Complaints or Poor Historians: Multiple complaints makes it more difficult to determine what the call is actually regarding, and it is difficult to give accurate advice if you cannot make a complete assessment based upon what information the caller is giving you.
These types of calls deserve extra attention to the protocol and follow through. If there is any question about level of understanding, concerns about adequate caregiver availability, risk of the caregiver and/or patient not following advice given, or any risk to the patient's well being, the physician on call should be contacted to lessen the responsibility of the nurse, and possibly even referred to the ED for further evaluation and care.

How To Be An Effective Triage Nurse

I just returned from a great two day conference in Atlanta that was hosted by Carol Rutenberg's Company, Telephone Triage Consulting, Inc. The guest speaker was Kathy Koehne, BSN, RNC-TNP. What a wonderful presenter she is!
One of the things that really stuck out to me were the characteristics of effective triage nurses. They must be self-directed, focused on short-term results, be a strong patient advocate, and have practical intelligence.
With self direction, you must be able to function independently, especially if you are working from a remote location. There is no one there to call on if you have a question, need help in making a decision, or your call volume begins to get overwhelming. Sure there are co-workers on line or one that you can call, but yet, you have to be autonomous. All the while, it is important to realize the value of your position and your role, even though your authority is limited.
To be successful, you have to have a good work ethic. You must be reliable and dependable, especially so if you work remotely. So many times nurses think if they are working from home, they can work if they feel like it. No matter the location, you still have patients depending on you, just as if you worked in a facility. If there are no nurses, the patients don't get taken care of, and therefore no business.
This position requires honesty. You are given the trust to work independently, and many times, you are the only nurse that patient encounters. Your supervisor is trusting you to be honest in your advice, documentation, and productivity.
You must also be flexible. This is not a 9 to 5 job with weekends and holidays off. If you desire a position like that, maybe you should ask yourself, "Why did I choose to be a nurse?" Sickness does not decide to only occur during business hours, and therefore, it requires us to be flexible in our schedules to accommodate higher call volume needs.
To be focused on short-term results, you have to be good with time management. You have to be able to take control of the call to complete it in a timely manner, complete your documentation before the next business day, and be able to be productive enough to be a team player in getting the calls done.
You have to like checklists and bite-sized tasks. After all, when you are assessing the patient on the other end of the phone, you are going through mini checklists of each system in your brain, and the task at hand is to get the caller to the next level of care, whatever that may be.
You have to enjoy and measure effectiveness with measurable outcomes. You are gathering information, deciding on a plan and teaching the caller. You can measure the effectiveness of your teaching by asking the caller to repeat instructions back to you, and the outcome is, did they follow your teaching by seeking the appropriate follow-up? Did you make a difference in what could be a potentially life-threatening call? Do patient satisfaction surveys reflect happy patients as an outcome?
You must be a strong patient advocate. One of the most important points in gaining a caller's trust is if the nurse is empathetic. You will also be much more effective if the caller trusts you, but be careful with giving your own personal experiences. You may think you are being empathetic, but sometimes the caller only wants to talk about themselves. They do not care to hear about you. You must know when the right time to share your experiences with the patient is.
The last characteristic, practical intelligence, is one that you either have or you don't. You cannot teach someone common sense, and to be successful in this position you must be a quick learner, relate new information to previous knowledge, and enjoy learning. You must keep abreast with new trends in healthcare, and new medications, and be able to apply that to and build on what knowledge you already have.
Wow,what a tremendous amount of responsibility! Yet, if you are a telephone triage nurse, you should be proud of your position. We have the ability to change someone's life in one phone call!
You may be the last person that caller ever talks to...Make it count!

The Angry Caller

A co-worker the other day, about 3 hours into her shift commented that so far she had been told she was stupid, that she needed to go back to school, and was hung up on twice. I have felt her frustration many times, but I could not help but wonder what her approach was.
Granted, we have all dealt with those kinds of callers, and I have had my share of them, but at least 95 percent of the time, the call starts that way and ends with the caller thanking you for your help if you chose your words carefully.
The first thing to remember is...deep breath. The caller does not know you at all, and they are not mad at you. They could be frustrated with chronic illness, the medical system, the pharmacy or their physician. You just happen to be the cat to kick out of the way at the moment.
The second step is close your mouth and listen...really listen. Acknowledge their frustrations and feelings. Tell them you hear their frustration and concerns and would love to help them, and do, if you can. If you cannot, give them a logical explanation why, and instruct them instead on what they need to do to solve their problem.
Lastly, thank them for calling, even if you were not able to solve their concerns. Reassure them that you are there to help, and encourage them to call again if further questions or concerns arise.
Many times the caller knows you may not be able to fix their issue, and they just want to know there is a friendly voice on the other end of the phone that they can talk to night or day. Remember, what you say to them in that conversation can make a lasting impression, and word travels back to their physician's office of what kind of impression that was.

Scared of Rashes

So many times, I hear nurses say they hate rash calls. It is because they are afraid of what they cannot see, and I find myself saying, "Let your ears be your eyes".
When you receive a rash call, the first thing you must do is assess if there are associated signs with it. This helps you decide which protocol to use. One of the first questions I ask with a rash is, "Is there a fever?". The questions that follow should determine if the patient is on any medications, presence of itching, and/or has had any new exposures. Common new exposures that cause rashes are new unlaundered clothes; new soaps and laundry detergents; new beauty supplies, including lotions and sunscreen; new pets; new hobbies; and outdoor plant contact. Inflammation should be assessed by asking if the rash is tender to touch.
The location of the rash is easy to determine. Locations are either described as focal, patchy, or diffuse. A focal rash is specific to a specific body part. If the rash is only on a specific body part, it is still considered focal (eg, the hands, cheeks, or lower extremities). A patchy rash is considered on more than one body part but not on all body parts. For example, the rash could be all on exposed body parts only, or only on covered body parts. A diffuse rash covers multiple body parts, usually the entire body.
If a rash cannot be felt, or is not raised, it is said to be macular or consist of macules. If a rash can be felt and is raised, then it is papular or consists of papules. A lesion that contains clear fluid is a vesicle, and a rash that contains cloudy fluid or purulent material is a pustule. Some rashes can be macular and papular, with some areas being palpable and others not.
Describing the color is simple. Just ask the caller the color of the rash. If the do not volunteer an answer, give them the choice of skin colored, pink, red, purple, hypo- or hyper-pigmented.
One of the most important characteristics of a rash that is also the hardest to determine over the phone, and is so important to determine, is if the rash is blanching or non-blanching. If it is non-blanching, it could indicate the presence of blood outside of the blood vessels as occurs with petechiae or purpura. One method to determine this is have the caller apply pressure to the rash with a finger and then quickly remove the finger and look and see if the color changes. The caller needs to be told to look quickly if the rash loses its color then changes back.
The shape of the rash can be described as annular (circular), linear, or irregular. If a rash is confluent, then it covers the entire region without large areas of normal skin. If it is patchy, then areas of normal skin are interspersed with rash areas. A rash with central clearing has normal skin encircled with a rash.
The last characteristic is the appearance of the rash as dry, wet (weeping), scaly or crusted.
It can be overwhelming to attempt to decide which rash protocol to use. You have to consider what other factors are present, not just the rash. Is there a fever? Presence of fever can indicate many childhood illnesses such has Chicken Pox or Hand, Foot and Mouth Disease, but it could also be something indicative of a more serious illness such as Meningitis can also sometimes have the presence of rash.
What is the location of the rash? If it is widespread, is the patient on any new medications, especially antibiotics? If it is a child, have they been exposed to viruses? If it is a localized rash, and all else fails, ask the caller if they have any idea where the rash came from. Of course, you cannot just assume that is the cause without ruling out other possibilities, but often, the caller may know.
Rashes should not scare the triage nurse. They are challenging that is for sure, but keep in mind, it is not the rash that is often the most troubling, but other symptoms that the patient may have will often lead you to determining the protocol to use.

Who Said This Is All Cut and Dried?

How do you begin to tell someone what a telephone triage nurse's job description entails? My advice is you just have to watch one work a shift to know. I really don't know there are enough words that could describe everything that goes on during that shift. In speaking with a colleague the other day, I described it as the hardest job I have ever done in my 20 years of nursing, and I meant every word of it. It is hard because it is very mentally demanding.
A lot of people have a preconceived notion that being a triage nurse means getting to chat on the phone and give advice. This could not be farther from the truth. You have to rely strongly on your ability to ask questions, and your ability to listen. Along with these traits, you must have excellent assessment skills, and most important of all, experience. You rely heavily on this alot.
You hope the calls you get are simple like colds or fever but the reality is, very few are like that. Many times, you make the call, thinking it is going to be something like this, and suddenly have to shift gears. The call has suddenly turned into acute croup, meaning you have to find that protocol quickly, because the ones you thought you were going to use suddenly do not pertain anymore.
You cannot physically assess the patient, and therefore, you have to be skilled in asking the appropriate questions to get the answers you need. And, if you are not listening closely, you may miss that one piece of information that could decide what disposition you chose.
So many times I hear, "This is not cut and dried as it should be. There are too many exceptions." But is not every patient different, and their symptoms different? So, how can anyone expect it to be cut and dried?
Along with the patient, each office has their own preferences on how to handle certain calls, so you must always be familiar with them, and if you make appointments, where do you make them and when? Still, along with all this, you have to have the ability to type, listen and talk. Don't forget there is the ability to control the call, and resolve the patient's problem in a timely manner, and move on because you have what seems like another hundred calls waiting.
So, in conclusion, if you are looking for something that is cut and dried, telephone triage nursing is far from it. Each day, brings new experiences and challenges, but when you hang up the phone knowing the caller on the other end is appreciative of your help, it makes each day worth it.