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.
Tuesday, December 13, 2011
Wednesday, October 19, 2011
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.
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.
Monday, August 15, 2011
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.
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.
Thursday, July 14, 2011
Unraveling The Mystery
Anyone who knows me knows that I eat, sleep and breathe triage, but especially documentation. That, after all, is a huge part of a triage nurse's life. Or, at least it should be.
Every time I think of documentation, I remember a nursing school school instructor's words ringing in my ears, "If it isn't written, it wasn't done". And so many times, when you examine a note, it appears it wasn't done, because the nurse forgot to add it. This is so easily done in our fast paced environment, but that one little sentence you forgot to add could be your down fall in court.
I like to compare notes to reading a mystery novel. You should be able to pick it up, not knowing anything about the patient, and it give you a story from beginning to end. If it does not, something is missing.
The story should begin with the concern that the caller is reporting, and related symptoms. Details are the adjectives, who, what, when, where, and to what extent. Descriptions should be as complete as possible and paint a picture of the problem.
The body should include treatment that has been tried for the problem, if any, and the outcome.
The ending should include your advice to the caller, including protocols referenced that were followed. If any advice is given that is not included in the protocol, then it must be spelled out in the notes. If it is not, you cannot prove it was done. This is where so many nurses make their mistakes, and the story leaves you hanging. You do not know the ending, and no one likes being left at the end of a mystery with no conclusion.
So, strive to give all your stories an ending, and leave the reader satisfied that they got the complete story.
Every time I think of documentation, I remember a nursing school school instructor's words ringing in my ears, "If it isn't written, it wasn't done". And so many times, when you examine a note, it appears it wasn't done, because the nurse forgot to add it. This is so easily done in our fast paced environment, but that one little sentence you forgot to add could be your down fall in court.
I like to compare notes to reading a mystery novel. You should be able to pick it up, not knowing anything about the patient, and it give you a story from beginning to end. If it does not, something is missing.
The story should begin with the concern that the caller is reporting, and related symptoms. Details are the adjectives, who, what, when, where, and to what extent. Descriptions should be as complete as possible and paint a picture of the problem.
The body should include treatment that has been tried for the problem, if any, and the outcome.
The ending should include your advice to the caller, including protocols referenced that were followed. If any advice is given that is not included in the protocol, then it must be spelled out in the notes. If it is not, you cannot prove it was done. This is where so many nurses make their mistakes, and the story leaves you hanging. You do not know the ending, and no one likes being left at the end of a mystery with no conclusion.
So, strive to give all your stories an ending, and leave the reader satisfied that they got the complete story.
Monday, May 23, 2011
What The Caller Really Means To Say
Often, you may get calls where the caller does not really understand the medical terminology they use. Many times, this is a lack of education or fear of what is really wrong with the patient. It is the telephone triage nurse's job to interpret and clarify what the caller is really trying to say. The nurse many times cannot take the caller's description verbatim and should document the difference between the caller's words, and what they are really trying to say. Let's look at some of the terms the caller may say, and what they may actually mean.
Lethargic means a serious change in activity where a patient is too weak or exhausted to move or interact, but to the caller, this may just mean a decrease in activity level. Ask what the patient has been specifically doing. Have they been been getting up to the bathroom, eating, walking or watching television? If so, they are not lethargic. The term lethargic should not appear in the nurse's documentation unless the disposition is call 911. If the patient is not getting up as often, or the child is not getting up and playing with toys but may be lying on the couch watching TV, then an alternate description would be decreased activity.
Limp means a loss of tone, and can be serious. Many times this means decreased activity and lying down most of the day, when the caller uses this term. Again, decreased activity would be an alternate description.
When a caller uses the term "coughing nonstop", they may mean the cough has been occurring hourly or daily. However, a continuous cough is one that prevents the patient from eating, drinking, sleeping, or participating in normal activities. If possible, the nurse needs to listen to the patient to determine if it is occurring frequently enough to interfere with activities. An alternative description would be frequent cough, but able to perform normal activities.
Never accept the caller's diagnosis of a rash unless their description is consistent with that of the definition in the guideline or the patient has already been diagnosed by a healthcare professional who has seen the patient. Often patients or parents will diagnose insect bites, impetigo, viral rashes and contact dermatitis as chickenpox, measles, welts, or hives. The best thing to do is describe the rash than using a diagnosis as a label.
It is important to differentiate between decreased urine output and no output. If the caller says no urine output, they may mean the output is greatly decreased or they have not witnessed any output by the patient. For patients who wear diapers, it is important to ask if the diaper is completely dry or slightly damp. Any urine in the diaper is reassuring. It is best to ask how often the patient is voiding and when was the last time, and note output is decreased.
It is obviously a red flag if the caller says the patient is having trouble breathing. Assessment is based on the patient's age. If an infant, the ability to drink a bottle normally and breathing through the nose is reassuring. If older children are able to sing, play and talk, then their respiratory distress is not severe. Often, callers will use trouble breathing to say their children are congested or breathing fast. A better term to use would be nasal congestion or upper airway congestion.
Constant abdominal pain, if significant, will leave the patient with impairment in activities. Most likely, the patient will not be active, probably not have an appetite, and have trouble sleeping. Intermittent pain is different and often represents pain associated with intestinal motility. A better description would be to use intermittent abdominal pain.
Diarrhea is often used to describe loose stools. One or two stools does not indicate diarrhea. Diarrhea refers to increased frequency, amount, and looseness of bowel movements. The best description to use is loose stools.
Constipation does not necessarily mean the patient is having trouble having a bowel movement. Constipation refers to infrequent stools that are usually hard and, in infants, pellet-like. If the feces are soft and the bowel movements are regular then it is not constipation. Regular bowel movements could range from several a day to one every 2 to 3 days. An alternative description would be trouble having bowel movement, but soft and regular.
Vomiting must be distinguished from spitting up to normal reflux of gastric contents. The difference is spitting up is usually not forceful and dribbles out of the mouth without effort. Spitting up is usually consistent of formula and not bile. Both can come out of the nose. Vomiting requires contraction of the abdominal muscles and takes effort. Spitting up is effortless. An alternate description would be spitting up.
Lethargic means a serious change in activity where a patient is too weak or exhausted to move or interact, but to the caller, this may just mean a decrease in activity level. Ask what the patient has been specifically doing. Have they been been getting up to the bathroom, eating, walking or watching television? If so, they are not lethargic. The term lethargic should not appear in the nurse's documentation unless the disposition is call 911. If the patient is not getting up as often, or the child is not getting up and playing with toys but may be lying on the couch watching TV, then an alternate description would be decreased activity.
Limp means a loss of tone, and can be serious. Many times this means decreased activity and lying down most of the day, when the caller uses this term. Again, decreased activity would be an alternate description.
When a caller uses the term "coughing nonstop", they may mean the cough has been occurring hourly or daily. However, a continuous cough is one that prevents the patient from eating, drinking, sleeping, or participating in normal activities. If possible, the nurse needs to listen to the patient to determine if it is occurring frequently enough to interfere with activities. An alternative description would be frequent cough, but able to perform normal activities.
Never accept the caller's diagnosis of a rash unless their description is consistent with that of the definition in the guideline or the patient has already been diagnosed by a healthcare professional who has seen the patient. Often patients or parents will diagnose insect bites, impetigo, viral rashes and contact dermatitis as chickenpox, measles, welts, or hives. The best thing to do is describe the rash than using a diagnosis as a label.
It is important to differentiate between decreased urine output and no output. If the caller says no urine output, they may mean the output is greatly decreased or they have not witnessed any output by the patient. For patients who wear diapers, it is important to ask if the diaper is completely dry or slightly damp. Any urine in the diaper is reassuring. It is best to ask how often the patient is voiding and when was the last time, and note output is decreased.
It is obviously a red flag if the caller says the patient is having trouble breathing. Assessment is based on the patient's age. If an infant, the ability to drink a bottle normally and breathing through the nose is reassuring. If older children are able to sing, play and talk, then their respiratory distress is not severe. Often, callers will use trouble breathing to say their children are congested or breathing fast. A better term to use would be nasal congestion or upper airway congestion.
Constant abdominal pain, if significant, will leave the patient with impairment in activities. Most likely, the patient will not be active, probably not have an appetite, and have trouble sleeping. Intermittent pain is different and often represents pain associated with intestinal motility. A better description would be to use intermittent abdominal pain.
Diarrhea is often used to describe loose stools. One or two stools does not indicate diarrhea. Diarrhea refers to increased frequency, amount, and looseness of bowel movements. The best description to use is loose stools.
Constipation does not necessarily mean the patient is having trouble having a bowel movement. Constipation refers to infrequent stools that are usually hard and, in infants, pellet-like. If the feces are soft and the bowel movements are regular then it is not constipation. Regular bowel movements could range from several a day to one every 2 to 3 days. An alternative description would be trouble having bowel movement, but soft and regular.
Vomiting must be distinguished from spitting up to normal reflux of gastric contents. The difference is spitting up is usually not forceful and dribbles out of the mouth without effort. Spitting up is usually consistent of formula and not bile. Both can come out of the nose. Vomiting requires contraction of the abdominal muscles and takes effort. Spitting up is effortless. An alternate description would be spitting up.
Wednesday, April 27, 2011
Nurse's Week 2011
Another year has gone by...Wow, where did it go? As National Nurse's Week approaches again, I have been reflecting on our business and the great nurses I am so blessed to know.
Who would think that working in a virtual environment that you would really get to know your co-workers? Most people have a perception of working in a virtual environment as being for those who do not enjoy the socialization of others, but I believe we truly have our own Utopia.
So many of us have known each other for a while now, and have developed some close bonds. Who would think that some great friendships would come from sitting in front of a computer day after day, and be built over thousands of miles. But, here at NTTS, that is what has happened. In fact, we have developed our own little "family".
Wikipedia defines family as those that are transplanted via migration to flourish in their new societies. Science classifies family as being groups that are closely related. That is what has happened within our organization. Nurses, who are closely related in what we do, have flourished in our little society. I have had the privilege of watching this first hand, and it is amazing to see what we can accomplish together.
So, to my fellow nurses, Happy Nurse's Week! You do a great job at taking care of the patients we serve! I am so proud to know all of you, and thank you for making this a great place to be!
Who would think that working in a virtual environment that you would really get to know your co-workers? Most people have a perception of working in a virtual environment as being for those who do not enjoy the socialization of others, but I believe we truly have our own Utopia.
So many of us have known each other for a while now, and have developed some close bonds. Who would think that some great friendships would come from sitting in front of a computer day after day, and be built over thousands of miles. But, here at NTTS, that is what has happened. In fact, we have developed our own little "family".
Wikipedia defines family as those that are transplanted via migration to flourish in their new societies. Science classifies family as being groups that are closely related. That is what has happened within our organization. Nurses, who are closely related in what we do, have flourished in our little society. I have had the privilege of watching this first hand, and it is amazing to see what we can accomplish together.
So, to my fellow nurses, Happy Nurse's Week! You do a great job at taking care of the patients we serve! I am so proud to know all of you, and thank you for making this a great place to be!
Saturday, March 26, 2011
Protocols Are Not the Gospel
As telephone triage nurses, sometimes we get tunnel vision. By that, I mean, all we see are the protocols and not the rest of the picture. We forget that first, we are RNs, meaning we have the ability to work independently and make independent decisions.
Protocols are a guideline and only that. They give us the minimum action that should be taken and guidelines for advice, but we should be using our nursing judgment and assessment skills to complete the picture. Too many times I hear nurses say, "But the protocol calls for them to be seen in the ED" when the child is screaming with an earache.
Yes, it does say that, but other factors have to be taken into consideration as well. Is the correct dose of medication being given for the child's weight? If I were a betting girl, I would bet 50 percent of parents are under dosing their children when it comes to giving OTC pain relievers and fever reducers. Also, keep in mind each child is different, one medication make work more effectively for some children than others. Nothing wrong with suggesting to try Ibuprofen if Acetaminophen is not working, unless of course the child has an allergy or has been previously instructed not to use by the primary physician.
Read the protocol! Lots of helpful information in there on how to get the parent through the night until the office opens in the morning. Has the parent tried heat or ice for 20 min? Is the child's head elevated? What about a humidifier running? If there are co-existing cold symptoms, maybe relieving those symptoms will help with the ear pain and pressure.
Also, never forget, kids are real little drama kings and queens. With some children, they will scream over a hang nail. And, the best judge of that is the parent. Ask them how well the child tolerates pain.
Finally, once all of these measures have been tried and exhausted, then of course, follow your protocol guidelines. Remember, we are here to give the best advice possible, and if that means we can go the extra mile to keep the patient out of the ED when it is not necessary, then our job has been well done.
Learn to use what we were trained to do friends! Take those blinders off and be the independent decision maker you were trained to be, follow your guidelines, but take all factors into consideration before giving your disposition.
Protocols are a guideline and only that. They give us the minimum action that should be taken and guidelines for advice, but we should be using our nursing judgment and assessment skills to complete the picture. Too many times I hear nurses say, "But the protocol calls for them to be seen in the ED" when the child is screaming with an earache.
Yes, it does say that, but other factors have to be taken into consideration as well. Is the correct dose of medication being given for the child's weight? If I were a betting girl, I would bet 50 percent of parents are under dosing their children when it comes to giving OTC pain relievers and fever reducers. Also, keep in mind each child is different, one medication make work more effectively for some children than others. Nothing wrong with suggesting to try Ibuprofen if Acetaminophen is not working, unless of course the child has an allergy or has been previously instructed not to use by the primary physician.
Read the protocol! Lots of helpful information in there on how to get the parent through the night until the office opens in the morning. Has the parent tried heat or ice for 20 min? Is the child's head elevated? What about a humidifier running? If there are co-existing cold symptoms, maybe relieving those symptoms will help with the ear pain and pressure.
Also, never forget, kids are real little drama kings and queens. With some children, they will scream over a hang nail. And, the best judge of that is the parent. Ask them how well the child tolerates pain.
Finally, once all of these measures have been tried and exhausted, then of course, follow your protocol guidelines. Remember, we are here to give the best advice possible, and if that means we can go the extra mile to keep the patient out of the ED when it is not necessary, then our job has been well done.
Learn to use what we were trained to do friends! Take those blinders off and be the independent decision maker you were trained to be, follow your guidelines, but take all factors into consideration before giving your disposition.
Subscribe to:
Posts (Atom)