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Triage for Practice

“Why didn’t they just go to the
hospital, don’t they know they’re
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

„ 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
„ 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
„ Don’t be distracted by
repeat attendees,
histrionics, other family
members or “hangers
„ Focus on the patient at
Chest Pain Assessment

Triage Assessment

„ 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

„ 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
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 individual’s 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
- Typical angina
- Prinzmetal or variant angina
- Unstable or accelerating angina
- Acute myocardial infarction
- Aortic dissection
- Mitral valve prolapse
- Pericarditis
- Dressler’s Syndrome
Differential Diagnosis –
Chest Pain
- Pleuritic chest pain
- Pneumonia
- Pulmonary embolism
- Pulmonary hypertension
- Spontaneous pneumothorax
Differential Diagnosis –
Chest Pain
- Reflux oesophagitis
- Oesophageal spasm
- Peptic ulcer
- Pancreatitis
- Cholecystitis
- Cholelithiasis
Differential Diagnosis –
Chest Pain
Musculoskeletal disorders
- Costochondritis
- Tietze’s 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
- Herpes zoster
- Anxiety/depressive disorder
- Panic disorder
Telephone Triage

„ Telephone Triage is the practice of

conducting a verbal interview to
assess a patient’s 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
„ 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
Telephone Triage
The process of telephone triage has 5 main
„ 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

„ 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
„ Listen to what is not said as well as what is
„ 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
Telephone Triage

Step 3: Making a triage decision.

„ Nursing diagnosis: establishes
priorities of care based on the
patient’s signs and symptoms
„ Medical diagnosis: establishes the
cause of the patient’s 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

„ 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
- 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,
„ 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
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
- pulse: tachycardia (bradycardia with
children) may indicate hypoxia
Respiratory Distress
Assessment - Asthma
„ Vital signs cont.
-blood pressure: note pulsus
- 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,
- 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
„ Signs of external trauma
Adult Asthma Severity

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

- 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

- 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
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
2 = obvious use of accessory muscles
3 = maximal use of accessory muscles
Paediatric Asthma
- Child who is not distressed
- WS = 0,1
- AMS = 0 or 1
- o2sat = >95% in air
Paediatric Asthma
- a distressed child with obvious
wheeze, tachypnoea, tachycardia
- WS = 2 or 3
- AMS = 2
- o2sat = 91%-95%
Paediatric Asthma
- Marked distress, tachycardia,
tachypnoea, marked reduction in
volume of breath sounds
- WS = 3
- AMS = 3
- o2sat = < 90%

„ 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.
„ 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").
A good mnemonic would be PQRST:
„ P: Provocative-Palliative factors; "what makes it worse or
„ Q: Qualitative: "Is it sharp, dull, aching, stabbing, burning,
„ 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.
„ Questions regarding PMH may elicit
hypertension, cancer which may be
metastatic, TIAs, URTI or allergy symptoms,
sinus or cranial surgery, ventriculo-
peritoneal 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.
„ 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