Assessment
The four parts to the assessment phase of nurse triage.
What are chief complaint, history of current illness, brief medical history, and objective data?
Nursing diagnosis or problem statement.
What is the type of diagnosis made during triage?
Deciding the appropriate next steps in the student's care.
What is the goal of the disposition phase of nurse triage?
Guide student in slow, deep breathing exercises.
What does the nurse do when a 22 year-old experiencing what seems like a panic attack presents in urgent care and is having a hard time speaking.
First step of evaluation phase.
Summarize for patient the steps of the care plan.
The primary goal of the assessment phase in triage.
What is to determine the patient's level of urgency?
The primary focus of the diagnosis phase of triage.
What is determining urgency of symptoms and potential confounding factors.
The 3 most common dispositions in nurse triage.
What are self care at home, evaluation of condition prior to it deteriorating and definitive care prior to a catastrophic event?
When you disposition is for patient to be seen within 24 hours in the general medicine clinic, it is Friday, and the GM has no available appointments.
When it is appropriate to have patient seen in urgent care even if set protocols indicate that GM clinic is the preferred clinic.
What do you do when a student calls stating he is way behind in classes due to recent death of his grandfather who was an important figure in his life?
Teach back method.
What is one of the most effective ways to ensure the student understands his/her responsibility in the plan of care?
By asking open ended questions and redirecting when needed.
Cost, insurance type, access to specialists, family support or lack thereof.
What are potential barriers to care in the college population?
Helpful resource if self-care at home is determined to be the best disposition.
What are the self-care documents linked on the UHC website under "services"?
Patient safety and immediate needs.
What does the nurse assess in order to prioritize interventions?
Stress management techniques, daily walking or yoga, importance of adequate sleep.
Appropriate self-care recommendations for student with anxiety whom you referred to the counseling center.
Ask student to list symptoms that warrant further follow-up.
How to use the teach back method for step 3 of the evaluation phase: verifying student understands reasons to seek care
The 8 areas to assess when collecting the history of present illness, if pertinent.
What are OLDCARTS: onset, location, duration, characteristics, alleviating factors, relieving factors, timing and severity.
Redness to eye associated with throbbing pain with walking.
What is a red flag for urgent evaluation of the eye within 24 hours?
Choose the more conservative approach.
What to do if you cannot decide between 2 different dispositions?
When a student is having side effects from a medication prescribed by a specialist.
What is an example of when it is appropriate for nurse triage to refer a student to a provider outside of UHC.
When a 17 year-old with a history of anxiety and asthma presents with tachypnea of 25, recurrent coughing, pulse ox of 88, normal pulse and blood pressure and a fearful demeanor.
When is it appropriate to immediately room a patient, apply 2L oxygen via NC and guide student in deep breathing while also notifying UC provider?
The best way to end a triage call/visit.
Red flags to look for in a student suspected of having early-onset Guillain Barre.
What are numbness, tingling, and/or weakness in the lower extremities that starts in the feet and gradually moves towards head, especially if student recently had a virus or vaccine.
Chronic back pain in student with a normal back exam and an abnormal PHQ-2.
What is an example of when the most concerning symptom from the medical professional's standpoint differs from the symptom the student is most worried about
Symptom of allergic reaction that indicates student needs immediate, definitive plan of care to prevent catastrophic event.
What is stridor?
PCC driving student to ED.
What is a past practice for transportation that we no longer use due to possible legal ramifications.
A professor walks a student into UC.
When a student should be seen by nurse triage prior to the front desk scheduling an appointment.
Student who discloses significant substance to you during the triage call/visit.
What is an example of a high risk student/situation that warrants triage nurse taking initiative for follow-up?