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Final Telephone Tria
Telephone Triage
| Question | Answer |
|---|---|
| telephone nursing | quick assessment |
| quick assessment info = | who is the caller * what is the stated concern or ?*What are the risks*triage what is the worst thing that could happen in the situation*what R most inportant ? to ask *is the problem non urgent*what r the problems & resourses*what is the time factorwhat |
| triage | A process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment. Triage is used in hospital emergency rooms, on battlefields, and at disaster sites when limited medical resources must be allocate |
| triage | what is the worst thing that could happen in the situation |
| Telephone nursing quick assessment who | is the caller |
| Telephone nursing quick assessment WHAT IS | the ?, the worst thing that could happen in the situcation, the time factor, the plan? |
| Telephone nursing quick assessment WHAT ARE | the risks, the most inportant ? to ask, |
| Telephone nursing quick assessment IS | the problem non urgent? |
| Telephone nursing quick assessment WHAT ARE | the risks, the problems & resources, |
| Telephone nursing quick assessment WHAT | Info s/ documented? |
| Telephone assessment | What is it? What is significance |
| Telephone assessment is used for what type of pacient | Used in ambulatory care |
| ambulatory | patient that can walk Designed for or available to patients who are not bedridden: ambulatory care; ambulatory |
| Benefits of telephone assessment= | Decreases use of ER *Increases access to care*Increases access to care *Increases pt satisfaction *After hours *Matches pt w/ appropriate physician*Access for those w/o insurance*Information seekers telephone nurse link to hc * Preventative care, health |
| Nursing skills needed 4 telephone assessment = | •Communication Thorough assessment Structured history taking ,Creative problem solving ,,Accurate documentation,Knowledge of nursing process |
| Knowledge of nursing process for telephone assessment | Assessment *Diagnosis Plan *Implementation * *–*Evaluation* |
| Assessment | Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status. It is the first stage in the nursing process. |
| Diagnosis | A nursing diagnosis is a standardized statement about the health of a client (who can be an individual, a family, or a community) for the purpose of providing nursing care. Nursing diagnoses are developed during the course of performing health assessments |
| Plan | In agreement with the patient, the nurse addresses each of the problems identified in the planning phase. For each problem a measurable goal is set. For example, for the patient discussed above, the goal would be for the patient's skin to remain intact. T |
| Implementation | The methods by which the goal will be achieved is also recorded at this stage. The methods of implementation must be recorded in an explicit and tangible format in a way that the patient can understand should he wish to read it. Clarity is essential as it |
| Evaluation | The purpose of this stage is to evaluate progress toward the goals identified in the previous stages. If progress towards the goal is slow, or if regression has occurred, the nurse must change the plan of care accordingly. Conversely, if the goal has been |
| AMA Classification of Medical Problems | Emergent *Urgent *Non-urgent |
| AMA Classification of the Medical Problem Emergent | requires immediate medical attention, delay could be harmful to pt.-acute –life threatening |
| AMA Classification of Medical Problem Urgent | requires medical attention within a few hours acute but not severe |
| AMA Classification of Medical Problem Non- Urgent | disorder is minor or not acute |
| acute | Having a rapid onset and following a short but severe course: acute disease.Afflicted by a disease exhibiting a rapid onset followed by a short, severe course: acute patients. |
| Limitations of a telephone assessment are? | No visible cues *No chart to examine •All data is subjective *Inform caller that telephone conversation is confidential |
| the Limitations of All data is subjective in a telephone assessment are? | no labs – no TPR –Consider tone of voice,hesitations, slurred speech |
| the Limitations of informing caller that telephone conversation is confidential in a telephone assessment are? | –Reinforce w/ sensitive calls such as substance abuse,reproductive issues and STD’s |
| TPR | Temperature Pulse Respiration |
| Professionalism | Telephone nursing is a part of professional nursing practice |
| All state laws regarding nursing practice | apply |
| Thorough documentation is | essential |
| If it isn’t documented, it | didn’t happen |
| Use of Nursing ProcessAgencies that use telephone assessment have | protocols and guidelines |
| Following nsg process will help | make decisions r/t pt. problem |
| Assess | Interview-pt may be unable to explain problem * |
| NSG | Nursing Specialist Group |
| r/t | Real Time |
| Assess | Interview-pt may be unable to explain problem • doesn’t understand med terminology •May have vague idea about problem •May fear consequences |
| Asess cont | Nurse needs to determine real reason for call |
| Communication cont. | Clarify •Reflect •Ask about patient’s feelings •Ask age •Onset of symptoms •Similar episodes in past? •Ask other appropriate questions as when assessing a chief complaint •May help w/ nsg. diagnosis |
| Classifying Problems types Physiological | - CHF |
| Classifying Problems typesSign- | ankle edema |
| Classifying Problems types Symptom- | chest pain |
| Classifying Problems types Risk factor- | 3 ppd cigarettes |
| Classifying Problems types Social problem- | unemployment |
| Classifying Problems types Operation- | cholestectomy |
| Physiological | (blank) |
Created by:
garrowcousino
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