Chris Rooney BSN, RN BC

Health Services

Millersville University of Pennsylvania

Located in Millersville, Pa.,

8400 students

3 miles from Lancaster City

1 1⁄2 hours from Philadelphia

2 1⁄2 hours from Washington D.C.

3 hours from New York City

Staffing

◦ Full Time Medical Director - D.O.

◦ NP 1.75 FTE (12 mo and 9 mo)

◦ RNs 4.75 FTE

◦ Clerical Support 1.80 FTE (12 mo and 10 mo)

Visits per year 11,000

Hours 8a-5 p M-F

7 Exam Rooms Built 1968

Health Fee Funding

Define Nursing Triage in the college health setting

Discuss treatment protocols after triage

Identify tools to expedite statistical analysis of triage and treatments small school style

Main Entry: tri·age

Pronunciation: \trē-ˈäzh, ˈtrē-ˌ\

Function:

—triage noun

1 : the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors

2 : the sorting of patients (as in an emergency room ) according to the urgency of their need for care transitive verb

Merriam Webster Dictionary

Scope of practice -

Direct Nursing Care

Collaborative Role

Health Educator

Research/Consultant

Advocacy

Combining Triage with College

Health Nursing

History taking with physical/mental/spiritual assessment with cultural competency

Acute illness and injury care – chronic illness

Health Education and Promotion – disease prevention

Management and leadership of risk reduction, resources, facilities, environment, including safety, infection control, etc

Prioritization of services for individuals based on assessment and triage

 Staffing

 Staff – provider type

 Time – hours of service , time of day

 Method of contact

 Walk in

 Phone interaction

 Chief Complaint - Assessment

 Appointment/walk-in

 Need for ancillary services - immediate lab/x-ray

 Other considerations

 Transportation

 Distance to acute care/ER

State Board of Nursing Law

Standard of Care

◦ National Council of State Boards of Nursing. https://www.ncsbn.org/312.htm

◦ Article 2, chapter 2

Medical Direction – what is your medical director comfortable with?

◦ Protocols/documentation

◦ Expertise of staff

Case 1

◦ Joe, 18 y/o male walks into your Health Center requesting an Albuterol Inhaler in no acute distress. 4:00 p.m. on Friday Afternoon before

Spring Break. Providers – Physician, PA/NP – out of the building. Front Office staff and 2 RN’s

Literature

Review of

Protocols

None specific to college health

2007 JCN -Clinical decision making

2008 IJN - Knowing the patient

2009JCN – Context vs protocols

2008 JTIICC – Triage Tools

2009 IJCN - Expertise

URI Assessment sheet

URI/Respiratory

NAME:_____________________________________________________ Date of Birth____________

Address___________________________________Best Phone # to call________________________________

DATE:_______________TIME_________ Page #___________

Medications

Allergies

PMH

SUBJECTIVE

OBJECTIVE: T P R BP O2 Sat Flu Screen □ Pos □ Neg

□ Not assessed by RN__________________________________

Skin: □ Not Assessed □ Normal: Warm, dry, color normal, no rash □ Hot □ Cold □ Diaphoretic □ Cyanotic □ Pale

□ Jaundice □ Edema/Swelling______________□ Ecchymosis_____________ □Rash __________________________________

Eyes □ Not Assessed □ Normal PERRLA, Conjunctiva normal, normal acuity , no drainage, swelling, or pain

□Abnormal □ R Pupil __mm □ L Pupil __mm □Swelling/edema/__________________

□ Conjunctiva: Pale □ Injected □ Ichteric □ Exudate: ______________ Other

Ears □ Not Assessed □ Normal: Canals patent, +light reflex, TM normal, acuity normal

□ Abnormal TM R L □ Bulging □ Erythema □ Retracted □ Tender to touch R L Both

□ External Ear_______________________ □ Other _______________ □Hearing Deficit

□ Abnormal Canal R L □ Erythema □Cerumen □ Edema □ Other ____________________________________________

Nose □ Not Assessed □ Normal: Sinus nontender, turbinate normal, septum midline, no drainage/congestion

□ Sinus Congestion □ Sinus Tenderness: Maxillary/Frontal □ Rhinnorhea: Clear Yellow Green Other_______________

□ Turbinate Mucosal Color___________ □Other

Throat □ Not Assessed □ Normal: Normal Pharynx, tonsils, mucous membranes

□Tonsils □Normal □Absent Size_____ □Inflammed □Exudate_____________□ Cryptic

Post Phyx □ Normal □ Erythema □ Cobblestone □ PND_____________ □ Ulcers _______________________________

Mucous Membranes □ Normal □ _________________ Dentition □ Normal □ ________________________□Other

Neck/Nodes □ Not Assessed □ Normal No Adenopathy, non tender, neck supple, normal ROM

□ R Ant_________Post_________ □ L Ant_________ Post__________ □ Tenderness

□ Rigidity □ Stiffness □ Vertebral tenderness _________ □ ROM limited / painful _______________□Other

Respiratory □ Not Assessed □ Normal No pain, normal excursion/expansion, no retractions, no SOB, CTA

□ Retractions □ Unequal/↓ BS_______________□Nasal Flaring □ Pain or tightness □ Chest Tender to palpation______________

□ Rales ______ □ Rhonchi ______□Wheezing______ □ Labored □ Stridor □ Cough □Productive _________________□ SOB

□ Peak Flow ______/PN_____ ______% □Other

□ Rapid Strep □ Discussed □ Rapid Mono □Discussed □ Throat Culture Sent □ Discussed T/C □ Rapid Flu

URI/Respiratory

NAME:_____________________________________________________ Date of Birth___________

DATE:_______________Cont’d

Page #___________

Assessment:

Plan:

Evaluation by MD/DO/NP Signature:

Plan:

Acetaminophen 325 mg 2 or 3 tabs PO Q 4 – 6 hrs.

Acetaminophen 500 mg (ES Tylenol) 2 tabs PO Q 4-6hrs

Ibuprofen 200mg ____ PO Q 6 hrs with food Pkgs____

Hycodan ________________________________

(DROWSINESS)

Amoxicillin 500 mg 1 cap PO three times a day #30

(OCP Prec.)

Naproxen Sodium 220mg ____ PO q 12 hours Pkgs____

Saline Nasal Spray

Saline Gargle

Throat Spray □ Lozenges

Afrin Nasal Spray 2-3 sprays each nostril every

Azithromycin (Z-Pack) 250mg as directed

with food. (OCP Prec.)

Bactrim DS 1 PO BID #20 (OCP Prec.)

Cephalexin (Keflex) 500 mg #40 1cap PO QID

12 hours x 3 Days

(OCP Prec) 2 cap PO BID

Doxycycline 100 mg. 1 PO BID #20 (OCP Prec.)

Cold Relief Tabs (Acetomenophen 325 mg; Guaifenesin

Penicillin VK 500 mg #40 1 tab PO QID

100mg, Phenylphrine 5 mg, Dextromethoraphan 15 mg, )

2 tabs PO Q 4-6 hours #____

Pkgs____

Pseudoephedrine 30 mg 60 mg PO Q 6 hrs #______

(OCP Prec.) 2 tab PO BID

Albuterol Inhaler 2 puffs every 4-6 hours or as directed

Prednisone 5mg #36 Per schedule □

Loratadine 1 PO Q 24 hrs (drowsiness) #______

10 mg #12 #18 Per schedule

Chlorpheniramine Maleate 4 mg PO Q 6 hours #______

(DROWSINESS)

Guaifenesin DM Plain 10cc PO Q 4 hrs prn cough

Mucinex 600 mg 1 Q 12 hours #10 Increase PO Fluids

Drink plenty of fluids □ Written instructions

Thermometer

_______________________________________________

_______________________________________________

Agrees / Expresses understanding of POC

□ F/U if persists or worsens ____________________

Appt with MD/DO/NP_________________

Class Excuse □ Social Distancing

Home

Signature_____________________________________

Agrees/Expresses understanding of POC

F/U if persists or worsens ____________________

Appt with MD/DO/NP_________________

Social Distancing

Home

Pandemic Influenza Triage Screening Tool

1.Has there been exposure/contact with anyone else with symptoms?

2.Is there a documented fever of 101 or higher?

3.Does the patient have any of the following: runny nose/nasal congestion, cough, sore throat?

4.Did the illness begin abruptly – how long present

5.Ongoing chronic illness? Diabetes, immunosuppression, asthma organ recipient, gastric bypass?

6.Difficulty breathing, severe N/V dark urine, fever more than 72 hours

7.Pregnant?

8.Does the student believe they need to be seen in person

Yes to 1 and/or 2 – Follow Respiratory Nursing Procedure/Standing

Orders

Yes to 1,2,3, and 4 – less than 48 hours – same day nurse appt – Flu test and referral as appropriate

Yes to 1, 6, 7, or 9 – Same day appt with provider

Yes to 7 – consider immediate or ER Eval – clinical decision/symptoms

Telephone call at 11:00 a.m. from 21 year old female student, LeaAnn, reporting abdominal pain for 3 days.

Slight nausea, right sided lower back pain, denies fever,

(doesn’t have a thermometer.) Hasn’t been to class the last three days.

States pain is so bad - can’t get out of bed.

Can you ambulate? Can you get to

Health Services?

The nurse asks more questions:

Vomiting No

Diarrhea No

Dysuria Yes x 3 days

LMP 2 weeks ago - normal

What other questions are you going to ask before you determine course of action?

Resource: Telephone Triage Protocols for Nurses Julie K Briggs

Lippincott 2006

Appointment scheduled for assessment --- with provider if available/with nurse for triage.

Abdominal Pain

Nursing Management and Standing Orders

Definition: Recent onset of abdominal pain

Pathogenesis:

Major mechanisms of acute abdominal pain include obstruction, distention, peritoneal irritation, mucosal ulceration, vascular compromise, traumatic injury, and referral from an extra-abdominal site

Types of abdominal pain o Visceral pain is deep, dull, crampy, poorly localized o Somatoparietal pain is sharp, well localized, and originates from noxious stimulation of the parietal peritoneum and generally is more intense and more precisely located than visceral pain o Referred pain in pain that is experienced at a distance from the disease

Clinical Presentation

Location of the pain may provide clues to common causes of abdominal pain from both intra-abdominal and extra-abdominal sources (See attached chart)

Nursing Guidelines

The nurse will evaluate the following data

Subjective

- History o Age, gender o Past medical/surgical history o Current medications o Medical allergies o History of alcohol or Tobacco use

- History of Present Illness o Determine onset, location, and quality of pain o Have patient rate pain on scale of 1-10, does it interfere with sleep o Has pain changed since onset o Does pain radiate or refer to other sites o

Is the pain relieved or aggravated by anything o Any vomiting, changes in bowel habits, urinary symptoms o In females – any pelvic symptoms - dyspareunia, abnormal vaginal discharge, irregular menstrual bleeding, any possibility of pregnancy

Objective

Vital signs

General appearance – pallor, perspiration, restlessness, distress

Auscultate bowel sounds

Palpate abdomen, assess for rebound tenderness or guarding

Assess CVA tenderness

Standing Orders

Constipation

Abdominal Pain

Standing Orders

Obtain clean catch urine sample o Dip urine via Clinitec Machine, per laboratory procedure. o If pregnancy suspected/concern – do pregnancy test, per laboratory procedure.

If MD/NP present – refer for evaluation

If MD/NP not present and: o If Temp > 100.5, HR > 120, or RR >24, pain is moderate to severe, localized, associated with nausea, vomiting, back pain, moderate dehydration, vaginal bleeding, hematuria, or if in your clinical judgment referral is needed or patient or parents request a referral

Refer to Emergency Department o If Pregnancy test Positive

 Refer to Emergency Department o If Right lower quadrant pain, absent or diminished bowel sounds, abdominal guarding, or positive rebound tenderness

Refer to Emergency Department

If MD/NP not present and patient is: o Afebrile, vital signs normal, normal appetite with unremarkable abdominal exam

Phone consult with physician

Use Cipro if Bactrim DS was previously used and visa versa (prior three months)

Only send cultures in the following circumstances o Suspected Pyelonephritis o Recurrent infections (within 4 weeks) o No improvement in 72 hours after starting antibiotic treatment o Infection symptoms in patients with diabetes, renal stones, pregnancy, tuberculosis, sickle cell, fever > 101, catheters, GU structural abnormalities, female patient is < 16 years old, all male patients o

No Provider available

Follow up urinalysis is unnecessary if symptoms resolve

Expert opinion favors a three day course of Bactrim DS as initial therapy

(Clinics in Family Practice – article March 2004 referenced in the Infectious

Disease Society of America)

According to this data review, nursing care and physician standing orders were developed.

Nursing Guidelines:

The nurse will evaluate the following data:

Subjective

History: o Age, gender o

Past medical/surgical history o Current medications o Medical allergies o Normal voiding patterns, fluid intake o Past history of UTI’s – number in past year, type of treatment o GU abnormalities o LMP o Sexual activity o Contraceptive use o Vaginal/urethral discharge

History of Present illness o Dysuria, frequency, urgency o Hematuria o Abdominal tenderness o CVA tenderness o Nausea/vomiting o Urinary incontinence

Objective

Vital signs

Palpate abdomen

Assess for CVA tenderness

Standing Orders

Perform urine pregnancy test if indicated

Collect clean catch urine

Dip urine via Clinitec Machine, for nitrates, leuk esterase, blood and specific gravity, and record in chart o

If MD/NP present:

 Spin urine for microscopic examination. Hold portion for possible culture and sensitivity o If MD/NP not present and patient has fever, moderate to severe symptoms, back pain/CVA tenderness, urine grossly bloody, multiple antibiotic allergies or pregnancy test positive, refer to Urgent Care or ED. o If MD/NP not present, urine dip is + for leuk esterase*, or nitrate* and the patient is non-toxic:

Dispense Bactrim DS (#3) 1 PO BID x 3 days or Cipro 500mg (#3) 1

PO BID x 3 days , if sulfa allergy

 Send urine for culture and sensitivity

 Obtain telephonic approval from MD/NP

Arrange F/U appointment with MD/NP within 72 hours

 Ensure chart review by MD

* Unreliable on dipstick if pyridium has been used

UTI Flow sheet

GI/Abdominal Pain

Flow sheet

Gastrointestinal/Abdominal Pain

NAME:____________________________________ Date of Birth____________

Address_________________________________Best Phone # to call_________________________________

DATE:__________TIME_________ Page #___________

Medications

Allergies

LMP:

Menses Normal Y N

PMH

Last BM Tobacco Use Y N

ETOH Use Y N

OBJECTIVE : T P R BP O2 Sat

General Appearance □ NAD □ Normal: Warm, dry, color normal, no rash, turgor elastic, moist mucus memb.

Ent/Respiratory: □ Not Assessed □ Normal eyes, nose, throat, lungs CTA, no SOB

Abdomen: □ Normal: Soft, nontender, non distended, BS normal, no organomegaly

□ Pain Location_______________ Quality_________________ Severity (1-10)_______

□ Rebound_____ □Guarding____

□ Bowel Sounds: Absent Normal Hypoactive Hyperactive

□Other____________________________________________________________

GYN/GU: □ Normal: No suprapubic or CVA tenderness

□ CVA Tenderness □ R □ L □Suprapubic pain on palpation

□ Abnormal Vag/Penile Discharge _______________________

□ Rash/Sores/lesions_________________________________________________

Pysch: □ Normal: Affect and behavior appropriate

Assessment :

Plan : □ Evaluation by MD/DO/NP □ Admitted for observation

□ Dicyclomine (Bentyl) 10 mg 20 mg 1 tab PO AC and hs (drowsiness)

□ Diotame 2 tabs PO Q 30-60 mins, no more than 16/24hrs

□ Prevacid 30mg PO daily #_______

□ Pepcid 1 cap PO AC #________

□ Zofran 4 mg 1 po/sl now Time______ (drowsiness) □ Zofran 4 mg 1 po/sl Q 6 hours prn _____#

□ Mylanta 10-20cc PO PC HS

□ Acetaminophen 325mg 500 mg #_____ PO Q 4 6 hrs prn pain/fever

□ Loperamine (Imodium AD) 2 cap PO after each loose BM no more than 8/24hrs

□ Diet Instructions ________________________________________________________________________

□ _______________________________________________________________________________________

□ Written instructions □ Expresses understanding of POC □Appt schedules with MD/DO/NP______________

□ F/U if persists or worsens

Signature :

Vital Signs imperative

Policy/Guidelines – follow documentation form

Guideline resources abundant but not specific to college health

Nursing judgment/clinical decision making within the scope of practice of

Registered Nurse if based on assessment findings and nursing guidelines

Nursing Diagnosis?

Staffing?

Time?

Education

Mental Health

Chronic Conditions

Public Health

Threat

Overview :

The Illness/Injury Severity Index is a triage tool which can be used to recommend patient disposition after assessing the severity of traumatic injury.

Parameters:

Copyright (c) 2006-2007, Institute for

Algorithmic Medicine, Houston, TX, USA.

All rights reserved.

(1) pulse

(2) blood pressure

(3) skin color

(4) respiratory condition

(5) consciousness

(6) bleeding

(7) region of injury

(8) type of injury

(9) age of patient

(10) previous history of condition

Parameter pulse blood pressure in mm Hg skin color respiratory condition age consciousness bleeding region of injury type of injury previous history of condition being treated

Finding

60 - 100

< 60, or 100 - 140

> 140 or irregular absent systolic 100 - 150; diastolic 60 - 90 systolic 80 - 100 or 150 - 200; diastolic 90 - 120 systolic < 80 or > 200; diastolic > 120 absent dry and normal reddish coloration ashen and/or moist cyanotic

12 - 20 breaths per minute

>= 20 breaths per minute

< 12 breaths per minute, or labored breathing or chest pain absent respirations alert and oriented incoherent or obtunded difficult to awaken unconscious none controllable hard to control uncontrollable none observed extremities back chest head, neck, abdomen none observed laceration or contusion fracture stab wound blunt trauma or missile

< 2 years of age

2 - 60 years of age

> 60 years of age no yes

3

4

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

4

1

0

1

0

1

3

0

1

2

3

0

1

2

Points

0

1

2

3

0

1

2

Copyright (c) 2006-2007, Institute for Algorithmic Medicine, Houston, TX, USA. All rights reserved. where:

• The scoring of systolic and diastolic blood pressure is unclear; it is presented as a ratio, could be ANDed, but implemented as OR

• The above table differs from the table in Bever and Veenker with the addition of "none" for both region of injury and type of injury. This is explained in the text on page 45.

• Age and previous history are listed as footnotes in the original table. illness/injury severity index =

= (points for pulse) + (points for blood pressure) + (points for skin color) + (points for respiratory condition) + (points for consciousness) + (points for bleeding) + (points for region of injury) + (points for type of injury) + (points for age)

+ (points for previous history)

Interpretation:

• minimum index: 0

• maximum index: 28

Index

<= 3

4 - 6

7 - 11

>= 12

Index

<= 5

6 - 13

14 - 24

25 - 28

Outcome in Illness Group patients can be released from the Emergency Department patient admitted to hospital but non-critical care unit patient admitted to critical care unit or had surgery predicts patient death in the emergency department

Outcome in Injury Group patients can be released from the Emergency Department patient admitted to hospital but non-critical care unit patient admitted to critical care unit or had surgery predicts patient death in the emergency department

NOTE: The table in Ford differs from the original data in Bever and Veenker for (a) points for region of injury, (b) points for type of injury, and (c) interpretive breakpoints.

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References:

Bever DL, Veenker CH. An illness-injury severity index for nonphysician emergency medical personnel. EMT Journal.

1979 (March); 45-49.

Ford EG. Chapter 4: Trauma Triage. pages 95-117 (page 101). IN: Ford EG, Andrassy RJ. Pediatric Trauma - Initial

Assessment and Management. W.B. Saunders Company. 1994.

 Create an assessment check list that when completed gives a numeric score that determines disposition.

 Utilize the guide to determine disposition or treatment per standing order.

 Does nursing already do that – mentally/experientially?

 Do we have tools that are part of that system

Centor Score –

Pharyngitis

Exudate

Tender Nodes

Fever >101

Absence of Cough

None or 1 – symptomatic TX

2,3,4 – do Rapid Step

+ treat/- Consult

Provider

Ottawa Ankle Rules

Pain in malleolar zone and one of:

Pain posterior 1/3 distal tibia/med malleolus

Pain distal

Fibula/lateral malleolus

Inability to take 4 steps

Institute for Clinical Systems Improvement www.icsi.org

Flow charts and algorithms for triage

Rapid Assessment A Flowchart Guide to Evaluating Signs and

Symptoms Lippincott 2004 $45

Adult Telephone Protocols: Office Version (Spiral-bound)

~ David A Thompson $85 (Amer. Acad. Of Peds)

Telephone Triage Protocols for Nurses Julie K Briggs Lippincott

3 rd Edition $50

Emergency Severity Index, Version 4: Implementation Handbook

Chapter 2. Triage Acuity Systems http://www/ahrg.gov/research/esi/esi2.htm

(Adaptable ED acuity systems with Practice Cases)

 Assessment needs to include cultural/ethnic variations

Example: Muslims may believe that sickness is a test from God, seen as a purification from sins and require a cure from God

 Students’ limitations in ambulation and communication and differentiation between acute and chronic neurological conditions are the main challenges in the triage of students with special needs and disabilities.

 Language Barriers – Use of interpreters – Time – use internet translators Google’s Language tools AltaVista

Translator TTY/Deaf

Document calls and the triage decision in the medical chart, indicating the protocol used and the advice provided. Use the caller’s own words to describe the reason for the call.

Develop triage algorithms to assist the RN, NP/PA/Physician in appropriate documentation of telephone conversations.

Develop a written policy defining the role and limitations of non-clinical or unlicensed staff, as well as specific symptoms requiring immediate attention.

Review all telephone triage decisions for appropriateness of actions taken.

Review all scheduling encounters for appropriateness and timeliness of appointments.

Allow only qualified staff to provide telephone advice.

Examples of nurse initiated interventions to expedite care at triage may include:

Administration of analgesia; antipyretics; oral rehydration; oxygen therapy

Diagnostic testing: Rapid Strep or Flu, Blood glucose measurement; Urinalysis

First aid (BLS, splinting, RICE, eye irrigation) wound management

Self Care – OTC’s, Discharge instructions, education

F/u care recommendations – when, why, with whom

All nurse-initiated interventions should be in accordance with organizational guidelines and policies.

General lack of evidence based research in terms of Nursing Triage and Treatment outside of emergency rooms.

Non existent in College Health

 No financial reimbursement for nurse visit

 Variety of scope of service across campuses

 Centrality to mission and goals of Health Services

What information

How to gather

What to do with it

Paper and pencil spreadsheet by the night nurse who “counted” the days activities.

Monthly total/Yearly total

Penetration rate?

Utilization by individual students?

Justification for resources?

Encounter form

Demographic data

Diagnosis

Interventions and Disposition

SCANABLE PAPER FORMS

Pros:

Equipment on campus for test scoring

Accurate data

Included Penetration

Good snap shot of Health Services

Easy for staff to complete at end of visit

Cons:

Data – Scanned monthly – reports at end of term

IT – physically cumbersome – carried across campus to scan

Cost of Printed sheet/paper/HIPAA

Change form – new form design/retool scanner/

Students hated completing the demographic portion of bubble sheet -

Excel Spread Sheet – Concurrent use in Fall

09 with bubble sheets.

Outlook Scheduling – Started in Fall 2009 – prior had paper and pencil schedule

◦ No reporting capability

◦ Appt and treatment – not connected

Interested in looking under the hood?

Customized Scheduler with database - Asset management system

IT department configured Database with Open

Source EMR

Web based – accessible from any PC on HS

Intranet

Link the appt with treatment

Cost – IT support to configure/debug

Discussion

◦ How do you quantify your nurse triaged patients?

◦ Do you evaluate effectiveness of your protocol?

◦ Satisfaction of students?

◦ Learning Outcomes?

Other comments?

Nurses – Assessment and triage of students in college health settings is within the scope of registered nursing practice.

Develop simple easy to use algorithms and base documentation on their use.

Alter in the event of significant medical occurrence – Pandemic – create tools

Maintain cultural competency

Quantify and evaluate effectiveness

Need to research and publish evidence based data in College Health Nursing Triage

Encourage collaboration with Nursing Staff in creating Triage Protocols

Chris Rooney, BSN RN BC

Millersville University Health Services chris.rooney@millersville.edu

Thank you!