Teleph ne Triage - APHON€¦ · TELEPHONE TRIAGE Providing health care via the telephone has developed into an important nursing role; this is in part due to a global need to reduce

GUIDELINESTeleph 1st

EDITION ne TriageA PROFESSIONAL RESOURCE FOR PEDIATRIC HEMATOLOGY/ONCOLOGY

AND STEM CELL TRANSPLANT NURSES

EDITORS

SUSAN BURKE, MA CPNP CPHON®, MEGHAN BELONGIA, MSN RN CPNP

SAMPLE

TELEPHONE TRIAGE GUIDELINESA PROFESSIONAL RESOURCE FOR PEDIATRIC HEMATOLOGY/ONCOLOGY AND STEM CELL TRANSPLANT NURSES

FIRST EDITION

EDITORSSusan Burke, MA CPNP CPHON®

Meghan Belongia, MSN RN CPNP

PUBLISHING STAFFExecutive Director: Dave Bergeson, PhD CAESenior Operations Manager: Nicole Wallace Managing Editor: Katherine WayneAssociate Editor: Kelly BaleAssistant Editor: Jaclyn WelterGraphic Designer: Jill Cooper

Copyright © 2013 Association of Pediatric Hematology/Oncology Nurses

All rights reserved. No part of this book may be reproduced or transmitted in any manner, including photocopying, without written permission from the publisher.

Printed in the United States of America

Association of Pediatric Hematology/Oncology Nurses8735 West Higgins Road, Suite 300 • Chicago, IL 60631

Library of Congress Catalog Number: 2013944100 ISBN: 978-0-9666193-8-6

Note: As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The authors, editors, and publisher have done everything possible to make this book accurate, up-to-date, and in accord with the standards accepted at the time of publication. The recommendations contained herein reflect APHON’s judgment regarding the state of general knowledge and practice in the field as of the date of publication. Any practice described in this book should be applied by the healthcare practitioner in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution especially is urged when using new or infrequently ordered drugs or treatments. Tables in the book are used as examples only. They are not meant to be all-inclusive, nor do they represent endorsement of any particular institution or procedure by APHON. Any mention of specific products and opinions related to those products does not indicate or imply endorsement by APHON. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of this book and make no warranty, expressed or implied, in regard to the contents of this book.

This publication includes information about legal issues and legal developments. Such materials are for informational purposes only and may not reflect the most current legal developments. These informational materials are not intended, and should not be taken, as legal advice on any particular set of facts or circumstances. You should contact an attorney for advice on specific legal problems.

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Contents • APHON Telephone Triage Guidelines ix

CONTENTS

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Overview of Telephone Triage . . . . . . . . . . . . . . . . 1

Development and Utilization of APHON’s Telephone Triage Guidelines . . . . . . . . . . 9

Communication Principles and Techniques . . . . . . 15

Legal Issues of Telephone Triage . . . . . . . . . . . . . 21

Symptom Guidelines. . . . . . . . . . . . . . . . . . . . . . . 33

Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Chills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Confusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Depressed Mood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Difficulty Eating. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Difficulty Urinating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Dizziness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Dyspnea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Fatigue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Hematuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

Irritability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Mucositis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Nausea and Vomiting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Paresthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

Phlebitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

Priapism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

Pruritus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

Rash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

Sleep Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

Swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

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Contents • APHON Telephone Triage Guidelines x

Educational Guidelines . . . . . . . . . . . . . . . . . . . . 241

Alopecia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243

Communicable Diseases and Immunizations . . . . . . . . . . . . . . 247

Medication Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

School Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

Sun Exposure and Insect Repellent Use. . . . . . . . . . . . . . . . . . . 261

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

Telephone Triage Documentation Forms. . . . . . . . . . . . . . . . . . 267

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269

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OVERVIEW OF TELEPHONE TRIAGE

Susan Burke, MA RN CPNP CPHON®

Meghan Belongia, MSN RN CPNP

Overview of Telephone Triage • APHON Telephone Triage Guidelines 1

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Overview of Telephone Triage • APHON Telephone Triage Guidelines 2

TELEPHONE TRIAGEProviding health care via the telephone has developed into an important nursing role; this is in part due to a global need to reduce health-related spending and to improve patient satisfaction. Various terminologies have been used to describe this aspect of nursing, such as telehealth, telephone advice services, telenursing, telephone consultation, and telephone triage. Many of these terms have been interchangeable; however, these roles traditionally have placed greater emphasis on patient advice, support, and teaching. In health care today, the term telephone triage expands on the role of the nurse from adviser, supporter, and teacher to one with greater emphasis on nursing assessment, patient management, and referral to the appropriate level of care (Wilson & Hubert, 2002).

Various definitions have been utilized to define telephone triage. The American Academy of Ambulatory Care Nursing (AAACN) (2007) defines telephone triage as a “component of telephone nursing practice that focuses on assessment, prioritization, and referral to the appropriate level of care” (p. 22). Rutenberg (2009) further described this as

an encounter with a patient/caller in which a specially trained, experienced nurse, utilizing clinical judgment and the nursing process, is guided by medically approved decision support tools to determine the urgency of the patient’s problem and to direct the patient to the appropriate level of care. This plan of care is developed in collaboration with the caller and includes patient education and/or advice as appropriate and necessary and follow-up as indicated to assure a safe outcome (p. 4).

HISTORICAL PERSPECTIVEThe use of triage in health care originated in the battlefields when dealing with mass casualty situations in which soldiers required rapid assessment of their injuries, with care prioritized to ensure the most effective use of limited medical resources (Wilson & Hubert, 2002). The use of triage via the telephone expanded in the United States in the 1970s when Health Maintenance Organizations (HMOs) initiated telephone advice lines staffed by registered nurses (RNs). The primary goal of this service was to reduce costs by eliminating unnecessary visits

to the emergency room or office and to support patients in the self-care role (Wilson & Hubert, 2002).

Continued expansion of telephone triage was seen in the 1990s in pediatrics. One of the primary reasons for this growth was the continued body of literature that supported the nurse’s competency in performing telephone triage (American Academy of Pediatrics, 1998). By utilizing nurses in this role, physicians were able to focus more time on patients who required a higher level of care. As patients and families adapted to this service, their satisfaction increased as they experienced more rapid access to healthcare services and an associated reduction in healthcare costs (American Academy of Pediatrics, 1998).

At the same time, telephone triage services and call centers were being initiated in Canadian provinces and internationally. The rationale for these services was similar to those in the United States, with an emphasis on conservation of resources, reduction in healthcare spending, and promotion of self-care.

Telephone triage in oncology nursing emerged as a direct response to patient and family needs for additional support and teaching (Black, 2007; Wilson & Hubert, 2002). Due to the rising costs of health care, hospitals and physician practices were challenged to become more fiscally responsible. As a result, complex oncology care that was traditionally provided in the inpatient setting was shifted to the outpatient arena, and a greater emphasis was placed on delivery of care in the home. Many cancer patients today do not require hospitalization because diagnostic work-ups may be performed and treatments can be administered in the ambulatory care setting.

As telephone triage programs expand, more emphasis is being placed on the nurse as patient advocate and teacher. Nurses play a key role in providing ongoing support and education to the patient and family as they strive to manage these complex care issues. Nurses are pivotal in promoting continuity of care to patients (Black, 2007) and instrumental in promoting early recognition of complications. A potential advantage in oncology telenursing is that the nurse, patient, and family may have a previously established relationship. The nurse’s decision making in telephone triage may be enhanced by knowledge of the patient’s health history, previous complications of therapy, emotional state, compliance

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Ann Reali Stratton, MSN RN CNP CPHON®

ANXIETY

Anxiety • APHON Telephone Triage Guidelines 35

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PROBLEM: ANXIETY

Anxiety is a feeling of apprehension and fear characterized by physical symptoms such as palpitations, sweating, and feelings of stress. Anxiety can be severe and debilitating. SAMPLE


GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your child’s activity level changed?

Is your child experiencing any respiratory symptoms (e.g., shortness of breath, chest pain, rapid breathing)?

Is your child having heart palpitations? Is your child sweating?

Has your child ever been told he or she has a heart condition?

Does your child complain of headaches, dizziness, or blurred vision?

Is your child able to talk to you in complete sentences (if age appropriate)?

Has your child had any sleep issues?

Is your child currently taking pseudoephedrine or cough medicine? Have there been any changes in his or her medication regimen?

Has your child ever received or is your child currently receiving steroids? If yes, what is the dose, duration, and has there been any recent changes in dose?

Has your child ingested large amounts of caffeine, alcohol, or any other substances?

Has your child recently received anesthesia or sedation medication?

Has your child had any recent changes to his or her health?

Has your child had any recent trauma/injury or surgery?

Does your child have an upcoming medical procedure?

Have there been any changes at home or school? Any reports of bullying?

Has your child had any changes in his or her relationships with other family members or friends?

Does your child have any suicidal thoughts or ideations?

Has your child experienced a recent loss/death of a friend, family member, or pet?

Has your child ever had issues with anxiety in the past? If yes, how was it treated?

Do you have any other concerns you would like to address?

(Cepuch et al., 2007; Cohen, 2010; Filin et al., 2009; Kersun & Elia, 2007; Pao et al., 2006)

GENERAL RISK FACTORS• Female gender

• Chronic illness

• Recent changes in health status

• Hemorrhage

• Emotional stressors (problems with school, relationship changes)

• Substance abuse (tobacco, alcohol, drugs)

• Medications

SAMPLE

BLEEDING

Sharon Bauer, BA-HCM RNCatherine Reese, MSN APRN BC

Bleeding • APHON Telephone Triage Guidelines 43

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PROBLEM: BLEEDING

Bleeding refers to the loss of blood. This can occur slowly or rapidly, and symptoms may differ depending on the speed of the blood loss. The cause of the bleeding can be disease specific, the result of an injury, or from treatment. Thrombocytopenia has been identified as the primary cause of bleeding in children with cancer and blood disorders, and it occurs as a result of decreased platelet production, increased platelet destruction, or sequestration of platelets in the liver or spleen.

(Baggott, Fochtman, Foley, & Kelly, 2011; Kline, 2008)SAMPLE



How is your child acting right now? Has his or her activity level changed?

When were your child’s last blood counts, and what were the results?

Where is your child bleeding?

How long has your child been bleeding?

What has been done to stop the bleeding?

Do you know what caused the bleeding?

Is your child on anticoagulation medicine? Has he or she been taking the medication as prescribed?

Has your child suffered a recent injury, or does your child have an open wound?

Has your child had increased bruising or petechiae?

If female, is your child menstruating? If yes, is the menses heavy? How many pads or tampons is your child using during a 24-hour period? How saturated are they when changed? How many days has your child had vaginal bleeding?

Are there any associated symptoms, such as fever, pain, swelling, headache, or dizziness?

What is the color of your child’s urine?

When was your child’s last stool? What color was the stool?

Has your child recently had surgery?

Do you have any other concerns that you would like to address?

GENERAL RISK FACTORS• Injury

• Medications that affect platelet production or function

• Menses

• Mucositis

• Protracted vomiting

• Surgery

• Thrombocytopenia

• Uremia(Baggott et al., 2011; Kouides, 2008; Polovich, Whitford, & Olsen,

2009)

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CHEST PAIN

Linda J. Del Vecchio-Gilbert, DNP CPNP-PC ACHPN CPON®

Chest Pain • APHON Telephone Triage Guidelines 51

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PROBLEM: CHEST PAIN

Chest pain is a discomfort or pain anywhere along the front or back of the body between the neck and upper abdomen. It can be acute (less than 48 hours) or chronic (longer than 6 months) in duration.

(Schwartz, 2000)SAMPLE



How is your child acting right now? Is your child awake, alert, and oriented?

Is your child experiencing difficulty breathing (e.g., nasal flaring, grunting, or stridor)?

Does your child have a history of underlying cardiac or lung disease?

What is the location of your child’s pain? Does your child’s pain radiate?

How severe is the chest pain? Is the pain interfering with your child’s activities of daily living?

How does your child describe the pain (e.g., numbness, tingling, burning, stabbing, aching, throbbing, twisting, pinching, dull)?

When did your child’s chest pain begin? Is this new or has your child experienced this pain in the past?

How often does your child’s pain occur (intermittent or constant)?

How long does your child’s pain last?

Can your child rate his or her pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain imaginable?

What level of pain is acceptable to your child?

What makes your child’s chest pain worse?

What makes your child’s chest pain better?

What have you tried to treat your child’s pain?

Is your child experiencing fever, cough, wheezing, or any other upper respiratory symptoms?

Is your child anxious, restless, or confused?

Is your child experiencing weakness, lightheadedness, or fatigue?

Is your child’s pain induced by exercise?

Has your child experienced recent trauma, rough play, or muscle overuse?

Does your child complain of a bitter taste in their mouth? Does your child complain of burping? Has your child ingested spicy foods?

Is your child currently taking oral contraceptives? Have there been any changes in his or her medication regimen?

Does your child have a history of heart disease?


(Schwartz, 2000)

GENERAL RISK FACTORS• Anemia

• Anxiety

• Cardiac abnormalities (e.g., arrhythmia, congestive heart failure)

• Respiratory illness (e.g., asthma, atelectasis, cough, pneumonia, pneumothorax)

• Gastrointestinal disorders (e.g., esophagitis, gastroesophageal reflux disease [GERD], pancreatitis, cholecystitis)

• Ingestion of caustic agent or foreign body

• Infection

• Congenital disorders (e.g., Kawasaki disease, Marfan disease)

• Musculoskeletal trauma (e.g., chest wall strain, costochondritis, direct trauma)

• Pulmonary embolism

• Recent cardiothoracic surgery

• Trauma/rib fracture

• Toxic exposure (e.g., smoking, use of illegal drugs)

SAMPLE

CHILLS

Meghan Belongia, MSN RN CPNPRenee Harteau, BSN RN

Chills • APHON Telephone Triage Guidelines 59

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PROBLEM: CHILLS

Chills are “a feeling of cold with shivering and pallor that is sometimes accompanied by an elevation of temperature in the interior of the body” (The American Heritage Medical Dictionary, 2007). Chills are a “kinetic thermoeffector response that employs aerobic muscle activity” (Hortzclaw, 2004, p. 268). Shivering is a “protracted generalized course of involuntary contractions of skeletal muscles that are usually under voluntary control.” (Hemingway, 1963, p. 398). SAMPLE




Does your child have a fever?

How long has your child had chills? Are the chills constant or intermittent?

Are your child’s extremities violently shaking?

Is your child’s skin cold, clammy, diaphoretic, mottled, or cyanotic?

Does your child have signs of breathing difficulties?

Does your child feel a racing or intense heart beat?

Has your child had a recent infection? If so, when, where, and what was the treatment?

Does your child have a cough, runny nose, mouth sores, pain, or skin wounds?

Does your child have a central venous access device? If yes, when was it last flushed?

Has your child had a recent surgery or been sedated for a procedure?

Has your child received a recent blood product transfusion?

Has your child had a recent amphotericin, IVIG, or antibody infusion?

Is your child taking all of his or her medications as prescribed?

Has your child had contact with anyone who is sick?


(Holtzclaw, 1990a, 1990b, 2004)

GENERAL RISK FACTORS• Infection

• Central venous access device

• Anemia

• Neutropenia

• Recent blood product transfusion

• Cold environment (exam instruments, X-ray tables, halls, water)

• Malnutrition/decreased muscle mass

• Postanesthesia recovery

• Open wounds or body cavities

• Medication

• Receiving cool intravenous infusion or irrigation

SAMPLE

CONFUSION

Confusion • APHON Telephone Triage Guidelines 65

Rebecca R. Rusch, MSN RN CPNP

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PROBLEM: CONFUSION

There are several levels of altered consciousness.

• Confusion: the loss of ability to think rapidly and clearly, impaired judgment or decision making

• Disorientation: impaired memory; confusion regarding time, place, and self

• Lethargy: easy arousal with normal speech or touch, limited spontaneous movement or speech, may not be oriented

• Obtundation: mild to moderate reduction in alertness, falls asleep unless stimulated verbally or tactilely

• Stupor: a condition of deep sleep or unresponsiveness from which the person may be aroused only by vigorous and repeated stimulation

• Coma: no response to the environment or stimuli(Huether & McCance, 2004)

SAMPLE




Does your child have a fever or signs of infection?

When did your child become confused? Was the onset gradual or sudden?

Does your child have a history of strokes or transient ischemic attacks (TIAs)?

Does your child have a history of seizures?

Does your child have weakness, or is your child more clumsy?

Has your child had any recent trauma or head injury? If so, describe the injury.

Does your child have any of the following neurological symptoms or symptoms of increased intracranial pressure?

• Headache• Blurry vision, double vision, or changes in vision• Nausea or vomiting• Increased irritability• Increased fatigue or sleepiness• Impairment of motor or speech function• Stiff neck

Does your child have a VP shunt?

Is your child able to follow simple commands?

Does your child have any sensory deficits?

• Changes in hearing• Changes in taste• Loss of pain sensation• Dizziness or vertigo

Does your child have increased bruising or bleeding?

Is your child currently taking any of the following medications?

• Antiseizure medications• Pain medications • Sedating medications (Benadryl or Ativan)• Medications to prevent or treat blood clots


Does your child have any symptoms of anemia (e.g., fatigue, pallor, headache, tachycardia, or tachypnea)?

Has your child’s oral intake changed?

Does your child have a history of high or low blood sugars? Does your child take insulin? If so, what was his or her most recent blood sugar?

Has your child recently been diagnosed with an infection?

Has your child recently ingested any drugs or alcohol?


(Burns, Dunn, Brady, Starr, & Blosser, 2004; Kline, 2009)

GENERAL RISK FACTORS• Thrombocytopenia• Infection/sepsis• Hypoxia• Malnutrition• Chronic nausea and vomiting

• Immunosuppression• Electrolyte imbalances (hypokalemia,

hyponatremia)• Endocrine dysfunction (hypoglycemia,

hyperglycemia)

• Medications• Anemia • Dehydration• Hemorrhage

SAMPLE

CONSTIPATION

Michael Comeau, MSN RN CPON®

Susanne Conley, MSN RN AOCNS CPON®

Constipation • APHON Telephone Triage Guidelines 71

SAMPLE


PROBLEM: CONSTIPATION

Constipation is a combination of symptoms that include stools that are infrequent, large, hard, palpable in the abdomen, and difficult to pass; cause straining; produce distress, abdominal pain, nausea, dizziness, soiling, and incontinence; or are visible in the rectum with difficulty to pass.

(Chase, Homsy, Siggard, Dit, & Bower, 2004; Itano & Taoka, 2005; Woolery et al., 2008)SAMPLE




How much is your child eating?

Has there been any recent change in your child’s diet?

What is your child’s usual pattern of stooling (frequency, before/after meals)?

When was your child’s last stool? What was its consistency, amount, and color? Was there any blood in the stool?

Is your child grunting, grimacing, or straining when stooling?

Is your child vomiting?

Does your child have abdominal distention or abdominal or rectal pain?

Is your child taking pain medicines or iron supplements?

Is your child on stool softeners or laxatives such as MiraLAX, lactulose, Senokot, or Colace?

Does your child have a history of constipation? What regimen has been successful in the past?

What other remedies (food, drinks, medications) have you tried recently to relieve the constipation?

How many ounces has your child had to drink in the last 24 hours?

How many wet diapers has your child produced or how frequently has your child urinated in the last 24 hours?

What is the appearance of your child’s urine (color, consistency, odor)?

Does your child appear dehydrated (dry mouth, decreased urine output, decreased tears)?

Is your child receiving IV hydration, total parenteral nutrition (TPN), or enteral feedings at home? If yes, what and how much?

Has your child had any recent trauma/injury or surgery?

Has there been any recent change in your child’s schedule? (Has he or she recently returned to school?)


(Chase et al., 2004; Coughlin, 2003; Hicks, 2001)

GENERAL RISK FACTORS• Diet (decreased fluid intake)

• Bowel obstruction

• Medications

• Lack of activity

• Electrolyte abnormalities (hypokalemia, hypocalcemia)

• Anxiety

• Surgery

(Chase, et al., 2004; Coughlin, 2003; Hicks, 2001)

SAMPLE

COUGH


Cough • APHON Telephone Triage Guidelines 77

SAMPLE


PROBLEM: COUGH

Cough is defined as a reflex that protects the airway by clearing inhaled material, such as pathogens, secretions, accumulated mucus, or foreign bodies. It may be acute or chronic and can be triggered by mechanical, chemical, thermal, or inflammatory irritation of the tracheobronchial tree.





Has your child’s activity level changed?

Is your child currently experiencing shortness of breath, wheezing, or difficulty breathing (e.g., nasal flaring, retracting, grunting, or stridor)?

What is your child’s respiratory rate (fast, slow, shallow)?

Does your child have any allergy symptoms (e.g., swelling around eyes, swelling around the mouth, or hives)?

Is your child experiencing changes in skin color (e.g., cyanosis, pallor)?

Is your child experiencing fever, chills, rhinorrhea, or chest pain?

Does your child have a recent history of an upper respiratory infection?

How long has your child had the cough?

How would you describe your child’s cough (e.g., dry, productive/wet, barking, honking)?

When does your child’s cough occur?

What makes your child’s cough better? What makes your child’s cough worse (e.g., smoke, cold air, dust)?

Is your child producing any mucus with the cough? What color is it? How much is there?

Is your child experiencing halitosis (i.e., bad breath), headache, or facial edema?


Does your child have a history of asthma or respiratory problems?

Has your child had any sick contacts?

Does your child have a history of vomiting with cough and/or reflux?

Does your child have any history of blood clots?



(Schwartz, 2000)

GENERAL RISK FACTORS• Anatomic abnormalities

• Aspiration

• Respiratory illness (e.g., asthma, bronchiolitis, bronchitis, sinusitis)

• Congestive heart failure

• Environmental irritants/pollutants (smoking)

• Gastroesophageal reflux disease (GERD)

• Habitual or psychogenic

• Infection

• Ingestion of caustic agent or foreign body

• Medications (ACE inhibitors and bronchodilators)

• Pulmonary embolism

• Tracheomalacia(Schwartz, 2000)

SAMPLE

DEPRESSED MOOD

Jill Lee, MSN RN CPNP-AC CPON®

Depressed Mood • APHON Telephone Triage Guidelines 85

SAMPLE


PROBLEM: DEPRESSED MOOD

Depressed mood is characterized by sadness, irritability, and loss of interest or pleasure in most activities. This may present in the context of an identifiable life stressor (adjustment disorder) or occur as a more persistent and chronic state (clinical depression).

(Lack & Green, 2009)SAMPLE




Does your child have a history of depression? If yes, is your child seeing someone to treat depression?

Has your child ever tried to hurt himself or herself in any way?

Has your child ever talked about a plan to hurt himself or herself in any way (suicidal ideation)? If yes, has your child given information about a plan?

Does your child have little interest or pleasure in doing things?

Does your child seem to feel down or hopeless? If yes, for how long?

Does your child seem irritable? If yes, for how long?

Does your child have trouble with sleeping? Does your child have trouble falling asleep or is your child sleeping too much?

Does your child seem fatigued or have little energy?

Does your child cry more frequently?

Does your child seem to have increasing negative thoughts (e.g., “No one likes me.” “Mom is really mad, so I must have done something wrong.” “I hate school now.”)?

Has your child been withdrawing from social situations?


Has your child had difficulty concentrating, such as when doing homework, reading, or watching television?

Has your child been moving or speaking more slowly than normal?

Has your child been restless?

Has your child complained of frequent symptoms such as a headache or stomach ache?

Has your child missed any school days as a result of the above symptoms? If so, how many?

Has your child had any recent change in school performance?

Do you suspect that your child has abused any substances (e.g., drugs, alcohol, prescription meds, etc.)?


(Bailey, Zauszniewski, Heinzer, & Hemstrom-Krainess, 2007; Lack & Green, 2009; Trends in Evidence Based Neuropsychiatry,

2003; U.S. Preventive Services Task Force, 2009)

GENERAL RISK FACTORS• Female gender

• Recent diagnosis of comorbid illness

• Emotional stressors (e.g., problems with school, relationship changes)

• Pubertal-related hormonal changes

• Family history of depression

• Medications (e.g., retinoic acid, steroids)

• Endocrinopathies (e.g., hypothyroidism, growth hormone deficiency, etc.)

• Encephalopathy

• Domestic and child abuse

• Substance abuse (e.g., tobacco, alcohol, drugs)

• Attention deficit hyperactivity disorder(Bailey et al., 2007; Lack, & Green, 2009; Trends in Evidence Based Neuropsychiatry, 2003; U.S. Preventive Services Task

Force, 2009)

SAMPLE

DIARRHEA

Pamela Dougher, BSN RN CPN CPON® Denise Gibson, RN CPON® Melissa Roslevege, BSN RN

Teresa Shapiro, MSN RN CRNP Amy Tubbs, BSN RN CPON®

Diarrhea • APHON Telephone Triage Guidelines 91

SAMPLE


PROBLEM: DIARRHEA

Diarrhea is very loose or liquid bowel movements that are more frequent than usual. This represents a change from one’s normal bowel habits and is often associated with abdominal cramping.

(Kline, 2009; Kufe, Pollock, Weichselbaum, Bast, & Gansler, 2003)SAMPLE




Does your child have a fever or chills?

When did the diarrhea begin?

What is the color, amount, and consistency of the diarrhea? Is there any blood or mucous in the stools?

How many diarrhea stools has your child had in the last 24 hours?

How many ounces of fluid has your child had to drink in the last 24 hours?


How many wet diapers or how frequently has your child urinated in the last 24 hours?

Does your child appear dehydrated (e.g., dry mouth, decreased urine output, decreased tears)?

Has your child’s oral intake changed? Have there been any dietary changes?

What is the pattern of the diarrhea? Does it occur after meals or at a certain time of day?

Is there a foul smell associated with the diarrhea?

Is your child vomiting? How much, how often, and when did it start?

Is there any associated abdominal or rectal pain? Can your child describe and rate his or her pain?

Does your child have breakdown around the rectal opening or a diaper rash?

Has your child had recent constipation?

Is your child on stool softeners or laxatives such as MiraLAX, Lactulose, Senokot, or Colace?

Is your child taking magnesium supplements?

Has your child recently been on antibiotics?

Have there been any recent changes in medications?

Do you know if your child has a history of Clostridium difficile (C. diff)?

Has your child traveled outside of the country or been in contact with visitors from outside of the country?

Has your child interacted with other people who also are experiencing diarrhea?

Does your child have symptoms of anxiety?

Has your child recently had surgery or a procedure?


(Baggott, Kelly, Fochtman, & Foley, 2002; Kline, 2009; Kufe et al., 2003)

GENERAL RISK FACTORS• Recent surgery (abdomen or pelvis)

• Medications (e.g., laxatives, antibiotics, withdrawal from narcotics)

• History of enteric pathogens (Clostridium difficile)

• Enteral or parenteral nutrition support

• Diet changes

• Constipation

• Exposure to sick contacts

• Travel to foreign countries

(Baggott et al., 2002; Bisanz et al., 2010; Kline, 2009)

SAMPLE

DIFFICULTY EATING (WEIGHT LOSS, ANOREXIA)

Sarah Royall, BSN RN CPON®

Pam Wojciki, MS RN-CS ARNP CPON®

Difficulty Eating • APHON Telephone Triage Guidelines 97

SAMPLE


PROBLEM: DIFFICULTY EATING

Difficulty eating is a decrease in appetite and/or inability to eat, resulting in decreased food consumption and weight loss.

(Freifeld et al., 2004; Mendes, Sapolnik, & Mendonca, 2007).SAMPLE




How much is your child eating?

Has there been any recent change in your child’s diet?



Does your child appear dehydrated (e.g., dry mouth, dry lips, decreased urine output, decreased tears)?

Is your child nauseated or vomiting? If so, when did the vomiting begin? What is the frequency of episodes? What is the quantity of emesis? How have you been treating the nausea and vomiting, and is the treatment helping?

Is your child having any abdominal cramping or pain when eating, drinking, or swallowing?


Does your child have any choking or breathing problems when eating or drinking?

Does your child have uncontrolled heartburn?

Does your child have sores on his or her lips or mouth?

Does your child have diarrhea or constipation? If yes, describe the number and quality of the stools.

Does your child have swelling in the abdomen, arms, or legs?

Does your child’s skin look yellow? Are the whites of your child’s eyes yellow?

Does your child have any dietary restrictions?

Does your child have any food allergies?

Has your child lost weight in the last week?

Have there been any changes in the types of food offered or food preparation?

Is your child taking any vitamins, herbs, or other dietary supplements?

Does your child have signs of depression or anxiety that may be affecting eating?


(Rodgers, 2009; Rodgers & Gonzalez, 2009)

GENERAL RISK FACTORS• History of kidney or liver dysfunction

• Medications

• Social (changes in caregivers or environment)

• Physiological influences (e.g., fatigue, depression, anxiety, food aversion, stress)

SAMPLE

Christine Armstrong, MScN RN (EC) NP PaediatricsLisa Honeyford, MN RN CPHON®

Jane Lowry, RN

DIFFICULTY URINATING

Difficulty Urinating • APHON Telephone Triage Guidelines 105

SAMPLE


PROBLEM: DIFFICULTY URINATING

Urinary retention is the inability to empty the bladder spontaneously for longer than 12 hours with a volume of urine expected for age or a palpable distended bladder without known voiding dysfunction. Symptoms may include hesitancy, dribbling, incomplete bladder emptying, overflow incontinence, or decrease in the force of the stream of urine. Dysuria is painful or difficult urination.

(Gatti et al., 2001)SAMPLE







Does your child sense the need to void? Has your child complained of pain, burning, or tenderness with the passing of urine?


Does your child have a history of difficulty urinating or urinary tract infections?


Does your child’s abdomen appear distended?



When was your child’s last stool? What was its consistency?

Has your child had any recent trauma, injury, or surgery?

Have there been any changes at home or school?

Is your child currently taking any medications?

Do you have other concerns that you would like to address?

(Barnard, 2004; Gatti et al., 2001; Russo, 2000; Von Gontaard & Neveus, 2006)

GENERAL RISK FACTORS• Dehydration (decreased oral intake, history

of gastroenteritis)

• Constipation

• Obstruction (e.g., clot, stone, calculi)

• Medications (e.g., narcotics, anticholinergics, alpha-agonists, anesthetics)

• Behavioral (lack of privacy)

(Barnard, 2004; Gatti et al., 2001; Russo, 2000; Von Gontaard & Neveus, 2006)

SAMPLE

DIZZINESS

Rebecca R. Rusch, MSN RN CPNP

Dizziness • APHON Telephone Triage Guidelines 111

SAMPLE


PROBLEM: DIZZINESS

Dizziness is defined as various abnormal sensations relating to perceptions of the body’s position or motion in relation to the environment. Dizziness may occur as a result of several different pathophysiologic processes.

• Vertigo is the illusion of true rotational movement of self or surroundings that is most likely related to vestibular organ dysfunction.

• Nonvertiginous symptoms include lightheadedness, generalized weakness, imbalance, tilting sensation, or unsteadiness that may be due to a variety of central nervous system (CNS), cardiovascular, or systemic diseases.

(Chan, 2009; Tusa, 2009)

SAMPLE





When did your child begin to complain of dizziness?

When does the dizziness occur? Is it constant or episodic? Does it occur with motion or position changes?

Is your child unsteady while standing or walking? Has your child fallen?

Is your child lightheaded, or does your child complain of weakness?

Does your child have a sense of rocking or swaying?

Has your child fainted?

What makes your child’s dizziness better?

What makes your child’s dizziness worse?

Does your child have symptoms of increased intracranial pressure, such as

• blurry vision, double vision, or changes in vision

• nausea or vomiting• increased irritability• increased fatigue or sleepiness?

Is your child having any seizure activity or abnormal movements?

Does your child currently have a headache? Does your child have a history of migraine headaches?

Is your child experiencing any motor or speech changes?

Does your child have a stiff neck?

Is your child confused?

Is your child having extremity tingling or weakness?

Does your child have a history of strokes or transient ischemic attacks (TIAs)?

Does your child have any symptoms of anemia, such as fatigue, pallor, headache, tachycardia, or tachypnea?

Does your child have any increased bruising or bleeding?

Has your child had any recent history of trauma?



How many wet diapers has your child had, or how frequently has your child urinated in the last 24 hours?

Does your child appear dehydrated (e.g., dry mouth, decreased tears, decreased urine output)?

Has your child eaten today?

Is your child experiencing diarrhea or vomiting?

Does your child have upper respiratory symptoms, such as sinus congestion or tenderness, or other signs of infection?

Does your child have any hearing loss, a feeling of pressure in the ears, or tinnitus (ringing in the ears)?

Has your child taken any new medications or herbal or natural products in the last 48 hours?

Has your child participated in recent drug or alcohol use?

Does your child have a history of motion sickness?

Does your child have any chest pain or shortness of breath?

Does your child have a history of cardiac abnormalities including a prolonged QT interval?

Does your child have a history of anxiety or display any symptoms of being anxious?



(Burns, Dunn, Brady, Starr, & Blosser, 2004; Chan, 2009; Cunningham, 2003; Graham & Uphold, 2003; Kline, 2009; Tusa, 2009)

SAMPLE

DYSPHAGIA

Ann Reali Stratton, MSN RN CNP CPHON®

Dysphagia • APHON Telephone Triage Guidelines 119

SAMPLE


PROBLEM: DYSPHAGIA

Dysphagia is any disruption in the swallowing process during transport from the oral cavity to the stomach. The symptoms may range from difficulties in swallowing to the complete inability to swallow. SAMPLE




Is your child having problems swallowing solids, soft foods, or liquids?

When did these symptoms start? Are they getting worse?


Does your child complain about a sore throat?

Does your child have any respiratory symptoms?

Have there been any changes to your child’s neurological status?

Is your child drooling?

Is your child able to speak?

Does your child have a hoarse voice, noisy breathing/stridor, or new onset snoring?

Does your child have any mouth sores?

Does your child have any white patches on her or his tongue?

Has your child recently received steroids or oral antibiotics?

Has your child vomited? If yes, was it bloody?

Does your child have any rashes?

Have there been any recent changes in your child’s medication regimen?

Has your child been treated for gastroesophageal reflux (GERD)? Does your child have any complaints of heartburn or abdominal pain?

Has there been any trauma to your child’s throat or neck?

Has your child recently had surgery? If yes, for what?

Is it possible your child ingested a foreign body, such as a coin or battery?



How many wet diapers has your child had or how frequently has your child urinated in the last 24 hours?


When did your child last eat?

Has your child been complaining of a dry mouth or jaw pain?


Has your child recently had radiation to the neck or chest?


(Bisset & Frush, 2005; Mouzan, Abdullah, Al-Mofleh, 2005; Furnival & Woodward, 2010; Takahashi, Paredes, Scavarda, &

Lena, 2007; Pittard, Abramo, & Arnols, 2009)

GENERAL RISK FACTORS• History of gastroesophageal reflux

• Oral infections (herpes virus or thrush)

• Pill esophagitis

• Mucositis

• Neurological side effects of medications

• Structural changes in the anatomy that are related to surgery to the head or neck

• History of environmental or food allergies(Bisset & Frush, 2005; Mouzan et al., 2005; Furnival &

Woodward, 2010; Pittard et al., 2009)

SAMPLE

DYSPNEA


Dyspnea • APHON Telephone Triage Guidelines 125

SAMPLE


PROBLEM: DYSPNEA

Dyspnea or shortness of breath (SOB) is defined as an uncomfortable or abnormal awareness of breathing, which may be described as breathlessness, chest tightness, air hunger, choking, or heavy breathing. It is a subjective feeling of having difficulty breathing.





Is your child having difficulty breathing right now?

Is your child on oxygen at home?

How long has your child had SOB?

Is the SOB with or without exertion?

Does your child have more difficulty breathing when lying flat?

Is your child experiencing retractions, use of accessory muscles, nasal flaring, grunting, or stridor?

What is your child’s respiratory rate—fast, slow, or shallow?

What is the color of your child’s skin? Is the skin temperature warm, cool, or diaphoretic? What is the color of your child’s nail beds?

Is your child experiencing fever, cough, wheezing, chest pain, or any other upper respiratory symptoms?

Has your child’s activity level changed, or has your child had any changes in comfort level?


How many words per breath can your child speak?

What makes your child’s breathing better? What makes your child’s breathing worse?

Does your child have any signs of allergic reaction (e.g., swelling eyes or lips, hives)

Is anyone at home sick or have a respiratory problem or illness?

Does your child have a history of heart problems?

Does your child have a history of asthma?

Does your child have a history of blood clots, or is your child on anticoagulation medication?

Has your child ever been hospitalized or had respiratory problems in the past?

Have there been any changes in your child’s medication regimen?

Does your child have a central venous line?



(Schwartz, 2000)


• Anemia

• Deconditioning

• Asthma

• Pain

• Anxiety

• Airway trauma

• Cardiac abnormalities (e.g., arrhythmia, congestive heart failure)

• Environmental irritants

• Hypoxia

• Pneumothorax

• Recent cardiothoracic surgery

• Tracheobronchial obstruction

• Pulmonary embolism(Schwartz, 2000)

SAMPLE

Mary Conway, MSN RN CPHON®

Sarah Matney, BSN RN CPON®

FATIGUE

Fatigue • APHON Telephone Triage Guidelines 131

SAMPLE


PROBLEM: FATIGUE

Fatigue is a profound sense of being tired that can interfere with movement, play, and concentration.

(Whitsett, Gudmundsdottir, Davies, McCarthy & Friedman, 2008)SAMPLE




What are your child’s symptoms? How long has your child been experiencing these symptoms? How do they differ from how he or she usually feels?

What makes your child’s fatigue better? What makes your child’s fatigue worse?

Is your child having symptoms other than fatigue, such as nausea or vomiting, pain, depression or changes in mood, or changes in attention or concentration?

Is your child taking any pain medication or sedating medication?

Does your child have any neurological changes (e.g., aphasia, vision changes, hemiparesis, or change in level of consciousness)?

Has your child suffered any recent head or other trauma?

Does your child have a ventriculoperitoneal shunt?

Is your child easily arousable? Is your child oriented to person, place, and time?

Does your child have signs of anemia (e.g., pallor, dyspnea, palpitations, headache, dizziness)?

Does your child have signs of bleeding or bruising, such as epistaxis or bloody stools?


Has your child had a recent blood transfusion?

If your child is female, is she menstruating (having her period)? If yes, when did it start? How heavy is the bleeding?


Have there been any changes in your child’s diet or appetite?

How many ounces of fluid has your child had to drink in the last 6–8 hours?

Has your child recently had a surgical procedure, or a bone marrow aspirate or lumbar puncture?

What are your child’s usual sleep patterns? Have there been any recent changes?

Has your child’s daily schedule recently changed (e.g., is your child going back to school)?

Have there been any significant changes or traumas in your family?

Is your child expressing any worries or fears?


(Panzarella et al., 2002)

GENERAL RISK FACTORS• Myelosuppression

• Infection/sepsis

• Anemia

• Dehydration/malnutrition

• Pain

• Changes in the pattern and quality of sleep

• Decreased physical activity and cognitive stimulation

• Isolation

• Anxiety or depression

• Medication

• Hypothyroidism

• Hemolytic process

• Intracranial hemorrhage/ increased intracranial pressure

(National Comprehensive Cancer Network [NCCN], n.d.)

SAMPLE

FEVER

Joy Bartholomew, MSN FNP-BC CPON®

Fever • APHON Telephone Triage Guidelines 137

SAMPLE


PROBLEM: FEVER

• Fever is a complex physiologic response mediated by pyrogenic cytokines and characterized by an elevation in core body temperature. The measuring degree that is considered a “fever” is variable and ranges from 38° C (100.4° F) to 38.7° C (101.5° F), depending on patient disease status and treating institution.

• In practice, a single temperature measurement of > 38.3° C (101° F) in the absence of environmental factors is usually considered to be a fever. A temperature of > 38.0° C (100.4° F) for > 1 hour indicates a febrile state in a standard oncology patient (Hughes et al., 2002) or > 38.0° C (100.4° F) once in high-risk patients (i.e., status post bone marrow transplant).

SAMPLE



How is your child acting right now? Has your child’s activity level changed? Is your child playing?

Does your child appear ill?

What is your child’s temperature right now? What has it been in the last 24 hours?

Is your child experiencing chills and/or shaking?

Is your child’s skin cold, clammy, blotchy, or blue-gray in color? Is your child sweaty?

Does your child have body aches?

Does your child have upper respiratory symptoms (e.g., cough, runny nose)?

Is your child having any difficulty breathing?

Does your child have abdominal pain, vomiting, or diarrhea?

When did your child last urinate? Is your child having any difficulty with urination?

Does your child have mouth sores, pain, or skin wounds?

Does your child complain of neck pain or stiffness?

Has your child had a recent infection? If yes, when, where, and what was the treatment?

Has your child had a previous blood infection? If yes, when did the infection occur?

Does your child have a central line? Is there any redness, swelling, or drainage?

Does your child have any other implanted device (e.g., Ommaya reservoir, ventriculoperitoneal shunt)?


Is your child currently receiving IV or oral antibiotics? If yes, did the fever resolve initially after antibiotics were administered?

Is your child currently taking steroids or have steroids recently been discontinued?

What, if anything, have you given your child for the fever? If you have given your child something, when did you administer the medication?

Has your child been in contact with anyone who is sick?


(Alexander, Wade, Hibberd, & Parsons, 2002; Donowitz, Maki, Crninch, Pappas, & Rolston, 2001; Saltzer et al., 2003)

GENERAL RISK FACTORS• Disease process

• Neutropenia defined as absolute neutrophil count (ANC) of < 500 μl or < 1000 μl with predicted decline (Freifeld et al., 2004) ANC = (WBC count) x (neutrophils % + bands %)

• Immunosuppressant medications, including steroids

• Central venous access

• Asplenia, functional or surgical

• Known exposure to sick contacts

• Infection (bacterial, fungal, viral)

• Mucositis

• Areas of skin breakdown

• History of heart disease or other chronic illness

• Recent surgery(Alexander et al., 2002; Donowitz et al., 2001; Freifeld et al.,

2011; Saltzer et al., 2003)

SAMPLE

HEADACHE

Ann Stiefbold, MSN RN APN CPON®

Headache • APHON Telephone Triage Guidelines 143

SAMPLE


PROBLEM: HEADACHE

Headache is pain or discomfort in the head or face. Headaches may be classified as primary or secondary depending on their cause. Primary headaches, such as tension headaches and any of the various types of migraine headaches, are not associated with an underlying pathology. Secondary headaches are related to an underlying condition or disease.

(Silberstein et al. 2004; Walker & Teach, 2008)SAMPLE



How is your child acting right now? Is your child consolable? Has her or his activity level changed?

Are you concerned about changes in your child’s neurological state, such as speech, vision, or mental status?

Where does your child’s head hurt?

When did your child’s headache(s) begin? Is this new or has your child experienced this pain in the past?

How often are your child’s headaches occurring (intermittent or constant)? Do they occur at a particular time of day?

How long do your child’s headaches last?

Do the headaches keep your child awake or awaken your child from sleep?


Has the intensity of your child’s pain changed?

Can your child rate her or his pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain imaginable?• What level of pain is acceptable to your child?

What makes your child’s pain worse (activity or rest)? What makes your child’s pain better?

What have you tried to treat your child’s pain (e.g., medication, rest, increased fluids)?

What medications does your child use at home for pain management?

Are there any emotional or behavioral changes associated with the headaches?

Do your child’s headaches interfere with school, play, or other activities?

Are there any associated systemic signs or symptoms (e.g., nausea and/or vomiting, fever and/or stiff neck, light or noise sensitivity)?

Has your child experienced any recent trauma to the head?

Does your child have any upper respiratory symptoms?

Does your child have any signs of dehydration? How many ounces of fluid has your child had to drink in the last 24 hours?

Has your child reported any change in sensory function, or have you seen a change in motor function?

Does your child have a history of migraines or tension/stress headaches, hypertension, sinus infections, seizures, or allergies?

Does your child have a bleeding or clotting disorder or a history of blood clots?

Is your child taking any blood thinning medications?


Has your child had a recent transfusion or factor infusion? If yes, what and when was the transfusion?

Does your child wear glasses?

Is there a family history of migraine headaches?


(Dooley, 2004)


• History of headaches

• Anemia

• Dehydration

• Hypercoagulability or thrombophilia

• Intracranial hemorrhage

• Infection

• Pseudotumor cerebri

• Cerebral vascular accident (stroke)

• Stress, depression, anxiety

• Vision changes

• Medications (anticoagulants)(Conicella et al., 2008; Distelmaier et al., 2007; Silberstein et al., 2004)

SAMPLE

HEMATURIA

Pam Wojciki, MS RN-CS ARNP CPON®

Hematuria • APHON Telephone Triage Guidelines 151

SAMPLE


PROBLEM: HEMATURIA

Hematuria is the presence of red blood cells in the urine.

(Gulati & Pena, 2010)SAMPLE




What color is your child’s urine (e.g., red, pink, dark red, brown, tea colored)?

How long has the urine been this color?

Is your child able to pass urine?

If toilet trained, does your child have control of his or her urine, or is your child having urinary accidents?

Has your child’s urination pattern changed? If yes, how often is your child urinating?

Does your child have pain with urination or abdominal or flank pain? If yes, how does your child describe the pain (e.g., dull, squeezing, stabbing, pounding, throbbing)?


• What level of pain is acceptable to your child?

Do you see any clots, debris, or crystals in your child’s urine?


If your child is a pubertal female, is she currently having her period (menstruating)?

Has your child eaten any beets, blackberries, or foods with red dyes in the last 12 hours?

Has your child had a recent sore throat or cold symptoms?

Does your child have a skin rash (e.g., viral exanthem, petechiae, purpura, bruising)?

Has your child had any trauma to the back, abdomen, or genital areas?

Is your child on blood-thinning medication?

Does your child have any swelling around the eyes, arms or legs, or abdomen?

Does your child have any redness, swelling, or lumps in the genital area?

Does your child have any joint pain or stiffness?

Has your child performed heavy exercise recently?

Does your child have diarrhea or constipation? If yes, describe the number and quality of stools.

Is your child taking any vitamins, herbs, or other dietary supplements?

Has your child had recent surgery in the abdomen, pelvis, kidneys, or bladder?


Has your child had a recent blood transfusion?

Does your child or any family members have any known kidney or urinary problems?


(Gagnadoux, 2011, 2010; Meyers, 2004; Park et al., 2005; Youn, Trachtman, & Gauthier, 2006)


• Infection

• Cystitis

• Kidney disease

• Glomerulonephritis

• Kidney stones

• Medications

• Strenuous exercise

• Trauma

SAMPLE

IRRITABILITY

Christine Armstrong, MScN RN(EC) NP PaediatricsJane Lowry, RN

Lisa Honeyford, MN RN CPHON®

Irritability • APHON Telephone Triage Guidelines 157

SAMPLE


PROBLEM: IRRITABILITY

Irritability is a term used to describe individuals experiencing an excessive response to stimuli. Infants and children experiencing irritability may show behavioral symptoms such as being fussy, whiny, and fretful despite attempts to comfort and soothe them. Inconsolability is another term often used to describe irritability. Irritability can be an early yet nonspecific sign of a serious problem, particularly in the very young or nonverbal child. It is a symptom commonly reported by children with cancer.

(Vorvick & Kaneshiro, 2009; Williams et al., 2012)SAMPLE




What is concerning you most about your child’s current behavior?

How long has your child been acting or behaving differently? Is this a behavior that your child has demonstrated in the past (temper tantrums)?

Does your child have a fever? Does your child have chills?

How many ounces of fluid has your child had to drink during the last 24 hours?




Is your child more fatigued? Is your child complaining of dizziness, lightheadedness, or headaches?

Is your child complaining of pain? If yes, what have you done to relieve the pain?

Is your child consolable?

Does your child’s behavior interfere with eating, sleeping, playing, or toileting?

Has your child had any recent changes to her or his health?

Has your child had any recent trauma, injury, or surgery?

Have there been any changes at home or school? Any reports of bullying?

Has your child’s medication regimen recently changed?

Is your child currently receiving steroids or has your child recently completed steroids?

Does your child have any food, drug, or environmental allergies?

Do you have any other concerns that relate to this problem?

GENERAL RISK FACTORS• Anemia

• Fever

• Infection

• Dehydration

• Hyperglycemia/hypoglycemia

• Medications (opioid withdrawal or steroid use)

• Pain

• Sleep deprivation or fatigue

• Stress

• Hospitalization

• Mental health concerns

• Conditions or diseases that affect the central nervous system (Baggott et al., 2010; Jacob, 2008; Kline, 2008; Rodgers, 2009;

Tomlinson & Kline, 2010; Watral, 2008; Wilne et al., 2007; Yilmaz, Tas, Muslu, Basbakkal, & Kantar., 2010)

SAMPLE

Meghan Belongia, MSN RN CPNPJolene Epding, BSN RN CPHON®

Kitty Montgomery, MS RN PCNS-BC CPHON®

JAUNDICE

Jaundice • APHON Telephone Triage Guidelines 163

SAMPLE


PROBLEM: JAUNDICE

Jaundice is a yellowish color of the skin or sclera (white of the eye) that occurs as a result of hyperbilirubinemia. Hyperbilirubinemia is categorized into two groups:

• unconjugated hyperbilirubinemia, which occurs as a result of overproduction of bilirubin, reduced bilirubin uptake, and impaired bilirubin conjugation.

• conjugated hyperbilirubinemia, which is caused by biliary obstruction (extrahepatic cholestasis), intrahepatic cholestasis, and hepatocellular injury.

(Chowdhury & Chowdhury, 2010)

SAMPLE




Is your child difficult to wake, or does your child appear confused?


Has your child had any recent illness?


When did the yellow color begin?




What color is your child’s urine?

When was your child’s last stool? What was its consistency and color?

Does your child have abdominal pain?

Has your child had any episodes of vomiting, or does your child complain of nausea?


Does your child have a rash? Is your child itching?

Is your child taking any herbal supplements?


Has your child recently traveled outside of the United States?

Has your child had any known exposure to household cleaners or chemical products?

Has your child had any recent blood transfusions? If yes, when?

Have you been informed that your child’s liver function tests have been elevated in the past? Do you know your child’s most recent liver function test results?


GENERAL RISK FACTORS• History of blood transfusions

• Hemolysis

• Gall stones

• Infection (viral vs. bacterial)

• Sepsis

• Hypothyroidism

• Total parenteral nutrition

• Hepatotoxic medications(Chowdhury & Chowdhury, 2010; Landers & O’Hanlon-Curry, 2009; Snyder & Pickering, 2000; Whitington & Alonso, 1998)

SAMPLE

Meghan Belongia, MSN RN CPNPJolene Epding, BSN RN CPHON®


JAUNDICE


SAMPLE


PROBLEM: JAUNDICE

Jaundice is a yellowish color of the skin or sclera (white of the eye) that occurs as a result of hyperbilirubinemia. Hyperbilirubinemia is categorized into two groups:

• unconjugated hyperbilirubinemia, which occurs as a result of overproduction of bilirubin, reduced bilirubin uptake, and impaired bilirubin conjugation.

• conjugated hyperbilirubinemia, which is caused by biliary obstruction (extrahepatic cholestasis), intrahepatic cholestasis, and hepatocellular injury.

(Chowdhury & Chowdhury, 2010)

SAMPLE




Is your child difficult to wake, or does your child appear confused?


Has your child had any recent illness?


When did the yellow color begin?




What color is your child’s urine?

When was your child’s last stool? What was its consistency and color?

Does your child have abdominal pain?

Has your child had any episodes of vomiting, or does your child complain of nausea?


Does your child have a rash? Is your child itching?

Is your child taking any herbal supplements?


Has your child recently traveled outside of the United States?

Has your child had any known exposure to household cleaners or chemical products?

Has your child had any recent blood transfusions? If yes, when?

Have you been informed that your child’s liver function tests have been elevated in the past? Do you know your child’s most recent liver function test results?


GENERAL RISK FACTORS• History of blood transfusions

• Hemolysis

• Gall stones

• Infection (viral vs. bacterial)

• Sepsis

• Hypothyroidism

• Total parenteral nutrition

• Hepatotoxic medications(Chowdhury & Chowdhury, 2010; Landers & O’Hanlon-Curry, 2009; Snyder & Pickering, 2000; Whitington & Alonso, 1998)

SAMPLE

Mucositis • APHON Telephone Triage Guidelines 169

MUCOSITIS

Jill Lee, MSN RN CPNP-AC CPON®

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PROBLEM: MUCOSITIS

Mucositis is an inflammation or ulceration of the mucous membranes that may occur anywhere throughout the gastrointestinal tract.

(Tomlinson, Judd, Hendershot, Maloney, & Sung, 2007)SAMPLE




Is there any redness, sores, ulcers, or white patches present in your child’s mouth or on his or her lips?

Does your child have breakdown in the rectal area? Is your child complaining of pain with stooling?

Is your child having any bleeding (oral or rectal)?

Is your child having difficulty breathing?

Is your child having difficulty or pain with swallowing?

Is your child having difficulty eating? How much is your child eating?

Is your child having difficulty drinking? How many ounces of fluid has your child had to drink in the last 24 hours?


Is your child drooling or experiencing pooling of saliva? Is the saliva thick and sticky?

Is your child having any difficulty with speaking?

Does your child have a fever or any other associated symptoms, such as nausea, vomiting, diarrhea, rash, abdominal pain?

Does your child have pain, or is your child fussy or irritable? If yes, when did it begin?

Has your child taken any pain medication?

• If yes, what were the medications given, how much was given, and how often?

• Was your child’s pain improved after the medication?

• Was this medication started because of mouth sores, or was your child already taking pain medication?

What makes your child feel better? What makes your child feel worse?

What is your child’s mouth care regimen (e.g., tooth brushing, mouthwashes)? How often is your child practicing mouth care?


Does your child have a history of cold sores?



(Landers & O’Hanlon-Curry, 2009; Kushner, et al., 2008; Tomlinson et al., 2009; Tomlinson, Judd, Hendershot,

Maloney, & Sung, 2007, 2008)

GENERAL RISK FACTORS• Infection • Neutropenia

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NAUSEA AND VOMITING

Christine Armstrong, MScN RN(EC) NP PaediatricsMaryJo DeCourcy, MScN RN CPHON®

Bruna DiMonte, BScN RN

Nausea and Vomiting • APHON Telephone Triage Guidelines 175

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PROBLEM: NAUSEA AND VOMITING

Nausea is the sensation of the need to vomit that may or may not result in vomiting. Vomiting is the expulsion of gastric contents through the mouth.

(Hedstrom, Haglund, Skolin, & von Essen, 2003)SAMPLE




Is your child irritable and inconsolable?

Is your child pale, weak, sweating, or dizzy?

Does your child have abdominal pain? What part of the abdomen is painful?

How does your child describe the pain (dull, squeezing, stabbing, pounding, or throbbing)?



Is your child nauseated? If yes, when did it begin?

Is your child also vomiting? If yes, when did the vomiting begin?

What is the frequency of your child’s vomiting?

What is the quantity of emesis?

Is your child’s vomiting forceful?

Describe the color and texture of the emesis (e.g., bloody, coffee–ground like, or bilious)?

Is there a pattern to your child’s nausea or vomiting, such as upon awakening or after meals?

What makes your child’s nausea or vomiting better? What makes your child’s nausea or vomiting worse?

Is your child taking antiemetics? What is the medication, and when was it last given?



How many wet diapers has your child had, or how frequently has your child urinated in the last 24 hours?

What is the appearance of your child’s urine (what is the color, consistency, and odor)?



When was your child’s last stool? What was its consistency?

Are there any other associated symptoms, such as pain, fever, recent injury?


Have there been any changes at home or school?

Has your child recently had surgery or a procedure?

Is your child anxious?

Is your child taking all of her or his medications as prescribed?


GENERAL RISK FACTORS• Sick contacts

• Younger age

• Female gender

• History of major organ dysfunction (hepatic, renal)

• Cholelithiasis

• Recent surgery

• Medication (narcotics)

• Constipation

• Diet changes

• Anxiety

• Sick contacts

SAMPLE

Meghan Belongia, MSN RN CPNPAnne Joseph, BSN RN CPHON®


Mollie Mulberry, MS RN CPNP CPON® Carolyn Ziebert, MS RN

PAIN

Pain • APHON Telephone Triage Guidelines 183

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PROBLEM: PAIN

Pain is a multidimensional symptom generally accepted to be an unpleasant sensory and emotional experience related to actual or potential tissue damage that often directly affects a patient’s quality of life. Pain is an abstract experience that includes emotional, psychological, social, and spiritual dimensions.

(Graham & Uphold, 2004; Walker, 2003)SAMPLE



How is your child acting now? Is your child awake, alert, and oriented?

Has you child’s activity level changed? Is your child’s pain interfering with normal activities of daily living?

Has your child had any recent trauma or injury?

Has your child recently had surgery or a procedure (e.g., bone marrow aspiration/biopsy or lumbar puncture)?

When did your child’s pain begin? Is this new or has your child experienced this pain in the past?

Where is your child’s pain?

How often does your child’s pain occur? Is it intermittent or constant?

How long does your child’s pain last?


Has the intensity of your child’s pain changed?

Is there a pattern to your child’s pain (occurs in the morning versus the evening)?



What makes your child’s pain worse (e.g., activity or rest)? What makes your child’s pain better?


What medications does your child use at home for pain management?




GENERAL RISK FACTORS• Injury

• Infection

• Medical or surgical procedures

• Secondary to other health problem (e.g., headache, constipation, heartburn)

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PARESTHESIA

Pam Jones, RN CNP CPON®

Paresthesia • APHON Telephone Triage Guidelines 191

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PROBLEM: PARESTHESIA

Paresthesia is an abnormal sensation that may be described as tingling, shooting, or burning and occurs as a result of sensory nerve dysfunction.

(Jacob, 2008; Numbness and Tingling, n.d.; Paresthesia, n.d.)SAMPLE




When did your child’s symptoms begin? Are they getting worse?

Have there been any changes to your child’s neurological status, such as loss of consciousness?

Does your child have slurred speech or visual changes?

Does your child have uncontrolled movement of an arm or leg, or has your child lost bladder or bowel control?

Does your child have any difficulty walking, holding certain objects, or weakness?

Where is your child’s numbness, tingling, or weakness? Is there any color change in this area? Does the area feel hot or cold?

Does your child have pain? If yes, where?

Does your child complain of a severe headache? What part of the head hurts? How long has your child had a headache? What makes the pain better?

Has your child complained of nausea? Has your child vomited?


Has your child had a recent viral illness?

Is your child constipated? When was your child’s last bowel movement?

Does your child have a rash?


Has your child suffered any recent trauma?



Do you have any other concerns that relate to this problem?

GENERAL RISK FACTORS• Vitamin deficiencies

• Diabetes

• Hypothyroidism

• Trauma (head, neck, or back)

• Medication

• Structural changes in anatomy that are related to surgery

• Disease process

• Herpes zoster(Armstrong, Almadrones, & Gilbert, 2005; Breakey, Bartels, &

Askalan, 2010; Jacob, 2008; Nielsen & Brant, 2002; Oakes, 2011; Rowland, 2005; Zempsky, Schechter, Altman, &

Weisman, 2004)

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PHLEBITIS

Kristi Geib, MSN RN CPNP CPON®

Phlebitis • APHON Telephone Triage Guidelines 197

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PROBLEM: PHLEBITIS

Phlebitis is the inflammation of a vein. It can be superficial or deep. Inflammation is accompanied by the formation of a clot (i.e., thrombosis), which occludes blood flow through the vein. This condition is called thrombophlebitis.SAMPLE




Where is the source of your child’s inflammation (e.g., old IV site, venipuncture site, central line site)?

How would you describe the appearance of the inflamed area (e.g., warmth, redness, tenderness, streaking, swelling, drainage)?

Is your child’s skin intact at the area of inflammation?

How would you describe the appearance of the involved extremity (e.g., swelling, redness)?

Can your child move the extremity without difficulty?

Does your child have a fever or chills?

Does your child have pain at the site of inflammation?

When did your child’s pain begin?

How often does your child’s pain occur (intermittent or constant)?

How does your child describe the pain (e.g., numbness, tingling, burning, sharp, achy)?

How would you rate your child’s pain (e.g., mild, moderate, severe)?

Is the pain interfering with your child’s activities of daily living?

What makes your child’s pain worse? What makes your child’s pain better?


Does your child currently have IV access (e.g., peripheral, peripherally inserted central catheter [PICC], central venous line [CVL], port)?

If the involved area is at a previous IV-access site, were there any difficulties in obtaining IV access or administering medications through the IV?

What medications were given through the IV site?

When was the last time the line was used? Was there any difficulty flushing the line?


Is your child receiving IV home medications? If yes, what and when was the last dose?

Does your child have a history of phlebitis or clots?

Has your child had any recent concern of illness or dehydration?


(Camp-Sorrell, 2000; Catney et. al, 2001)


• Neutropenia

• Current or recent IV access

• Administration of irritating IV fluids or medications

• Injury to the inner lining of the vein by the catheter

• Dehydration

• Inherited or acquired risk for clots

• Contraception or medications for menstrual suppression

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Deena Centofanti, MS RN AOCN®

Beth Savage, MSN CPNP CPON®

Priapism • APHON Telephone Triage Guidelines 203

PRIAPISM

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PROBLEM: PRIAPISM

Priapism is a prolonged, unwanted, and painful erection that affects males with sickle cell disease. Prolonged priapism is an episode that lasts longer than 3 hours. Stuttering priapism is defined as recurrent episodes that last less than 3 hours.

(National Institutes of Health [NIH], 2002; Ryan & Heeney, 2005)SAMPLE




Has your child been treated for priapism in the past? If yes, what was done to resolve the problem?

When did this begin? How long are the episodes lasting?

Has any treatment been provided?

Is your child able to urinate?

Does urination cause pain or burning?


Do you suspect that your child has abused any substances (e.g., alcohol, marijuana, cocaine, testosterone)?

What medications is your child currently taking?

Has your child had any recent trauma in the pelvic area, genital region, or spinal cord?


(Rogers, 2005)

GENERAL RISK FACTORS• Prior history of priapism

• Recent illicit drug use (e.g., cocaine, alcohol, marijuana use)

• Medications (e.g., antihypertensives, antidepressants, antipsychotics, tranquilizers, testosterone, some cough and cold medications)

• Trauma (e.g., pelvic/groin, genital, spinal cord)

(NIH, 2002; Rogers, 2005; Ryan & Heeney, 2005)

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PRURITUS


Pruritus • APHON Telephone Triage Guidelines 209

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PROBLEM: PRURITUS

Pruritus is defined as an unpleasant itch or sensation that is relieved by scratching. Words used to describe pruritus include tickling, burning, stinging, pins and needles, crawling sensation, and pain.





Where is your child itching?

How severe is the pruritus?• Is it intermittent or constant? • Does it increase at night? • Is it localized or generalized?

Is your child having difficulty breathing or experiencing other signs of an allergic reaction?

What makes the itching better? What makes the itching worse?

What effect does the itching have on your child’s everyday life or sleep pattern?

What is the condition of your child’s skin? Does your child’s skin appear dry and flaking?

What is your child’s current skin care regimen?

Does your child have a rash? If yes, where is the rash located? What does the rash look like? • Is there any redness, drainage, or swelling in

the area of the rash? • Are there any fluid-filled lesions?

What effect does this symptom have on your child’s everyday life or sleep pattern?

Does your child have any known kidney or liver problems?

Has your child had a recent lab test to check kidney or liver function? If yes, what were the results?


Does your child have a history of allergies, asthma, or eczema? If yes, what treatment has been used?

Has there been any recent change in your child’s medication regimen?

Has your child been exposed to any new or different soaps, detergents, or clothing?

Has your child been playing outside and been exposed to poison?

Has your child been exposed to anyone with a communicable disease or rash?

Has anyone complained of pruritus who has had contact with your child?


(McCord, Baker, & Mondozzi, 2009; Norville, 2008; Schwartz, 2008)

GENERAL RISK FACTORS• Allergy

• Altered organ dysfunction (renal dysfunction, liver disease)

• Hyperbilirubinemia

• Dermatologic disorders

• Dehydration

• Environmental irritants or toxins

• Infection

• Infestation (e.g., scabies, pediculosis, insect bites)

• Medications or drug sensitivity

• Psychologic

• Surgery, wound healing, and adhesions

• Urticaria (acute or chronic)(McCord et al., 2009; Norville, 2008; Schwartz, 2008)

SAMPLE

RASH

Hanna Tseitlin, MN PNP CPHON®

Rash • APHON Telephone Triage Guidelines 217

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PROBLEM: RASH

Rash is a change in texture, color, and temperature of the skin that represents a change from normal skin appearance. SAMPLE




Does your child have difficulty breathing?

What was your child doing when you noticed the rash or immediately prior to you noticing the rash?

When did your child’s rash begin?

Where is your child’s rash?

What color is your child’s rash?

What is the appearance of your child’s rash?

Is there any redness, drainage, or swelling in the area of the rash?

Are there any fluid-filled lesions?

Has your child had chicken pox? Has your child been immunized against chicken pox?

Does your child’s rash itch?

Is your child’s rash painful?

Has your child been exposed to new products (e.g., detergents, body soaps, body lotions)?

Does your child have a fever, or has your child had a recent febrile illness? Did the timing of the fever coincide with the rash?

Does your child have a headache?

Does your child complain of light sensitivity?

Does your child have difficulty bending his or her neck?


Has your child traveled outside of the country recently?

Has your child recently started any new medications?


GENERAL RISK FACTORS• Allergy

• Medication

• Irritant

• Sun exposure

• Infection

• Thrombocytopenia

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SEIZURE

Mary Conway, MSN RN CPHON®

Sarah Matney, BSN RN CPON®

Seizure • APHON Telephone Triage Guidelines 223

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PROBLEM: SEIZURE

Seizure is a central nervous system (CNS) irritation that “causes transient involuntary alterations in the neurologic system with changes in consciousness, behavior, motor function, sensation, or autonomic function.”

(Wilson, 2004, p. 341)SAMPLE



How is your child acting right now?

Is your child currently seizing? How long is the seizure? Has your child had repeated or multiple seizures?

Is your child having difficulty breathing? Do your child’s skin, lips, or nail beds appear blue?

Has your child passed out, or are you having difficulty rousing your child?

Has your child had a recent head injury?

Has your child experienced any other symptoms (e.g., eye rolling; twitches; incontinence; staring; changes in vision, speech, gait, or mood)?

Has your child ever had a seizure in the past? If yes, are these seizures the same?

Has your child previously been prescribed antiseizure medicine? If yes, what medications? Is your child taking the medication as prescribed?

Is your child taking any other medications?

Has your child ever had a stroke in the past?

Has your child recently had surgery or a surgical procedure?

Has your child ever had a blood clot? If yes, when and where? Is your child taking any medications to prevent or treat blood clots?

Does your child have low platelets or a bleeding disorder?

Does your child have any signs of infection (e.g., fever, headache, stiff neck, nausea, vomiting)?

What was your child doing immediately prior to the seizure?

When was your child’s last blood test, and what were the results?

Do you have other concerns that you would like to address?

GENERAL RISK FACTORS• Fever

• Infection

• Medications

• Trauma

• Intracranial hemorrhage or stroke

• Metabolic disorders or abnormalities (e.g., decreased sodium)

• Neurological disorders

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SLEEP DISORDERS

Deena Centofanti, MS RN AOCN®

Sleep Disorders • APHON Telephone Triage Guidelines 229

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PROBLEM: SLEEP DISORDERS

Sleep-wake disturbances are perceived or actual alterations that affect, disrupt, or involve night sleep with resultant daytime impairment. They occur in approximately 10%–15% of people (National Cancer Institute [NCI], 2011) and in 30%–75% of people diagnosed with cancer.

(Berger, 2009)SAMPLE




When did your child’s sleep issues begin?

When does your child usually go to bed? When does your child usually wake up?

How long does it take for your child to fall asleep?

Does your child wake up during the night? If yes, does your child have difficulty falling back asleep?

Does your child complain of feeling sleepy during the day?

Does your child sleep or take naps during the day? How long does your child sleep during the day?

Does your child complain of moving legs, jerking, or being restless at night?

What is your child’s typical bedtime routine?

Does your child eat or drink any caffeinated food or beverages prior to bedtime?

What makes your child’s sleep pattern worse? What makes your child’s sleep pattern better?

Has your child’s schedule recently changed?

Has your child recently been hospitalized?

Has there been a recent new stress in your child’s life, such as a move, death of family member or pet, or attending a new school?

Does your child have a history of snoring or sleep apnea?

Does your child have any associated symptoms (e.g., pain, incontinence, fever, respiratory illness)?

Does your child have a history of depression or anxiety?

Does your child have a history of drug or alcohol use?


(Berger, 2009; NCI, 2011)

GENERAL RISK FACTORS• Medications

• Pain

• Depression

• Frequent hospitalizations and recent intensive care unit (ICU) stay

• Past or family history of sleep disorders

• Illicit drug use(Berger, 2009; NCI, 2011)

SAMPLE

SWELLING

Karen MacDonald, MSN RN CPON®

Swelling • APHON Telephone Triage Guidelines 235

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PROBLEM: SWELLING

Swelling is a transient enlargement that is not caused by cellular proliferation. It can be generalized to a specific body part or diffuse. Swelling is characterized by location, severity, duration, and factors that either exacerbate or relieve findings.

(Baggott, Kelly, Fochtman, & Foley, 2002; Venes, 2009).SAMPLE




Where is your child’s swelling?

When did your child’s swelling begin?

Does your child have pain in the area of swelling?

Is there any bruising, discoloration, or drainage in the area of swelling?

Does your child complain of tingling or numbness in the area of swelling?

Is the area of swelling warm to touch?


Does your child have shortness of breath, difficulty breathing, or complain that his or her throat feels tight?

Is there a recent history of injury or trauma?

Is your child’s swelling in an extremity? Is your child able to move the extremity?

Does your child have a central line or PICC line? If yes, did your child recently receive chemotherapy or other medication through it?

Has your child had sudden weight gain, or does your child complain that her or his clothes are tight?

Has your child’s urine output decreased over the last 24–48 hours?

Does your child complain of nausea or dizziness?


Does your child have any known allergies?

Does your child have a rash?



(Baggott et al., 2002; Lanzkowsky, 2000)

GENERAL RISK FACTORS• Recent injury or trauma

• Surgery

• Infection

• Malnutrition

• Deep vein thrombosis

• Central venous catheter

• Compartment syndrome

• Anaphylaxis

• Infiltration/extravasation

• Renal insufficiency(Baggott et al., 2002; Kline, 2007)

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Teleph ne Triage - APHON€¦ · TELEPHONE TRIAGE Providing health care via the telephone has developed into an important nursing role; this is in part due to a global need to reduce