REI nurse triage Flashcards
Nurse Triage Models - 5 of them
Nursing process model
Problem oriented system
OLD CART
Communication model
Informal systems
Problem Oriented System - PQRSTT
Problem oriented system:
Utilization of alphabet P->T
Assists with inquiry/assessment of the problem the patient is reporting
provoking, quality, region, severity, time and treatment
OLD CART
OLD CART
Similar to the problem-oriented system
Utilization of the acronym OLD CART3.
O - onset
L- location
D- duration
C- characterstics
A- associated symptoms
R - relieving factors
T - treatment tried
OLD CART
Similar to the problem-oriented system
Utilization of the acronym OLD CART3.
Informal systems - Many clinics/institutions have developed their own process for what is acceptable triage.
Structured or Multi-model assessment process
Critical thinking
Resource/ tools
Training of care team
Common complaints seen in REI - pelvic pain
Ovarian cyst
OHSS
Ovarian torsion
Cramping/pain in pregnancy
Endometriosis/Other
Pelvic Pain -Ovarian cyst
A sac filled with fluid or semisolid matter that develops on an ovary.
Types
Functional
Benign Cyst Adenoma
Dermoid
Complex
Endometriosis
Malignant
Other
Complications
Rupture
Hemorrhage
Ovarian Torsion
Pelvic/Abdominal Pain - Ovarian Hyperstimulation Syndrome (OHSS)
Characterized by cystic enlargement of the ovaries and a fluid shift from the intravascular to the third space due to increased capillary permeability.
3-6% of patients may experience moderate
0.1-2% Severe
Signs/Symptoms
Abdominal distention, SOB, pelvic pain, fluid retention, nausea/vomiting
Pelvic/Abdominal Pain - Ovarian torsion
Ovary twists over ligaments that support it in the adnexa. With perfusion being impaired, if untreated, it can lead to necrosis and loss of the ovary.
<0.1% incidence
Signs/Symptoms:
Lower abdominal pain or pelvic pain.
Pain can be sharp, dull, constant, or intermittent.
Nausea/Vomiting
Symptoms may or may not be intermittent if the ovary is torsing and detorsing.8
Pelvic/Abdominal Pain
Ectopic pregnancy:
Fertilized egg growing outside of the main uterine cavity.
Over 98% occur in the fallopian tube9
Occurs in 0.3-.7% in spont pregnancy, 2.2-4.5% after ART
Heterotopic:
Both intrauterine and extra-uterine gestations occur simultaneously.
<1/30,000 natural conception pregnancies, with ART increases to 1/100 and 1/500 10
Signs/Symptoms:
Pain in the right or left lower abdomen
Shoulder pain, weakness, dizziness, syncope
Pelvic/Abdominal Pain- Endometriosis
Endometriosis is a disease characterized by implantation of endometrial glands and stroma outside of the uterine cavity.
Signs/symptoms:
Pelvic/abdominal or back pain, dyspareunia, dysmenorrhea
Other/Procedure related:
Normal post procedure pain management
Hemoperitoneum
Infection/Abscess
Rare –injury to pelvic structures
Vaginal Bleeding - Bleeding in early pregnancy (First trimester)
Occurs in ~ 16-25% of pregnancies
Subchorionic hematoma is primary cause of obstetric hemorrhage during 1st & 2nd trimester14
Differential:
Threatened abortion, early pregnancy loss, ectopic pregnancy, subchorionic hematoma(SCH)
If accompanied by pain and heavy bleeding, increased risk of early pregnancy loss.
Triage: Assessment/Training
Key Assessment questions and Triage workflow:
Questions to target chief complaint
Begin assessment to rule out differentials
Determine urgent/emergent/reassurance
Initiate appropriate actions based on data collection
Assessment Questions-Pain
Have you ever had this pain before? When did it start? Where is the pain located?
What is the quality of the pain (sharp, dull, tender, cramping, burning)?
On the 0 to 10 pain scale, 0 being no pain and 10 being the worst pain ever felt, what is your pain level right now?
Review patient history..
Are there associated symptoms, such as nausea and vomiting and/ or diarrhea?
Do you feel as though you have had a fever?
Have you taken any medication for the pain? If so, what did you take and how did it work?
Does anything make the pain better or worse?
Assessment questions – Vaginal Bleeding
Is patient currently pregnant or could they be pregnant?
If pregnant, assess gestational age & blood type.
Description of current bleeding (volume, duration, color)
Onset after an appt, exercise, intercourse, procedure?
Are there associated symptoms?
Is the patient feeling dizzy/lightheaded
Ensure they are safe, partner/friend to provide support and transport, as necessary
Triage: Resources/Tools
Utilize templates for assessment
Consider creating algorithms to help care team in determining urgency and necessity to escalate care
Ensure proper training of the team and clinical scope
Evaluate efficacy and accuracy of nurse triage system
