Telephone Triage Protocols for Nurses -- Contents -- Table of Contents by Body System -- Introduction: Practicing Telephone Triage Safely -- Triage Roles and Responsibilities -- Training Guidelines -- Using Protocols Safely -- Documentation -- Medical-Legal Safeguards -- PROTOCOLS -- Abdominal Pain, Adult -- Abdominal Pain, Child -- Abdominal Swelling -- Abrasions -- Alcohol Problems -- Allergic Reaction -- Altered Level of Consciousness -- Ankle Injury -- Ankle Problems -- Anxiety -- Appetite Loss, Adult -- Appetite Loss, Child -- Arm or Hand Problems -- Asthma -- Avian Infl uenza ("Bird Flu") Exposure -- Back/Neck Injury -- Back Pain -- Bad Breath -- Bedbug Exposure or Concerns -- Bed-Wetting -- Bee Stings -- Bites, Animal/Human -- Bites, Insect -- Bites, Marine Animal -- Bites, Snake -- Bites, Tick -- Black or Bloody Stools -- Bleeding, Severe -- Blood/Body Fluid Exposure -- Bone, Joint, and Tissue Injury -- Breast-Feeding Problems -- Breast Problems -- Breathing Problems -- Bruising -- Burns, Chemical -- Burns, Electrical -- Burns, Thermal -- Car Sickness -- Cast/Splint Problems -- Chest Pain -- Chest Trauma -- Chickenpox -- Child Abuse -- Choking -- Choking Emergency Procedure -- Circumcision Care -- Cold Exposure Problems -- Common Cold Symptoms -- Confusion -- Congestion -- Congestive Heart Failure -- Constipation -- Contact Lens Problems -- Contraception, Emergency (EC) -- Cough -- Croup -- Crying, Excessive, in Infants -- Dehydration -- Depression -- Diabetes Problems -- Diaper Rash -- Diarrhea, Adult -- Diarrhea, Child -- Dizziness -- Domestic Abuse -- Drowning (Near Drowning) -- Drug and Alcohol Problems -- Earache, Drainage -- Ear Injury, Foreign Body -- Ear Ringing -- Electric Injury -- Extremity Injury -- Eye Injury -- Eye Problems -- Facial Problems -- Facial Skin Problems -- Fainting -- Falls -- Fatigue -- Feeding Tube Problems.

Fever, Adult -- Fever, Child -- Finger and Toe Problems -- Food Allergy -- Food Poisoning, Suspected -- Foot Problems -- Foreign Body, Eye -- Foreign Body, Inhaled -- Foreign Body, Nose -- Foreign Body, Rectum -- Foreign Body, Skin -- Foreign Body, Swallowing of -- Foreign Body, Vagina -- Frostbite -- Gas/Belching -- Gas/Flatulence -- Genital Lesions -- Genital Problems, Male -- Glands, Swollen or Tender -- Hair Loss -- Hand/Wrist Problems -- Hay Fever Problems -- Headache -- Head Injury -- Hearing Loss -- Heartburn -- Heart Rate Problems -- Heat Exposure Problems -- Hemorrhoids -- Hepatitis -- Hiccups -- Hip Pain/Injury -- Hives -- HIV Exposure -- Hoarseness -- Hospice Problems -- Hypertension -- Hyperventilation -- Hypotension -- Immunization, Tetanus -- Immunization Reactions -- Impetigo -- Incontinence, Stool -- Incontinence, Urine -- Indigestion -- Infl uenza -- Insomnia -- Intravenous Therapy Problems -- Itching -- Jaundice -- Jaw Pain -- Joint Pain/Swelling -- Knee Pain/Swelling/Injury -- Laceration -- Leg Pain/Swelling -- Lice -- Menstrual Problems -- Mouth Problems -- Mumps -- Muscle Cramps -- Nausea/Vomiting, Adult -- Nausea/Vomiting, Child -- Neck Pain -- Neurological Symptoms -- Newborn Problems -- Nosebleed -- Nose Injury -- Numbness and Tingling -- Ostomy Problems -- Overdose -- Pertussis -- Piercing Problems -- Pink Eye -- Pinworms -- Poisoning, Suspected -- Postoperative Problems -- Postpartum Problems -- Pregnancy, Cold Symptoms -- Pregnancy, Fetal Movement Problems -- Pregnancy, Hypertension -- Pregnancy, Leaking Vaginal Fluid -- Pregnancy, Nausea and Vomiting -- Pregnancy Problems -- Pregnancy, Suspected Labor -- Pregnancy, Suspected Labor < 36 Weeks -- Pregnancy, Urination Problems -- Pregnancy, Vaginal Bleeding -- Puncture Wound -- Rash, Adult -- Rash, Child -- Rectal Problems -- Reye's Syndrome, Suspected -- Roseola.

Rubella (German Measles) -- Rubeola (Measles) -- Scabies -- Scrotal Problems -- Seizure -- Seizure, Febrile -- Severe Acute Respiratory Syndrome (SARS) -- Sexual Assault -- Sexually Transmitted Disease (STD) -- Shock, Suspected -- Shoulder Pain/Injury -- Sickle Cell Disease Problems -- Sinus Problems -- Skin Lesions: Lumps, Bumps, and Sores -- Sleep Apnea, Adult -- Sleep Apnea, Infant -- Sore Throat -- Speaking Difficulty -- Spitting Up, Infant -- Stools, Abnormal -- Stye -- Substance Abuse, Use, or Exposure -- Suicide Attempt, Threat -- Sunburn -- ASwbdaollmowinianlg P Dainffi, cAudlutylt -- Sweating, Excessive -- SwAelvlianng Infl uenza -- Swine Flu (H1N1 Virus) Exposure -- Tattoo Problems -- Teething -- Tongue Problems -- Toothache -- Tooth Injury -- Umbilical Cord Care -- Urinary Catheter/Nephrostomy Tube Problems -- Urination, Diffi cult -- Urination, Excessive -- Urination, Painful -- Urine, Abnormal Color -- Vaginal Bleeding -- Vaginal Discharge/Pain/Itching -- Vision Problems -- Weakness -- West Nile Virus -- Wheezing -- Wound Care: Sutures or Staples -- Wound Healing and Infection -- APPENDICES -- Appendix A: Abbreviations -- Appendix B: Sample Telephone Triage Protocol Form -- Appendix C: Community Resources Telephone Li -- Appendix D: Telephone Triage Quality Improvement Survey -- Appendix E: Telephone Triage Documentation Form -- Appendix F: Telephone Triage "Call Back" Log -- Appendix G: Consulting Nurse Call Tape Review . -- Appendix H: Consulting Nurse Call Documentation Review -- Appendix I: Telephone Triage Training Outline -- Appendix J: Guidelines for Scenario Practice -- Appendix K: Diffi cult Caller Practice Scenario -- Appendix L: Mystery Caller Practice Session -- Appendix M: Communicable Diseases -- Appendix N: Sexually Transmitted Diseases -- Appendix O: Typical Immunization Schedule.

Appendix P: Temperature Conversion Chart -- Appendix Q: Weight Conversion Chart . -- Appendix R: Acetaminophen Dosage Chart -- Appendix S: Ibuprofen Dosage Chart -- Appendix T: Infant Feeding Guide . -- Appendix U: Teaching Self-Assessment -- Appendix V: Abdominal Pain: Causes and Characteristics -- Appendix W: Chest Pain: Causes and Characteristics -- Appendix X: Headache: Causes and Characteristics -- Appendix Y: Resources -- Bibliography -- Index.