How to Triage as a Primary Care Nurse

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When I first started my job, I had no idea how to triage in a primary care setting. I knew that patients called up and complained about an issue and I had to make sure I got all of the information that I thought the provider would need so I could give their orders to direct the patient on what to do. But triaging is a skill that I became better and better at the more that I did it. I knew the essential questions that the providers needed and I became comfortable in advising if a patient needed ER care or an office visit in the same day or if it could wait until the next day. I am much more confident now in triaging the patients that call but I also find this easier as well because I have created a trusting relationship with the providers so they are more accessible to me in order to ask them anything at anytime – even if it just to validate my thoughts. 

When I am presented with a patient calling with a complaint, I am ultimately trying to figure out how soon this patient needs to be seen and where they should be seen. I also try to think of some possible reasons why a patient could be experiencing these symptoms so I make sure to ask questions that would either validate or invalidate my thoughts. This is why it’s important to ask key questions to help navigate through the triage. Put on your thinking caps and let’s give an easy example of a patient calling with complaint of, let’s say…. Rectal bleeding (Trust me on this example – I have a reason why I chose this one LOL). When you hear rectal bleeding it starts to raise some red flags (no pun intended) because depending on the answer to certain questions, it could be something or it could be nothing. I’d begin the triage by asking when did the bleeding start? Has it happened before? What did the blood look like? Was it bright red and on the toilet bowl/paper or did you see it in the stool? Did your stool appear normal or more tarry? When you were going, were you straining? Do you have any nausea, vomiting or abdominal pain? Are you experiencing any dizziness? By asking these questions, I am trying to figure out if this patient has simply aggravated a hemorrhoid or has internal bleeding because depending on these answers directs me on what the next step for the patient is. If it’s hemorrhoids, I would send a message to a provider to see if they want to advise a stool softener to help with straining or if it’s internal bleeding, direct them to the ER for emergent care. 

I have to admit that triaging chest pain of any kind is probably the most stressful ones for me. This is because someone experiencing a heart attack does not always present classically with crushing chest pain and shortness of breath. But then there are also times when people complain of chest pain and admit to increased anxiety so it’s important to understand what the differences are and the appropriate questions to ask to determine that. Looking at a patient’s snapshot of their overall health will also help to determine the level of acuity. If I speak with a man in his 50’s who is a smoker and on medications for hypertension who is complaining of chest pain compared to a 25 year old with no risk factors and a history of anxiety, it’s pretty clear that the first example is someone who could truly be experiencing a life threatening medical emergency. It’s important to get a good sense of their medical history in order to make the best informed decisions. 

During the first month of my job as a primary care nurse, I mis-triaged a patient having a heart attack because his symptoms were not typical of a heart attack and when he called, he wasn’t experiencing chest pain at the time. So after learning from that mistake by being re-educated by the providers I work for, I read up about the non-typical signs of heart attack and used it to help me properly triage these types of symptoms going forward. So one day, I was speaking with a patient in his late 50’s who called complaining of chest pain for the past 3 days. It was on/off but was not relieved with Tums which he had thought the discomfort was caused by indigestion. The day of the call, he had went for a walk and played golf but he had experienced this same some chest discomfort he did a couple days ago along with some shortness of breath. Even though this man was not in acute distress at the time of the phone call, his symptoms were eerily similar to the patient I had mis-triaged months ago so I advised for him to head to the nearest ER due to his symptoms and his risk factors. I knew in my gut that I made a solid decision to advise him to the ER and sure enough, he was experiencing a heart attack.

Speaking about gut instincts, sometimes you just know that something isn’t right or something more is going on with a patient. Recently, I triaged a patient who had been diagnosed with Covid 10 days ago but she was still experiencing fevers. The doctor had already reviewed the symptoms the day before but when the patient called the following day and said she was still experiencing fevers of Tmax 101, I knew that this wasn’t “normal” and she may be experiencing a secondary infection related to Covid. I have spoken to many patients who have had prolonged fevers with covid and almost all of those patients had a form of pneumonia so I was thinking that this could be what this patient was experiencing as well. When I spoke to the patient, I notified her that I would be asking the doctor to order a chest x-ray to see if there was anything else going on. The doctor agreed to order the chest x-ray and sure enough, this patient had pneumonia and was treated with an antibiotic. I am happy that I listened to my gut and requested for the doctor to order the chest x-ray so that this patient could receive appropriate treatment. 

If you have a gut instinct about something, listen to it. If something does not sit right with you about a patient’s symptoms, don’t ignore it. Follow up on that feeling and collaborate with someone to figure it out. Patient’s rely on us for our medical expertise and recommendations so it is incredibly important to make sure that they are getting the best advice for their concerns.

Triaging can be difficult because you need to know the right questions to ask and you need to know what things raise those red flags. These skills take time to develop so don’t be discouraged if you didn’t gather all of the information to put your puzzle together. It’s important to understand that this is the reason why critical thinking skills are essential as a nurse. You need to be a detective to gather all the clues and information and put it together to figure out what you are going to do with your patient. Don’t be afraid to make suggestions to your providers if you feel it will better service a patient’s care. The worst that a doctor will say is no or they will offer a different recommendation. Doctors are not always right and that’s okay! This is one of the many reasons why we are here! Stay up to date about signs and symptoms of things, maintain open lines of communication with your providers that enable you to collaborate together which will result in exceptional patient care and always trust your instincts. I promise that you will become better with the experience you gain and always remember to learn from your mistakes.

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