1st Teleph EDITION ne Triage SAMPLEGUIDELINES A PROFESSIONAL RESOURCE FOR PEDIATRIC HEMATOLOGY/ONCOLOGY AND STEM CELL TRANSPLANT NURSES

EDITORS SUSAN BURKE, MA CPNP CPHON®, MEGHAN BELONGIA, MSN RN CPNP TELEPHONESAMPLE TRIAGE GUIDELINES

A PROFESSIONAL RESOURCE FOR PEDIATRIC HEMATOLOGY/ONCOLOGY AND STEM CELL TRANSPLANT NURSES FIRST EDITION

EDITORS PUBLISHING STAFF Susan Burke, MA CPNP CPHON® Executive Director: Dave Bergeson, PhD CAE Meghan Belongia, MSN RN CPNP Senior Operations Manager: Nicole Wallace Managing Editor: Katherine Wayne Associate Editor: Kelly Bale Assistant Editor: Jaclyn Welter Graphic 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 Nurses 8735 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. CONTENTS

Contributors ...... iii Dizziness ...... 111 Dysphagia ...... 119 Overview of Telephone Triage ...... 1 Dyspnea...... 125 Development and Utilization of Fatigue...... 131 APHON’s Telephone TriageSAMPLE Guidelines ...... 9 Fever ...... 137 Headache ...... 143 Communication Principles and Techniques ...... 15 Hematuria ...... 151 Legal Issues of Telephone Triage ...... 21 Irritability ...... 157

Symptom Guidelines...... 33 Jaundice ...... 163 Anxiety...... 35 Mucositis ...... 169 Bleeding ...... 43 Nausea and Vomiting...... 175 Chest Pain ...... 51 Pain ...... 183 Chills ...... 59 Paresthesia ...... 191 Confusion ...... 65 Phlebitis...... 197 Constipation ...... 71 Priapism...... 203 Cough ...... 77 Pruritus...... 209 Depressed Mood ...... 85 Rash ...... 217 Diarrhea...... 91 Seizure ...... 223 Difficulty Eating...... 97 Sleep Disorders...... 229 Difficulty Urinating ...... 105 Swelling ...... 235

Contents • APHON Telephone Triage Guidelines ix Educational Guidelines ...... 241 Alopecia ...... 243 Communicable Diseases and Immunizations ...... 247 Medication Administration ...... 253 School Issues...... 257 Sun Exposure and Insect RepellentSAMPLE Use...... 261 Appendix ...... 265 Telephone Triage Documentation Forms...... 267

Index...... 269

Contents • APHON Telephone Triage Guidelines x SAMPLE OVERVIEW OF TELEPHONE TRIAGE

Susan Burke, MA RN CPNP CPHON® Meghan Belongia, MSN RN CPNP

Overview of Telephone Triage • APHON Telephone Triage Guidelines 1 TELEPHONE TRIAGE to the emergency room or office and to support patients in the self-care role (Wilson & Hubert, 2002). Providing health care via the telephone has developed into an important nursing role; this is in part due to a global need to reduce Continued expansion of telephone triage was seen in the 1990s in health-related spending and to improve patient satisfaction. Various pediatrics. One of the primary reasons for this growth was the continued terminologies have been used to describe this aspect of nursing, body of literature that supported the nurse’s competency in performing such as telehealth, telephone advice services, telenursing, telephone telephone triage (American Academy of Pediatrics, 1998). By utilizing consultation, and telephone triage. Many of these terms have been nurses in this role, physicians were able to focus more time on patients interchangeable; however, these roles traditionally have placed greater who required a higher level of care. As patients and families adapted to emphasis on patient advice, support, and teaching. In health care this service, their satisfaction increased as they experienced more rapid today, the term telephone triageSAMPLE expands on the role of the nurse from access to healthcare services and an associated reduction in healthcare adviser, supporter, and teacher to one with greater emphasis on nursing costs (American Academy of Pediatrics, 1998). assessment, patient management, and referral to the appropriate level of care (Wilson & Hubert, 2002). At the same time, telephone triage services and call centers were being initiated in Canadian provinces and internationally. The rationale for Various definitions have been utilized to define telephone triage. The these services was similar to those in the United States, with an emphasis American Academy of Ambulatory Care Nursing (AAACN) (2007) defines on conservation of resources, reduction in healthcare spending, and telephone triage as a “component of telephone nursing practice that promotion of self-care. focuses on assessment, prioritization, and referral to the appropriate level of care” (p. 22). Rutenberg (2009) further described this as Telephone triage in oncology nursing emerged as a direct response to patient and family needs for additional support and teaching an encounter with a patient/caller in which a specially trained, (Black, 2007; Wilson & Hubert, 2002). Due to the rising costs of health experienced nurse, utilizing clinical judgment and the nursing care, hospitals and physician practices were challenged to become process, is guided by medically approved decision support tools more fiscally responsible. As a result, complex oncology care that to determine the urgency of the patient’s problem and to direct was traditionally provided in the inpatient setting was shifted to the the patient to the appropriate level of care. This plan of care is outpatient arena, and a greater emphasis was placed on delivery of care developed in collaboration with the caller and includes patient in the home. Many cancer patients today do not require hospitalization education and/or advice as appropriate and necessary and follow- because diagnostic work-ups may be performed and treatments can be up as indicated to assure a safe outcome (p. 4). administered in the ambulatory care setting. As telephone triage programs expand, more emphasis is being placed HISTORICAL PERSPECTIVE 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 The use of triage in health care originated in the battlefields when they strive to manage these complex care issues. Nurses are pivotal in dealing with mass casualty situations in which soldiers required rapid promoting continuity of care to patients (Black, 2007) and instrumental assessment of their injuries, with care prioritized to ensure the most in promoting early recognition of complications. A potential advantage effective use of limited medical resources (Wilson & Hubert, 2002). in oncology telenursing is that the nurse, patient, and family may have The use of triage via the telephone expanded in the United States in a previously established relationship. The nurse’s decision making in the 1970s when Health Maintenance Organizations (HMOs) initiated telephone triage may be enhanced by knowledge of the patient’s health telephone advice lines staffed by registered nurses (RNs). The primary history, previous complications of therapy, emotional state, compliance goal of this service was to reduce costs by eliminating unnecessary visits

Overview of Telephone Triage • APHON Telephone Triage Guidelines 2 SAMPLE

ANXIETY

Ann Reali Stratton, MSN RN CNP CPHON®

Anxiety • APHON Telephone Triage Guidelines 35 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

Anxiety • APHON Telephone Triage Guidelines 36 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Is your child currently taking pseudoephedrine Have there been any changes at home or child’s activity level changed? or cough medicine? Have there been any school? Any reports of bullying? changes in his or her medication regimen? Is your child experiencing any respiratory Has your child had any changes in his or her symptoms (e.g., shortness of breath, chest Has your child ever received or is your child relationships with other family members or pain, rapid breathing)? currently receiving steroids? If yes, what is the friends? dose, duration, and has there been any recent Is your child having heart palpitations?SAMPLE Is your changes in dose? Does your child have any suicidal thoughts or child sweating? ideations? Has your child ingested large amounts of Has your child ever been told he or she has a caffeine, alcohol, or any other substances? Has your child experienced a recent loss/death heart condition? of a friend, family member, or pet? Has your child recently received anesthesia or Does your child complain of headaches, sedation medication? Has your child ever had issues with anxiety in dizziness, or blurred vision? the past? If yes, how was it treated? Has your child had any recent changes to his or Is your child able to talk to you in complete her health? Do you have any other concerns you would like sentences (if age appropriate)? to address? Has your child had any recent trauma/injury or Has your child had any sleep issues? surgery? (Cepuch et al., 2007; Cohen, 2010; Filin et al., 2009; Kersun & Does your child have an upcoming medical Elia, 2007; Pao et al., 2006) procedure?

GENERAL RISK FACTORS • Female gender • Hemorrhage • Substance abuse (tobacco, alcohol, drugs) • Chronic illness • Emotional stressors (problems with school, • Medications • Recent changes in health status relationship changes)

Anxiety • APHON Telephone Triage Guidelines 37 SAMPLE

BLEEDING

Sharon Bauer, BA-HCM RN Catherine Reese, MSN APRN BC

Bleeding • APHON Telephone Triage Guidelines 43 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. SAMPLE (Baggott, Fochtman, Foley, & Kelly, 2011; Kline, 2008)

Bleeding • APHON Telephone Triage Guidelines 44 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has his or Has your child suffered a recent injury, or does Are there any associated symptoms, such as her activity level changed? your child have an open wound? fever, pain, swelling, headache, or dizziness?

When were your child’s last blood counts, and Has your child had increased bruising or What is the color of your child’s urine? what were the results? petechiae? When was your child’s last stool? What color Where is your child bleeding? If female, is your child menstruating? If yes, was the stool? SAMPLEis the menses heavy? How many pads or How long has your child been bleeding? tampons is your child using during a 24- Has your child recently had surgery? hour period? How saturated are they when What has been done to stop the bleeding? changed? How many days has your child had Do you have any other concerns that you vaginal bleeding? would like to address? Do you know what caused the bleeding?

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

GENERAL RISK FACTORS • Injury • Mucositis • Thrombocytopenia • Medications that affect platelet production or • Protracted vomiting • Uremia function • Surgery (Baggott et al., 2011; Kouides, 2008; Polovich, Whitford, & Olsen, • Menses 2009)

Bleeding • APHON Telephone Triage Guidelines 45 SAMPLE

CHEST PAIN

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

Chest Pain • APHON Telephone Triage Guidelines 51 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. SAMPLE (Schwartz, 2000)

Chest Pain • APHON Telephone Triage Guidelines 52 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Is your How often does your child’s pain occur Is your child experiencing weakness, child awake, alert, and oriented? (intermittent or constant)? lightheadedness, or fatigue?

Is your child experiencing difficulty breathing How long does your child’s pain last? Is your child’s pain induced by exercise? (e.g., nasal flaring, grunting, or stridor)? Can your child rate his or her pain on a scale of Has your child experienced recent trauma, Does your child have a history of underlying 0 to 10 with 0 being no pain and 10 being the rough play, or muscle overuse? cardiac or lung disease? SAMPLEworst pain imaginable? Does your child complain of a bitter taste in What is the location of your child’s pain? Does What level of pain is acceptable to your child? their mouth? Does your child complain of your child’s pain radiate? burping? Has your child ingested spicy foods? What makes your child’s chest pain worse? How severe is the chest pain? Is the pain Is your child currently taking oral interfering with your child’s activities of daily What makes your child’s chest pain better? contraceptives? Have there been any changes living? in his or her medication regimen? What have you tried to treat your child’s pain? How does your child describe the pain (e.g., Does your child have a history of heart numbness, tingling, burning, stabbing, aching, Is your child experiencing fever, cough, disease? throbbing, twisting, pinching, dull)? wheezing, or any other upper respiratory symptoms? Do you have any other concerns that you When did your child’s chest pain begin? Is this new would like to address? or has your child experienced this pain in the past? Is your child anxious, restless, or confused?

(Schwartz, 2000)

GENERAL RISK FACTORS • Anemia • Gastrointestinal disorders (e.g., esophagitis, • Musculoskeletal trauma (e.g., chest wall • Anxiety gastroesophageal reflux disease [GERD], strain, costochondritis, direct trauma) pancreatitis, cholecystitis) • Cardiac abnormalities (e.g., arrhythmia, • Pulmonary embolism congestive heart failure) • Ingestion of caustic agent or foreign body • Recent cardiothoracic surgery • Respiratory illness (e.g., asthma, atelectasis, • Infection • Trauma/rib fracture cough, pneumonia, pneumothorax) • Congenital disorders (e.g., Kawasaki • Toxic exposure (e.g., smoking, use of illegal disease, Marfan disease) drugs)

Chest Pain • APHON Telephone Triage Guidelines 53 SAMPLE

CHILLS

Meghan Belongia, MSN RN CPNP Renee Harteau, BSN RN

Chills • APHON Telephone Triage Guidelines 59 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

Chills • APHON Telephone Triage Guidelines 60 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Does your child feel a racing or intense heart Has your child received a recent blood product child’s activity level changed? beat? transfusion?

Does your child have a fever? Has your child had a recent infection? If so, Has your child had a recent amphotericin, IVIG, when, where, and what was the treatment? or antibody infusion? How long has your child had chills? Are the chills constant or intermittent? Does your child have a cough, runny nose, Is your child taking all of his or her medications SAMPLEmouth sores, pain, or skin wounds? as prescribed? Are your child’s extremities violently shaking? Does your child have a central venous access Has your child had contact with anyone who is Is your child’s skin cold, clammy, diaphoretic, device? If yes, when was it last flushed? sick? mottled, or cyanotic? Has your child had a recent surgery or been Do you have any other concerns that you Does your child have signs of breathing sedated for a procedure? would like to address? difficulties?

(Holtzclaw, 1990a, 1990b, 2004)

GENERAL RISK FACTORS • Infection • Cold environment (exam instruments, X-ray • Medication • Central venous access device tables, halls, water) • Receiving cool intravenous infusion or • Anemia • Malnutrition/decreased muscle mass irrigation • Neutropenia • Postanesthesia recovery • Recent blood product transfusion • Open wounds or body cavities

Chills • APHON Telephone Triage Guidelines 61 SAMPLE

CONFUSION

Rebecca R. Rusch, MSN RN CPNP

Confusion • APHON Telephone Triage Guidelines 65 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 SAMPLEsleep 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)

Confusion • APHON Telephone Triage Guidelines 66 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Does your child have any of the following Is your child currently taking any of the child’s activity level changed? neurological symptoms or symptoms of following medications? increased intracranial pressure? • Antiseizure medications Does your child have a fever or signs of • Headache • Pain medications infection? • Blurry vision, double vision, or changes in vision • Sedating medications (Benadryl or Ativan) When did your child become confused? Was • Nausea or vomiting • Medications to prevent or treat blood clots the onset gradual or sudden? SAMPLE• Increased irritability • Increased fatigue or sleepiness When were your child’s last blood counts, and Does your child have a history of strokes or • Impairment of motor or speech function what were the results? transient ischemic attacks (TIAs)? • Stiff neck Does your child have any symptoms of anemia Does your child have a history of seizures? Does your child have a VP shunt? (e.g., fatigue, pallor, headache, tachycardia, or tachypnea)? Does your child have weakness, or is your child Is your child able to follow simple commands? more clumsy? Has your child’s oral intake changed? Does your child have any sensory deficits? Has your child had any recent trauma or head • Changes in hearing Does your child have a history of high or low injury? If so, describe the injury. • Changes in taste blood sugars? Does your child take insulin? If so, • Loss of pain sensation what was his or her most recent blood sugar? • Dizziness or vertigo Has your child recently been diagnosed with Does your child have increased bruising or an infection? bleeding? Has your child recently ingested any drugs or alcohol?

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

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

GENERAL RISK FACTORS • Thrombocytopenia • Immunosuppression • Medications • Infection/sepsis • Electrolyte imbalances (hypokalemia, • Anemia • Hypoxia hyponatremia) • Dehydration • Malnutrition • Endocrine dysfunction (hypoglycemia, • Hemorrhage • Chronic nausea and vomiting hyperglycemia)

Confusion • APHON Telephone Triage Guidelines 67 SAMPLE

CONSTIPATION

Michael Comeau, MSN RN CPON® Susanne Conley, MSN RN AOCNS CPON®

Constipation • APHON Telephone Triage Guidelines 71 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. SAMPLE(Chase, Homsy, Siggard, Dit, & Bower, 2004; Itano & Taoka, 2005; Woolery et al., 2008)

Constipation • APHON Telephone Triage Guidelines 72 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Does your child have abdominal distention or What is the appearance of your child’s urine child’s activity level changed? abdominal or rectal pain? (color, consistency, odor)?

How much is your child eating? Is your child taking pain medicines or iron Does your child appear dehydrated (dry supplements? mouth, decreased urine output, decreased Has there been any recent change in your tears)? child’s diet? Is your child on stool softeners or laxatives such SAMPLEas MiraLAX, lactulose, Senokot, or Colace? Is your child receiving IV hydration, total What is your child’s usual pattern of stooling parenteral nutrition (TPN), or enteral feedings (frequency, before/after meals)? Does your child have a history of constipation? at home? If yes, what and how much? What regimen has been successful in the past? When was your child’s last stool? What was its Has your child had any recent trauma/injury or consistency, amount, and color? Was there any What other remedies (food, drinks, surgery? blood in the stool? medications) have you tried recently to relieve the constipation? Has there been any recent change in your Is your child grunting, grimacing, or straining child’s schedule? (Has he or she recently when stooling? How many ounces has your child had to drink returned to school?) in the last 24 hours? Is your child vomiting? Do you have any other concerns that you How many wet diapers has your child would like to address? produced or how frequently has your child urinated in the last 24 hours?

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

GENERAL RISK FACTORS • Diet (decreased fluid intake) • Lack of activity • Anxiety • Bowel obstruction • Electrolyte abnormalities (hypokalemia, • Surgery • Medications hypocalcemia) (Chase, et al., 2004; Coughlin, 2003; Hicks, 2001)

Constipation • APHON Telephone Triage Guidelines 73 SAMPLE

COUGH

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

Cough • APHON Telephone Triage Guidelines 77 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. SAMPLE (Schwartz, 2000)

Cough • APHON Telephone Triage Guidelines 78 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Is your Is your child experiencing fever, chills, Is your child experiencing halitosis (i.e., bad child awake, alert, and oriented? rhinorrhea, or chest pain? breath), headache, or facial edema?

Has your child’s activity level changed? Does your child have a recent history of an Is your child anxious, restless, or confused? upper respiratory infection? Is your child currently experiencing shortness Does your child have a history of asthma or of breath, wheezing, or difficulty breathing How long has your child had the cough? respiratory problems? (e.g., nasal flaring, retracting, grunting,SAMPLE or stridor)? How would you describe your child’s cough Has your child had any sick contacts? (e.g., dry, productive/wet, barking, honking)? What is your child’s respiratory rate (fast, slow, Does your child have a history of vomiting with shallow)? When does your child’s cough occur? cough and/or reflux?

Does your child have any allergy symptoms What makes your child’s cough better? What Does your child have any history of blood (e.g., swelling around eyes, swelling around the makes your child’s cough worse (e.g., smoke, clots? mouth, or hives)? cold air, dust)? When were your child’s last blood counts, and Is your child experiencing changes in skin color Is your child producing any mucus with the what were the results? (e.g., cyanosis, pallor)? cough? What color is it? How much is there? Do you have any other concerns that you would like to address?

(Schwartz, 2000)

GENERAL RISK FACTORS • Anatomic abnormalities • Environmental irritants/pollutants (smoking) • Ingestion of caustic agent or foreign body • Aspiration • Gastroesophageal reflux disease (GERD) • Medications (ACE inhibitors and • Respiratory illness (e.g., asthma, • Habitual or psychogenic bronchodilators) bronchiolitis, bronchitis, sinusitis) • Infection • Pulmonary embolism • Congestive heart failure • Tracheomalacia (Schwartz, 2000)

Cough • APHON Telephone Triage Guidelines 79 SAMPLE

DEPRESSED MOOD

Jill Lee, MSN RN CPNP-AC CPON®

Depressed Mood • APHON Telephone Triage Guidelines 85 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). SAMPLE (Lack & Green, 2009)

Depressed Mood • APHON Telephone Triage Guidelines 86 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Does your child have trouble with sleeping? Has your child been moving or speaking more child’s activity level changed? Does your child have trouble falling asleep or slowly than normal? is your child sleeping too much? Does your child have a history of depression? Has your child been restless? If yes, is your child seeing someone to treat Does your child seem fatigued or have little depression? energy? Has your child complained of frequent symptoms such as a headache or stomach Has your child ever tried to hurt himselfSAMPLE or Does your child cry more frequently? ache? herself in any way? Does your child seem to have increasing Has your child missed any school days as Has your child ever talked about a plan to hurt negative thoughts (e.g., “No one likes me.” a result of the above symptoms? If so, how himself or herself in any way (suicidal ideation)? “Mom is really mad, so I must have done many? If yes, has your child given information about a something wrong.” “I hate school now.”)? plan? Has your child had any recent change in school Has your child been withdrawing from social performance? Does your child have little interest or pleasure situations? in doing things? Do you suspect that your child has abused any Has your child’s oral intake changed? substances (e.g., drugs, alcohol, prescription Does your child seem to feel down or meds, etc.)? hopeless? If yes, for how long? Has your child had difficulty concentrating, such as when doing homework, reading, or Do you have any other concerns that you Does your child seem irritable? If yes, for how watching television? would like to address? long? (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 • Family history of depression • Domestic and child abuse • Recent diagnosis of comorbid illness • Medications (e.g., retinoic acid, steroids) • Substance abuse (e.g., tobacco, alcohol, • Emotional stressors (e.g., problems with • Endocrinopathies (e.g., hypothyroidism, drugs) school, relationship changes) growth hormone deficiency, etc.) • Attention deficit hyperactivity disorder • Pubertal-related hormonal changes • Encephalopathy (Bailey et al., 2007; Lack, & Green, 2009; Trends in Evidence Based Neuropsychiatry, 2003; U.S. Preventive Services Task Force, 2009)

Depressed Mood • APHON Telephone Triage Guidelines 87 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 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. SAMPLE(Kline, 2009; Kufe, Pollock, Weichselbaum, Bast, & Gansler, 2003)

Diarrhea • APHON Telephone Triage Guidelines 92 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Does your child appear dehydrated (e.g., dry Is your child on stool softeners or laxatives such child’s activity level changed? mouth, decreased urine output, decreased as MiraLAX, Lactulose, Senokot, or Colace? tears)? Does your child have a fever or chills? Is your child taking magnesium supplements? Has your child’s oral intake changed? Have When did the diarrhea begin? there been any dietary changes? Has your child recently been on antibiotics? What is the color, amount, and consistencySAMPLE of What is the pattern of the diarrhea? Does it Have there been any recent changes in the diarrhea? Is there any blood or mucous in occur after meals or at a certain time of day? medications? the stools? Is there a foul smell associated with the Do you know if your child has a history of How many diarrhea stools has your child had in diarrhea? Clostridium difficile (C. diff)? the last 24 hours? Is your child vomiting? How much, how often, Has your child traveled outside of the country How many ounces of fluid has your child had and when did it start? or been in contact with visitors from outside of to drink in the last 24 hours? the country? Is there any associated abdominal or rectal Is your child receiving IV hydration, total pain? Can your child describe and rate his or Has your child interacted with other people parenteral nutrition (TPN), or enteral feedings her pain? who also are experiencing diarrhea? at home? If yes, what and how much? Does your child have breakdown around the Does your child have symptoms of anxiety? How many wet diapers or how frequently has rectal opening or a diaper rash? your child urinated in the last 24 hours? Has your child recently had surgery or a Has your child had recent constipation? procedure? Do you have any other concerns that you would like to address?

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

GENERAL RISK FACTORS • Recent surgery (abdomen or pelvis) • History of enteric pathogens (Clostridium • Constipation • Medications (e.g., laxatives, antibiotics, difficile) • Exposure to sick contacts withdrawal from narcotics) • Enteral or parenteral nutrition support • Travel to foreign countries • Diet changes (Baggott et al., 2002; Bisanz et al., 2010; Kline, 2009)

Diarrhea • APHON Telephone Triage Guidelines 93 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 PROBLEM: DIFFICULTY EATING

Difficulty eating is a decrease in appetite and/or inability to eat, resulting in decreased food consumption and weight loss. SAMPLE(Freifeld et al., 2004; Mendes, Sapolnik, & Mendonca, 2007).

Difficulty Eating • APHON Telephone Triage Guidelines 98 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Is your child nauseated or vomiting? If so, when Does your child have swelling in the abdomen, child’s activity level changed? did the vomiting begin? What is the frequency arms, or legs? of episodes? What is the quantity of emesis? How much is your child eating? How have you been treating the nausea and Does your child’s skin look yellow? Are the vomiting, and is the treatment helping? whites of your child’s eyes yellow? Has there been any recent change in your child’s diet? Is your child having any abdominal cramping Does your child have any dietary restrictions? SAMPLEor pain when eating, drinking, or swallowing? How many ounces of fluid has your child had Does your child have any food allergies? to drink in the last 24 hours? Does your child have a fever? Has your child lost weight in the last week? How many wet diapers or how frequently has Does your child have any choking or breathing your child urinated in the last 24 hours? problems when eating or drinking? Have there been any changes in the types of food offered or food preparation? Does your child appear dehydrated (e.g., Does your child have uncontrolled heartburn? dry mouth, dry lips, decreased urine output, Is your child taking any vitamins, herbs, or decreased tears)? Does your child have sores on his or her lips or other dietary supplements? mouth? Does your child have signs of depression or Does your child have diarrhea or constipation? anxiety that may be affecting eating? If yes, describe the number and quality of the stools. Do you have any other concerns that you would like to address?

(Rodgers, 2009; Rodgers & Gonzalez, 2009)

GENERAL RISK FACTORS • History of kidney or liver dysfunction • Social (changes in caregivers or • Physiological influences (e.g., fatigue, • Medications environment) depression, anxiety, food aversion, stress)

Difficulty Eating • APHON Telephone Triage Guidelines 99 SAMPLE

DIFFICULTY URINATING

Christine Armstrong, MScN RN (EC) NP Paediatrics Lisa Honeyford, MN RN CPHON® Jane Lowry, RN

Difficulty Urinating • APHON Telephone Triage Guidelines 105 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. SAMPLE (Gatti et al., 2001)

Difficulty Urinating • APHON Telephone Triage Guidelines 106 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Does your child appear dehydrated (e.g., dry Is your child receiving IV hydration, total child’s activity level changed? mouth, decreased urine output, decreased parenteral nutrition (TPN), or enteral feedings tears)? at home? If yes, what and how much? How many ounces of fluid has your child had to drink in the last 24 hours? Does your child have a history of difficulty When was your child’s last stool? What was its urinating or urinary tract infections? consistency? Has your child’s oral intake changed? Have there been any dietary changes?SAMPLEDoes your child have a fever? Has your child had any recent trauma, injury, or surgery? How many wet diapers or how frequently has Does your child’s abdomen appear distended? your child urinated in the last 24 hours? Have there been any changes at home or When were your child’s last blood counts, and school? Does your child sense the need to void? Has what were the results? your child complained of pain, burning, or Is your child currently taking any medications? tenderness with the passing of urine? 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 • Obstruction (e.g., clot, stone, calculi) • Behavioral (lack of privacy) of gastroenteritis) • Medications (e.g., narcotics, (Barnard, 2004; Gatti et al., 2001; Russo, 2000; Von Gontaard & • Constipation anticholinergics, alpha-agonists, Neveus, 2006) anesthetics)

Difficulty Urinating • APHON Telephone Triage Guidelines 107 SAMPLE

DIZZINESS

Rebecca R. Rusch, MSN RN CPNP

Dizziness • APHON Telephone Triage Guidelines 111 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. SAMPLE (Chan, 2009; Tusa, 2009)

Dizziness • APHON Telephone Triage Guidelines 112 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Does your child currently have a headache? Has your child eaten today? child’s activity level changed? Does your child have a history of migraine Is your child experiencing diarrhea or headaches? Does your child have a fever? vomiting? Is your child experiencing any motor or speech When did your child begin to complain of Does your child have upper respiratory changes? dizziness? symptoms, such as sinus congestion or Does your child have a stiff neck? tenderness, or other signs of infection? When does the dizziness occur? IsSAMPLE it constant or episodic? Does it occur with motion or Is your child confused? Does your child have any hearing loss, a position changes? feeling of pressure in the ears, or tinnitus Is your child having extremity tingling or (ringing in the ears)? Is your child unsteady while standing or weakness? walking? Has your child fallen? Has your child taken any new medications or Does your child have a history of strokes or herbal or natural products in the last 48 hours? Is your child lightheaded, or does your child transient ischemic attacks (TIAs)? complain of weakness? Has your child participated in recent drug or Does your child have any symptoms of anemia, alcohol use? Does your child have a sense of rocking or such as fatigue, pallor, headache, tachycardia, swaying? or tachypnea? Does your child have a history of motion sickness? Has your child fainted? Does your child have any increased bruising or bleeding? Does your child have any chest pain or What makes your child’s dizziness better? shortness of breath? Has your child had any recent history of What makes your child’s dizziness worse? trauma? Does your child have a history of cardiac Does your child have symptoms of increased abnormalities including a prolonged QT How many ounces of fluid has your child had intracranial pressure, such as interval? to drink in the last 24 hours? • blurry vision, double vision, or changes in Does your child have a history of anxiety or Has your child’s oral intake changed? vision display any symptoms of being anxious? • nausea or vomiting How many wet diapers has your child had, or Has your child had any sick contacts? • increased irritability how frequently has your child urinated in the • increased fatigue or sleepiness? last 24 hours? Do you have any other concerns that you would like to address? Is your child having any seizure activity or Does your child appear dehydrated (e.g., abnormal movements? dry mouth, decreased tears, decreased urine output)?

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

Dizziness • APHON Telephone Triage Guidelines 113 SAMPLE

DYSPHAGIA

Ann Reali Stratton, MSN RN CNP CPHON®

Dysphagia • APHON Telephone Triage Guidelines 119 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 SAMPLEcomplete inability to swallow.

Dysphagia • APHON Telephone Triage Guidelines 120 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Does your child have any white patches on her Has your child’s oral intake changed? child’s activity level changed? or his tongue? How many wet diapers has your child had or Is your child having problems swallowing Has your child recently received steroids or how frequently has your child urinated in the solids, soft foods, or liquids? oral antibiotics? last 24 hours?

When did these symptoms start? Are they Has your child vomited? If yes, was it bloody? Does your child appear dehydrated (e.g., dry getting worse? SAMPLEmouth, decreased urine output, decreased Does your child have any rashes? tears)? Does your child have a fever? Have there been any recent changes in your When did your child last eat? Does your child complain about a sore throat? child’s medication regimen? Has your child been complaining of a dry Does your child have any respiratory Has your child been treated for mouth or jaw pain? symptoms? gastroesophageal reflux (GERD)? Does your child have any complaints of heartburn or Is your child receiving IV hydration, total Have there been any changes to your child’s abdominal pain? parenteral nutrition (TPN), or enteral feedings neurological status? at home? If yes, what and how much? Has there been any trauma to your child’s Is your child drooling? throat or neck? Has your child recently had radiation to the neck or chest? Is your child able to speak? Has your child recently had surgery? If yes, for what? Do you have any other concerns that you Does your child have a hoarse voice, noisy would like to address? breathing/stridor, or new onset snoring? Is it possible your child ingested a foreign body, such as a coin or battery? (Bisset & Frush, 2005; Mouzan, Abdullah, Al-Mofleh, 2005; Does your child have any mouth sores? Furnival & Woodward, 2010; Takahashi, Paredes, Scavarda, & How many ounces of fluid has your child had Lena, 2007; Pittard, Abramo, & Arnols, 2009) to drink in the last 24 hours?

GENERAL RISK FACTORS • History of gastroesophageal reflux • Mucositis • Structural changes in the anatomy that are • Oral infections (herpes virus or thrush) • Neurological side effects of medications related to surgery to the head or neck • Pill esophagitis • History of environmental or food allergies (Bisset & Frush, 2005; Mouzan et al., 2005; Furnival & Woodward, 2010; Pittard et al., 2009)

Dysphagia • APHON Telephone Triage Guidelines 121 SAMPLE

DYSPNEA

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

Dyspnea • APHON Telephone Triage Guidelines 125 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. SAMPLE (Schwartz, 2000)

Dyspnea • APHON Telephone Triage Guidelines 126 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Is your What is the color of your child’s skin? Is the skin Does your child have a history of heart child awake, alert, and oriented? temperature warm, cool, or diaphoretic? What problems? is the color of your child’s nail beds? Is your child having difficulty breathing right Does your child have a history of asthma? now? Is your child experiencing fever, cough, wheezing, chest pain, or any other upper Does your child have a history of blood clots, Is your child on oxygen at home?SAMPLErespiratory symptoms? or is your child on anticoagulation medication? How long has your child had SOB? Has your child’s activity level changed, or has Has your child ever been hospitalized or had your child had any changes in comfort level? respiratory problems in the past? Is the SOB with or without exertion? Is your child anxious, restless, or confused? Have there been any changes in your child’s Does your child have more difficulty breathing medication regimen? when lying flat? How many words per breath can your child speak? Does your child have a central venous line? Is your child experiencing retractions, use of accessory muscles, nasal flaring, grunting, or What makes your child’s breathing better? Is your child receiving IV hydration, total stridor? What makes your child’s breathing worse? parenteral nutrition (TPN), or enteral feedings at home? If yes, what and how much? What is your child’s respiratory rate—fast, slow, Does your child have any signs of allergic or shallow? reaction (e.g., swelling eyes or lips, hives) Do you have any other concerns that you would like to address? Is anyone at home sick or have a respiratory problem or illness? (Schwartz, 2000)

GENERAL RISK FACTORS • Infection • Airway trauma • Recent cardiothoracic surgery • Anemia • Cardiac abnormalities (e.g., arrhythmia, • Tracheobronchial obstruction • Deconditioning congestive heart failure) • Pulmonary embolism • Asthma • Environmental irritants (Schwartz, 2000) • Pain • Hypoxia • Anxiety • Pneumothorax

Dyspnea • APHON Telephone Triage Guidelines 127 SAMPLE

FATIGUE

Mary Conway, MSN RN CPHON® Sarah Matney, BSN RN CPON®

Fatigue • APHON Telephone Triage Guidelines 131 PROBLEM: FATIGUE

Fatigue is a profound sense of being tired that can interfere with movement, play, and concentration. SAMPLE(Whitsett, Gudmundsdottir, Davies, McCarthy & Friedman, 2008)

Fatigue • APHON Telephone Triage Guidelines 132 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Does your child have a ventriculoperitoneal How many ounces of fluid has your child had child’s activity level changed? shunt? to drink in the last 6–8 hours?

What are your child’s symptoms? How long has Is your child easily arousable? Is your child Has your child recently had a surgical your child been experiencing these symptoms? oriented to person, place, and time? procedure, or a bone marrow aspirate or How do they differ from how he or she usually lumbar puncture? feels? Does your child have signs of anemia (e.g., SAMPLEpallor, dyspnea, palpitations, headache, What are your child’s usual sleep patterns? What makes your child’s fatigue better? What dizziness)? Have there been any recent changes? makes your child’s fatigue worse? Does your child have signs of bleeding or Has your child’s daily schedule recently Is your child having symptoms other than bruising, such as epistaxis or bloody stools? changed (e.g., is your child going back to fatigue, such as nausea or vomiting, pain, school)? depression or changes in mood, or changes in When were your child’s last blood counts, and attention or concentration? what were the results? Have there been any significant changes or traumas in your family? Is your child taking any pain medication or Has your child had a recent blood transfusion? sedating medication? Is your child expressing any worries or fears? If your child is female, is she menstruating Does your child have any neurological changes (having her period)? If yes, when did it start? Do you have any other concerns that you (e.g., aphasia, vision changes, hemiparesis, or How heavy is the bleeding? would like to address? change in level of consciousness)? Does your child have a fever? (Panzarella et al., 2002) Has your child suffered any recent head or other trauma? Have there been any changes in your child’s diet or appetite?

GENERAL RISK FACTORS • Myelosuppression • Changes in the pattern and quality of sleep • Hypothyroidism • Infection/sepsis • Decreased physical activity and cognitive • Hemolytic process • Anemia stimulation • Intracranial hemorrhage/ increased • Dehydration/malnutrition • Isolation intracranial pressure (National Comprehensive Cancer Network [NCCN], n.d.) • Pain • Anxiety or depression • Medication

Fatigue • APHON Telephone Triage Guidelines 133 SAMPLE

FEVER

Joy Bartholomew, MSN FNP-BC CPON®

Fever • APHON Telephone Triage Guidelines 137 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-riskSAMPLE patients (i.e., status post bone marrow transplant).

Fever • APHON Telephone Triage Guidelines 138 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your When did your child last urinate? Is your child When were your child’s last blood counts, and child’s activity level changed? Is your child having any difficulty with urination? what were the results? playing? Does your child have mouth sores, pain, or skin Is your child currently receiving IV or oral Does your child appear ill? wounds? antibiotics? If yes, did the fever resolve initially after antibiotics were administered? What is your child’s temperature right now? Does your child complain of neck pain or What has it been in the last 24 hours?SAMPLEstiffness? Is your child currently taking steroids or have steroids recently been discontinued? Is your child experiencing chills and/or Has your child had a recent infection? If yes, shaking? when, where, and what was the treatment? What, if anything, have you given your child for the fever? If you have given your child Is your child’s skin cold, clammy, blotchy, or Has your child had a previous blood infection? something, when did you administer the blue-gray in color? Is your child sweaty? If yes, when did the infection occur? medication?

Does your child have body aches? Does your child have a central line? Is there Has your child been in contact with anyone any redness, swelling, or drainage? who is sick? Does your child have upper respiratory symptoms (e.g., cough, runny nose)? Does your child have any other implanted Do you have any other concerns that you device (e.g., Ommaya reservoir, would like to address? Is your child having any difficulty breathing? ventriculoperitoneal shunt)? (Alexander, Wade, Hibberd, & Parsons, 2002; Donowitz, Maki, Does your child have abdominal pain, Crninch, Pappas, & Rolston, 2001; Saltzer et al., 2003) vomiting, or diarrhea?

GENERAL RISK FACTORS • Disease process • Immunosuppressant medications, including • Mucositis • Neutropenia defined as absolute neutrophil steroids • Areas of skin breakdown count (ANC) of < 500 μl or < 1000 μl with • Central venous access • History of heart disease or other chronic predicted decline (Freifeld et al., 2004) • Asplenia, functional or surgical illness ANC = (WBC count) x (neutrophils % + bands %) • Known exposure to sick contacts • Recent surgery • Infection (bacterial, fungal, viral) (Alexander et al., 2002; Donowitz et al., 2001; Freifeld et al., 2011; Saltzer et al., 2003)

Fever • APHON Telephone Triage Guidelines 139 SAMPLE

HEADACHE

Ann Stiefbold, MSN RN APN CPON®

Headache • APHON Telephone Triage Guidelines 143 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. SAMPLE (Silberstein et al. 2004; Walker & Teach, 2008)

Headache • APHON Telephone Triage Guidelines 144 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Is your Can your child rate her or his pain on a scale of Does your child have any signs of dehydration? child consolable? Has her or his activity level 0 to 10 with 0 being no pain and 10 being the How many ounces of fluid has your child had changed? worst pain imaginable? to drink in the last 24 hours? Are you concerned about changes in your • What level of pain is acceptable to your child? Has your child reported any change in sensory child’s neurological state, such as speech, What makes your child’s pain worse (activity or function, or have you seen a change in motor vision, or mental status? rest)? What makes your child’s pain better? function? Where does your child’s head hurt?SAMPLEWhat have you tried to treat your child’s pain Does your child have a history of migraines or When did your child’s headache(s) begin? Is (e.g., medication, rest, increased fluids)? tension/stress headaches, hypertension, sinus this new or has your child experienced this What medications does your child use at home infections, seizures, or allergies? pain in the past? for pain management? Does your child have a bleeding or clotting How often are your child’s headaches occurring Are there any emotional or behavioral changes disorder or a history of blood clots? (intermittent or constant)? Do they occur at a associated with the headaches? Is your child taking any blood thinning particular time of day? Do your child’s headaches interfere with medications? How long do your child’s headaches last? school, play, or other activities? When were your child’s last blood counts, and Do the headaches keep your child awake or Are there any associated systemic signs or what were the results? awaken your child from sleep? symptoms (e.g., nausea and/or vomiting, fever Has your child had a recent transfusion or How does your child describe the pain (e.g., and/or stiff neck, light or noise sensitivity)? factor infusion? If yes, what and when was the numbness, tingling, burning, stabbing, aching, Has your child experienced any recent trauma transfusion? throbbing, twisting, pinching, dull)? to the head? Does your child wear glasses? Has the intensity of your child’s pain changed? Does your child have any upper respiratory Is there a family history of migraine headaches? symptoms? Do you have any other concerns that you would like to address? (Dooley, 2004)

GENERAL RISK FACTORS • Disease process • Hypercoagulability or thrombophilia • Cerebral vascular accident (stroke) • History of headaches • Intracranial hemorrhage • Stress, depression, anxiety • Anemia • Infection • Vision changes • Dehydration • Pseudotumor cerebri • Medications (anticoagulants) (Conicella et al., 2008; Distelmaier et al., 2007; Silberstein et al., 2004)

Headache • APHON Telephone Triage Guidelines 145 SAMPLE

HEMATURIA

Pam Wojciki, MS RN-CS ARNP CPON®

Hematuria • APHON Telephone Triage Guidelines 151 PROBLEM: HEMATURIA

Hematuria is the presence of red blood cells in the urine. SAMPLE (Gulati & Pena, 2010)

Hematuria • APHON Telephone Triage Guidelines 152 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Do you see any clots, debris, or crystals in your Does your child have any joint pain or stiffness? child’s activity level changed? child’s urine? Has your child performed heavy exercise What color is your child’s urine (e.g., red, pink, Does your child have a fever? recently? dark red, brown, tea colored)? If your child is a pubertal female, is she Does your child have diarrhea or constipation? How long has the urine been this color? currently having her period (menstruating)? If yes, describe the number and quality of SAMPLEstools. Is your child able to pass urine? Has your child eaten any beets, blackberries, or foods with red dyes in the last 12 hours? Is your child taking any vitamins, herbs, or If toilet trained, does your child have control of other dietary supplements? his or her urine, or is your child having urinary Has your child had a recent sore throat or cold accidents? symptoms? Has your child had recent surgery in the abdomen, pelvis, kidneys, or bladder? Has your child’s urination pattern changed? If Does your child have a skin rash (e.g., viral yes, how often is your child urinating? exanthem, petechiae, purpura, bruising)? When were your child’s last blood counts, and what were the results? Does your child have pain with urination or Has your child had any trauma to the back, abdominal or flank pain? If yes, how does your abdomen, or genital areas? Has your child had a recent blood transfusion? child describe the pain (e.g., dull, squeezing, stabbing, pounding, throbbing)? Is your child on blood-thinning medication? Does your child or any family members have any known kidney or urinary problems? Can your child rate his or her pain on a scale of Does your child have any swelling around the 0 to 10 with 0 being no pain and 10 being the eyes, arms or legs, or abdomen? Do you have any other concerns that you worst pain imaginable? would like to address? Does your child have any redness, swelling, or • What level of pain is acceptable to your lumps in the genital area? (Gagnadoux, 2011, 2010; Meyers, 2004; Park et al., 2005; Youn, child? Trachtman, & Gauthier, 2006)

GENERAL RISK FACTORS • Disease process • Kidney disease • Medications • Infection • Glomerulonephritis • Strenuous exercise • Cystitis • Kidney stones • Trauma

Hematuria • APHON Telephone Triage Guidelines 153 SAMPLE

IRRITABILITY

Christine Armstrong, MScN RN(EC) NP Paediatrics Jane Lowry, RN Lisa Honeyford, MN RN CPHON®

Irritability • APHON Telephone Triage Guidelines 157 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. SAMPLE (Vorvick & Kaneshiro, 2009; Williams et al., 2012)

Irritability • APHON Telephone Triage Guidelines 158 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Is your Does your child appear dehydrated (e.g., dry Has your child had any recent changes to her child awake, alert, and oriented? mouth, decreased urine output, decreased or his health? tears)? What is concerning you most about your child’s Has your child had any recent trauma, injury, or current behavior? When were your child’s last blood counts, and surgery? what were the results? How long has your child been acting or Have there been any changes at home or behaving differently? Is this a behaviorSAMPLE that Is your child more fatigued? Is your child school? Any reports of bullying? your child has demonstrated in the past complaining of dizziness, lightheadedness, or (temper tantrums)? headaches? Has your child’s medication regimen recently changed? Does your child have a fever? Does your child Is your child complaining of pain? If yes, what have chills? have you done to relieve the pain? Is your child currently receiving steroids or has your child recently completed steroids? How many ounces of fluid has your child had Is your child consolable? to drink during the last 24 hours? Does your child have any food, drug, or Does your child’s behavior interfere with environmental allergies? Is your child receiving IV hydration, total eating, sleeping, playing, or toileting? parenteral nutrition (TPN), or enteral feedings Do you have any other concerns that relate to at home? If yes, what and how much? this problem?

GENERAL RISK FACTORS • Anemia • Medications (opioid withdrawal or steroid use) • Mental health concerns • Fever • Pain • Conditions or diseases that affect the • Infection • Sleep deprivation or fatigue central nervous system (Baggott et al., 2010; Jacob, 2008; Kline, 2008; Rodgers, 2009; • Dehydration • Stress Tomlinson & Kline, 2010; Watral, 2008; Wilne et al., 2007; • Hyperglycemia/hypoglycemia • Hospitalization Yilmaz, Tas, Muslu, Basbakkal, & Kantar., 2010)

Irritability • APHON Telephone Triage Guidelines 159 SAMPLE

JAUNDICE

Meghan Belongia, MSN RN CPNP Jolene Epding, BSN RN CPHON® Kitty Montgomery, MS RN PCNS-BC CPHON®

Jaundice • APHON Telephone Triage Guidelines 163 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. SAMPLE (Chowdhury & Chowdhury, 2010)

Jaundice • APHON Telephone Triage Guidelines 164 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Is your child receiving IV hydration, total Is your child taking any herbal supplements? child’s activity level changed? parenteral nutrition (TPN), or enteral feedings at home? If yes, what and how much? Has your child had any sick contacts? Is your child difficult to wake, or does your child appear confused? How many wet diapers or how frequently has Has your child recently traveled outside of the your child urinated in the last 24 hours? United States? Does your child have a fever? SAMPLEWhat color is your child’s urine? Has your child had any known exposure to Has your child had any recent illness? household cleaners or chemical products? When was your child’s last stool? What was its Does your child’s skin look yellow? Are the consistency and color? Has your child had any recent blood whites of your child’s eyes yellow? transfusions? If yes, when? Does your child have abdominal pain? When did the yellow color begin? Have you been informed that your child’s liver Has your child had any episodes of vomiting, function tests have been elevated in the past? How many ounces of fluid has your child had or does your child complain of nausea? Do you know your child’s most recent liver to drink in the last 24 hours? function test results? Has your child’s oral intake changed? Have there been any dietary changes? Do you have any other concerns that you would like to address? Does your child have a rash? Is your child itching?

GENERAL RISK FACTORS • History of blood transfusions • Infection (viral vs. bacterial) • Total parenteral nutrition • Hemolysis • Sepsis • Hepatotoxic medications • Gall stones • Hypothyroidism (Chowdhury & Chowdhury, 2010; Landers & O’Hanlon-Curry, 2009; Snyder & Pickering, 2000; Whitington & Alonso, 1998)

Jaundice • APHON Telephone Triage Guidelines 165 SAMPLE

JAUNDICE

Meghan Belongia, MSN RN CPNP Jolene Epding, BSN RN CPHON® Kitty Montgomery, MS RN PCNS-BC CPHON®

Jaundice • APHON Telephone Triage Guidelines 163 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. SAMPLE (Chowdhury & Chowdhury, 2010)

Jaundice • APHON Telephone Triage Guidelines 164 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Is your child receiving IV hydration, total Is your child taking any herbal supplements? child’s activity level changed? parenteral nutrition (TPN), or enteral feedings at home? If yes, what and how much? Has your child had any sick contacts? Is your child difficult to wake, or does your child appear confused? How many wet diapers or how frequently has Has your child recently traveled outside of the your child urinated in the last 24 hours? United States? Does your child have a fever? SAMPLEWhat color is your child’s urine? Has your child had any known exposure to Has your child had any recent illness? household cleaners or chemical products? When was your child’s last stool? What was its Does your child’s skin look yellow? Are the consistency and color? Has your child had any recent blood whites of your child’s eyes yellow? transfusions? If yes, when? Does your child have abdominal pain? When did the yellow color begin? Have you been informed that your child’s liver Has your child had any episodes of vomiting, function tests have been elevated in the past? How many ounces of fluid has your child had or does your child complain of nausea? Do you know your child’s most recent liver to drink in the last 24 hours? function test results? Has your child’s oral intake changed? Have there been any dietary changes? Do you have any other concerns that you would like to address? Does your child have a rash? Is your child itching?

GENERAL RISK FACTORS • History of blood transfusions • Infection (viral vs. bacterial) • Total parenteral nutrition • Hemolysis • Sepsis • Hepatotoxic medications • Gall stones • Hypothyroidism (Chowdhury & Chowdhury, 2010; Landers & O’Hanlon-Curry, 2009; Snyder & Pickering, 2000; Whitington & Alonso, 1998)

Jaundice • APHON Telephone Triage Guidelines 165 SAMPLE

MUCOSITIS

Jill Lee, MSN RN CPNP-AC CPON®

Mucositis • APHON Telephone Triage Guidelines 169 PROBLEM: MUCOSITIS

Mucositis is an inflammation or ulceration of the mucous membranes that may occur anywhere throughout the gastrointestinal tract. SAMPLE (Tomlinson, Judd, Hendershot, Maloney, & Sung, 2007)

Mucositis • APHON Telephone Triage Guidelines 170 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Is your child having difficulty drinking? How Has your child taken any pain medication? child’s activity level changed? many ounces of fluid has your child had to • If yes, what were the medications given, drink in the last 24 hours? how much was given, and how often? Is there any redness, sores, ulcers, or white patches present in your child’s mouth or on his Is your child receiving IV hydration, total • Was your child’s pain improved after the or her lips? parenteral nutrition (TPN), or enteral feedings medication? at home? If yes, what and how much? • Was this medication started because of Does your child have breakdownSAMPLE in the rectal mouth sores, or was your child already area? Is your child complaining of pain with Is your child drooling or experiencing pooling taking pain medication? stooling? of saliva? Is the saliva thick and sticky? What makes your child feel better? What Is your child having any bleeding (oral or Is your child having any difficulty with makes your child feel worse? rectal)? speaking? What is your child’s mouth care regimen (e.g., Is your child having difficulty breathing? Does your child have a fever or any other tooth brushing, mouthwashes)? How often is associated symptoms, such as nausea, your child practicing mouth care? Is your child having difficulty or pain with vomiting, diarrhea, rash, abdominal pain? swallowing? Has your child had any sick contacts? Does your child have pain, or is your child fussy Is your child having difficulty eating? How or irritable? If yes, when did it begin? Does your child have a history of cold sores? much is your child eating? When were your child’s last blood counts, and what were the results?

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

(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

Mucositis • APHON Telephone Triage Guidelines 171 SAMPLE

NAUSEA AND VOMITING

Christine Armstrong, MScN RN(EC) NP Paediatrics MaryJo DeCourcy, MScN RN CPHON® Bruna DiMonte, BScN RN

Nausea and Vomiting • APHON Telephone Triage Guidelines 175 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. SAMPLE (Hedstrom, Haglund, Skolin, & von Essen, 2003)

Nausea and Vomiting • APHON Telephone Triage Guidelines 176 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Is your child’s vomiting forceful? Does your child appear dehydrated (e.g., dry child’s activity level changed? mouth, decreased urine output, decreased Describe the color and texture of the emesis tears)? Is your child irritable and inconsolable? (e.g., bloody, coffee–ground like, or bilious)? Is your child receiving IV hydration, total Is your child pale, weak, sweating, or dizzy? Is there a pattern to your child’s nausea or parenteral nutrition (TPN), or enteral feedings vomiting, such as upon awakening or after at home? If yes, what and how much? Does your child have abdominal SAMPLEpain? What meals? part of the abdomen is painful? When was your child’s last stool? What was its What makes your child’s nausea or vomiting consistency? How does your child describe the pain (dull, better? What makes your child’s nausea or squeezing, stabbing, pounding, or throbbing)? vomiting worse? Are there any other associated symptoms, such as pain, fever, recent injury? Can your child rate his or her pain on a scale of Is your child taking antiemetics? What is the 0 to 10 with 0 being no pain and 10 being the medication, and when was it last given? Has your child had any sick contacts? worst pain imaginable? • What level of pain is acceptable to your How many ounces of fluid has your child had Have there been any changes at home or child? to drink in the last 24 hours? school? Is your child nauseated? If yes, when did it Has your child’s oral intake changed? Have Has your child recently had surgery or a begin? there been any dietary changes? procedure?

Is your child also vomiting? If yes, when did the How many wet diapers has your child had, or Is your child anxious? vomiting begin? how frequently has your child urinated in the last 24 hours? Is your child taking all of her or his medications What is the frequency of your child’s vomiting? as prescribed? What is the appearance of your child’s urine What is the quantity of emesis? (what is the color, consistency, and odor)? Do you have any other concerns that you would like to address?

GENERAL RISK FACTORS • Sick contacts • Cholelithiasis • Diet changes • Younger age • Recent surgery • Anxiety • Female gender • Medication (narcotics) • Sick contacts • History of major organ dysfunction (hepatic, • Constipation renal)

Nausea and Vomiting • APHON Telephone Triage Guidelines 177 SAMPLE

PAIN

Meghan Belongia, MSN RN CPNP Anne Joseph, BSN RN CPHON® Kitty Montgomery, MS RN PCNS-BC CPHON® Mollie Mulberry, MS RN CPNP CPON® Carolyn Ziebert, MS RN

Pain • APHON Telephone Triage Guidelines 183 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. SAMPLE (Graham & Uphold, 2004; Walker, 2003)

Pain • APHON Telephone Triage Guidelines 184 GENERAL SYMPTOM ASSESSMENT

How is your child acting now? Is your child How often does your child’s pain occur? Is it What makes your child’s pain worse (e.g., awake, alert, and oriented? intermittent or constant? activity or rest)? What makes your child’s pain better? Has you child’s activity level changed? Is your How long does your child’s pain last? child’s pain interfering with normal activities of What have you tried to treat your child’s pain? daily living? How does your child describe the pain (e.g., numbness, tingling, burning, stabbing, aching, What medications does your child use at home Has your child had any recent traumaSAMPLE or injury? throbbing, twisting, pinching, dull)? for pain management? Has your child recently had surgery or a Has the intensity of your child’s pain changed? Does your child have a fever? procedure (e.g., bone marrow aspiration/ biopsy or lumbar puncture)? Is there a pattern to your child’s pain (occurs in Have there been any recent changes in your the morning versus the evening)? child’s medication regimen? When did your child’s pain begin? Is this new or has your child experienced this pain in the Can your child rate his or her pain on a scale of Do you have any other concerns that you past? 0 to 10 with 0 being no pain and 10 being the would like to address? worst pain imaginable? Where is your child’s pain? • What level of pain is acceptable to your child?

GENERAL RISK FACTORS • Injury • Secondary to other health problem (e.g., headache, constipation, • Infection heartburn) • Medical or surgical procedures

Pain • APHON Telephone Triage Guidelines 185 SAMPLE

PARESTHESIA

Pam Jones, RN CNP CPON®

Paresthesia • APHON Telephone Triage Guidelines 191 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. SAMPLE(Jacob, 2008; Numbness and Tingling, n.d.; Paresthesia, n.d.)

Paresthesia • APHON Telephone Triage Guidelines 192 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Does your child have any difficulty walking, Has your child had a recent viral illness? child’s activity level changed? holding certain objects, or weakness? Is your child constipated? When was your When did your child’s symptoms begin? Are Where is your child’s numbness, tingling, or child’s last bowel movement? they getting worse? weakness? Is there any color change in this area? Does the area feel hot or cold? Does your child have a rash? Have there been any changes to your child’s neurological status, such asSAMPLE loss of Does your child have pain? If yes, where? Have there been any recent changes in your consciousness? child’s medication regimen? Does your child complain of a severe Does your child have slurred speech or visual headache? What part of the head hurts? How Has your child suffered any recent trauma? changes? long has your child had a headache? What makes the pain better? Has your child recently had surgery? Does your child have uncontrolled movement of an arm or leg, or has your child lost bladder Has your child complained of nausea? Has When were your child’s last blood counts, and or bowel control? your child vomited? what were the results?

Does your child have a fever? Do you have any other concerns that relate to this problem?

GENERAL RISK FACTORS • Vitamin deficiencies • Trauma (head, neck, or back) • Disease process • Diabetes • Medication • Herpes zoster • Hypothyroidism • Structural changes in anatomy that are (Armstrong, Almadrones, & Gilbert, 2005; Breakey, Bartels, & Askalan, 2010; Jacob, 2008; Nielsen & Brant, 2002; Oakes, related to surgery 2011; Rowland, 2005; Zempsky, Schechter, Altman, & Weisman, 2004)

Paresthesia • APHON Telephone Triage Guidelines 193 SAMPLE

PHLEBITIS

Kristi Geib, MSN RN CPNP CPON®

Phlebitis • APHON Telephone Triage Guidelines 197 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 theSAMPLE vein. This condition is called thrombophlebitis.

Phlebitis • APHON Telephone Triage Guidelines 198 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your How often does your child’s pain occur If the involved area is at a previous IV-access child’s activity level changed? (intermittent or constant)? site, were there any difficulties in obtaining IV access or administering medications through Where is the source of your child’s How does your child describe the pain (e.g., the IV? inflammation (e.g., old IV site, venipuncture numbness, tingling, burning, sharp, achy)? site, central line site)? What medications were given through the IV How would you rate your child’s pain (e.g., site? How would you describe the appearanceSAMPLE mild, moderate, severe)? of the inflamed area (e.g., warmth, redness, When was the last time the line was used? Was tenderness, streaking, swelling, drainage)? Is the pain interfering with your child’s activities there any difficulty flushing the line? of daily living? Is your child’s skin intact at the area of Is your child receiving IV hydration, total inflammation? What makes your child’s pain worse? What parenteral nutrition (TPN), or enteral feedings makes your child’s pain better? at home? If yes, what and how much? How would you describe the appearance of the involved extremity (e.g., swelling, redness)? What have you tried to treat your child’s pain? Is your child receiving IV home medications? If yes, what and when was the last dose? Can your child move the extremity without Does your child currently have IV access difficulty? (e.g., peripheral, peripherally inserted central Does your child have a history of phlebitis or catheter [PICC], central venous line [CVL], clots? Does your child have a fever or chills? port)? Has your child had any recent concern of Does your child have pain at the site of illness or dehydration? inflammation? Do you have any other concerns that you When did your child’s pain begin? would like to address?

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

GENERAL RISK FACTORS • Infection • Administration of irritating IV fluids or • Dehydration • Neutropenia medications • Inherited or acquired risk for clots • Current or recent IV access • Injury to the inner lining of the vein by the • Contraception or medications for menstrual catheter suppression

Phlebitis • APHON Telephone Triage Guidelines 199 SAMPLE

PRIAPISM

Deena Centofanti, MS RN AOCN® Beth Savage, MSN CPNP CPON®

Priapism • APHON Telephone Triage Guidelines 203 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. SAMPLE(National Institutes of Health [NIH], 2002; Ryan & Heeney, 2005)

Priapism • APHON Telephone Triage Guidelines 204 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Has any treatment been provided? Do you suspect that your child has abused any child’s activity level changed? substances (e.g., alcohol, marijuana, cocaine, Is your child able to urinate? testosterone)? Has your child been treated for priapism in the past? If yes, what was done to resolve the Does urination cause pain or burning? What medications is your child currently problem? taking? Does your child have a fever? When did this begin? How long areSAMPLE the Has your child had any recent trauma in the episodes lasting? pelvic area, genital region, or spinal cord?

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

(Rogers, 2005)

GENERAL RISK FACTORS • Prior history of priapism • Medications (e.g., antihypertensives, • Trauma (e.g., pelvic/groin, genital, spinal • Recent illicit drug use (e.g., cocaine, antidepressants, antipsychotics, cord) alcohol, marijuana use) tranquilizers, testosterone, some cough and (NIH, 2002; Rogers, 2005; Ryan & Heeney, 2005) cold medications)

Priapism • APHON Telephone Triage Guidelines 205 SAMPLE

PRURITUS

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

Pruritus • APHON Telephone Triage Guidelines 209 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. SAMPLE (Schwartz, 2008)

Pruritus • APHON Telephone Triage Guidelines 210 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your What is your child’s current skin care regimen? Does your child have a history of allergies, child’s activity level changed? asthma, or eczema? If yes, what treatment has Does your child have a rash? If yes, where is been used? Where is your child itching? the rash located? What does the rash look like? • Is there any redness, drainage, or swelling in Has there been any recent change in your How severe is the pruritus? the area of the rash? child’s medication regimen? • Is it intermittent or constant? • Are there any fluid-filled lesions? • Does it increase at night? SAMPLEHas your child been exposed to any new or • Is it localized or generalized? What effect does this symptom have on your different soaps, detergents, or clothing? child’s everyday life or sleep pattern? Is your child having difficulty breathing Has your child been playing outside and been or experiencing other signs of an allergic Does your child have any known kidney or liver exposed to poison? reaction? problems? Has your child been exposed to anyone with a What makes the itching better? What makes Has your child had a recent lab test to check communicable disease or rash? the itching worse? kidney or liver function? If yes, what were the results? Has anyone complained of pruritus who has What effect does the itching have on your had contact with your child? child’s everyday life or sleep pattern? Does your child’s skin look yellow? Are the whites of your child’s eyes yellow? Do you have any other concerns that you What is the condition of your child’s skin? Does would like to address? your child’s skin appear dry and flaking? (McCord, Baker, & Mondozzi, 2009; Norville, 2008; Schwartz, 2008)

GENERAL RISK FACTORS • Allergy • Dehydration • Medications or drug sensitivity • Altered organ dysfunction (renal • Environmental irritants or toxins • Psychologic dysfunction, liver disease) • Infection • Surgery, wound healing, and adhesions • Hyperbilirubinemia • Infestation (e.g., scabies, pediculosis, insect • Urticaria (acute or chronic) • Dermatologic disorders bites) (McCord et al., 2009; Norville, 2008; Schwartz, 2008)

Pruritus • APHON Telephone Triage Guidelines 211 SAMPLE

RASH

Hanna Tseitlin, MN PNP CPHON®

Rash • APHON Telephone Triage Guidelines 217 PROBLEM: RASH Rash is a change in texture, color,SAMPLE and temperature of the skin that represents a change from normal skin appearance.

Rash • APHON Telephone Triage Guidelines 218 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Is there any redness, drainage, or swelling in Does your child have a headache? child’s activity level changed? the area of the rash? Does your child complain of light sensitivity? Does your child have difficulty breathing? Are there any fluid-filled lesions? Does your child have difficulty bending his or What was your child doing when you noticed Has your child had chicken pox? Has your child her neck? the rash or immediately prior to you noticing been immunized against chicken pox? the rash? SAMPLEHas your child had any sick contacts? Does your child’s rash itch? When did your child’s rash begin? Has your child traveled outside of the country Is your child’s rash painful? recently? Where is your child’s rash? Has your child been exposed to new products Has your child recently started any new What color is your child’s rash? (e.g., detergents, body soaps, body lotions)? medications?

What is the appearance of your child’s rash? Does your child have a fever, or has your child Do you have any other concerns that you had a recent febrile illness? Did the timing of would like to address? the fever coincide with the rash?

GENERAL RISK FACTORS • Allergy • Irritant • Infection • Medication • Sun exposure • Thrombocytopenia

Rash • APHON Telephone Triage Guidelines 219 SAMPLE

SEIZURE

Mary Conway, MSN RN CPHON® Sarah Matney, BSN RN CPON®

Seizure • APHON Telephone Triage Guidelines 223 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.” SAMPLE (Wilson, 2004, p. 341)

Seizure • APHON Telephone Triage Guidelines 224 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your child ever had a seizure in the past? If Does your child have low platelets or a yes, are these seizures the same? bleeding disorder? Is your child currently seizing? How long is the seizure? Has your child had repeated or Has your child previously been prescribed Does your child have any signs of infection multiple seizures? antiseizure medicine? If yes, what medications? (e.g., fever, headache, stiff neck, nausea, Is your child taking the medication as vomiting)? Is your child having difficulty breathing? Do prescribed? your child’s skin, lips, or nail bedsSAMPLE appear blue? What was your child doing immediately prior Is your child taking any other medications? to the seizure? Has your child passed out, or are you having difficulty rousing your child? Has your child ever had a stroke in the past? When was your child’s last blood test, and what were the results? Has your child had a recent head injury? Has your child recently had surgery or a surgical procedure? Do you have other concerns that you would Has your child experienced any other like to address? symptoms (e.g., eye rolling; twitches; Has your child ever had a blood clot? If yes, incontinence; staring; changes in vision, when and where? Is your child taking any speech, gait, or mood)? medications to prevent or treat blood clots?

GENERAL RISK FACTORS • Fever • Medications • Metabolic disorders or abnormalities (e.g., • Infection • Trauma decreased sodium) • Intracranial hemorrhage or stroke • Neurological disorders

Seizure • APHON Telephone Triage Guidelines 225 SAMPLE

SLEEP DISORDERS

Deena Centofanti, MS RN AOCN®

Sleep Disorders • APHON Telephone Triage Guidelines 229 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. SAMPLE (Berger, 2009)

Sleep Disorders • APHON Telephone Triage Guidelines 230 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Does your child sleep or take naps during the Has there been a recent new stress in your child’s activity level changed? day? How long does your child sleep during child’s life, such as a move, death of family the day? member or pet, or attending a new school? When did your child’s sleep issues begin? Does your child complain of moving legs, Does your child have a history of snoring or When does your child usually go to bed? jerking, or being restless at night? sleep apnea? When does your child usually wake up? SAMPLEWhat is your child’s typical bedtime routine? Does your child have any associated symptoms How long does it take for your child to fall (e.g., pain, incontinence, fever, respiratory asleep? Does your child eat or drink any caffeinated illness)? food or beverages prior to bedtime? Does your child wake up during the night? If Does your child have a history of depression or yes, does your child have difficulty falling back What makes your child’s sleep pattern worse? anxiety? asleep? What makes your child’s sleep pattern better? Does your child have a history of drug or Does your child complain of feeling sleepy Has your child’s schedule recently changed? alcohol use? during the day? Has your child recently been hospitalized? Do you have any other concerns that you would like to address?

(Berger, 2009; NCI, 2011)

GENERAL RISK FACTORS • Medications • Depression • Past or family history of sleep disorders • Pain • Frequent hospitalizations and recent • Illicit drug use intensive care unit (ICU) stay (Berger, 2009; NCI, 2011)

Sleep Disorders • APHON Telephone Triage Guidelines 231 SAMPLE

SWELLING

Karen MacDonald, MSN RN CPON®

Swelling • APHON Telephone Triage Guidelines 235 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. SAMPLE (Baggott, Kelly, Fochtman, & Foley, 2002; Venes, 2009).

Swelling • APHON Telephone Triage Guidelines 236 GENERAL SYMPTOM ASSESSMENT

How is your child acting right now? Has your Does your child have shortness of breath, Has your child’s urine output decreased over child’s activity level changed? difficulty breathing, or complain that his or her the last 24–48 hours? throat feels tight? Where is your child’s swelling? Does your child complain of nausea or Is there a recent history of injury or trauma? dizziness? When did your child’s swelling begin? Is your child’s swelling in an extremity? Is your Have there been any recent changes in your Does your child have pain in the SAMPLEarea of child able to move the extremity? child’s medication regimen? swelling? Does your child have a central line or PICC Does your child have any known allergies? Is there any bruising, discoloration, or drainage line? If yes, did your child recently receive in the area of swelling? chemotherapy or other medication through it? Does your child have a rash?

Does your child complain of tingling or Has your child had sudden weight gain, or Has your child recently had surgery? numbness in the area of swelling? does your child complain that her or his clothes are tight? Do you have any other concerns that you Is the area of swelling warm to touch? would like to address?

Does your child have a fever? (Baggott et al., 2002; Lanzkowsky, 2000)

GENERAL RISK FACTORS • Recent injury or trauma • Deep vein thrombosis • Infiltration/extravasation • Surgery • Central venous catheter • Renal insufficiency • Infection • Compartment syndrome (Baggott et al., 2002; Kline, 2007) • Malnutrition • Anaphylaxis

Swelling • APHON Telephone Triage Guidelines 237