guidelines for telephone triage include asking screening questions; determining when to immediately refer to emergency medical services (dial 911); and determining when to refer to same-day appointments, appointments in 24 to 72 hours, appointments in 4 days or more, or home care.

Unnecessary emergency department and clinic visits have decreased, saving medical costs and time for families in need of healthcare. 

Guidlines:

• Date and time

• Background

• Name, age, sex

• Chronic illness

• Allergies, current medications, treatments, or recent immunizations

• Chief complaint

• General symptoms

• Severity

• Duration

• Other symptoms

• Pain

• Systems review

• Steps taken

• Advised to call emergency medical services (911)

• Advised to see practitioner

• Advised regarding home care

• Advised to call back if symptoms worsen or fail to improve

is the capacity to understand what another person is experiencing from within that person's frame of reference; it is often described as the ability to put oneself in another's shoes.

The essence of empathic interaction is an accurate understanding of another's feelings.

Information overload; when an individual receives too much information or information that is overwhelming, they often demonstrate signs of increasing anxiety or decreasing attention.

Communication Barriers (Nurse)

• Socializing

• Giving unrestricted and sometimes unasked for advice

• Offering premature or inappropriate reassurance

• Giving overready encouragement

• Defending a situation or opinion

• Using stereotyped comments or clichés

• Limiting expression of emotion by asking directed, closed-ended questions

• Interrupting and finishing the person’s sentence

• Talking more than the interviewee

• Forming prejudged conclusions

• Deliberately changing the focus

Signs of Information Overload (Patient)

• Long periods of silence

• Wide eyes and fixed facial expression

• Constant fidgeting or attempting to move away

• Nervous habits (e.g., tapping, playing with hair)

• Sudden interruptions (e.g., asking to go to the bathroom)

• Looking around

• Yawning, eyes drooping

• Frequently looking at a watch or clock

• Attempting to change topic of discussion

• Explain to interpreter the reason for the interview and the type of questions that will be asked.

• Clarify whether a detailed or brief answer is required and whether the translated response can be general or literal.

• Introduce the interpreter to family, and allow some time before the interview for them to become acquainted.

• Communicate directly with family members when asking questions to reinforce interest in them and to observe nonverbal expressions, but do not ignore interpreter.

• Pose questions to elicit only one answer at a time, such as “Do you have pain?” rather than “Do you have any pain, tiredness, or loss of appetite?”

• Refrain from interrupting family member and interpreter while they are

conversing.

• Avoid commenting to interpreter about family members, since they may understand some English.

• Be aware that some medical words, such as allergy, may have no similar word in another language; avoid medical jargon whenever possible.

• Be aware that cultural differences may exist regarding views on sex, marriage, or pregnancy.

• Allow time after the interview for interpreter to share something that he or she thought could not be said earlier; ask about the interpreter’s impression of nonverbal clues to communication and family members’ reliability or ease in revealing information.

• Arrange for family to speak with the same interpreter on subsequent visits whenever possible.

• Allow children time to feel comfortable.

• Avoid sudden or rapid advances, broad smiles, extended eye contact, or other gestures that may be seen as threatening.

• Talk to the parent if child is initially shy.

• Communicate through transition objects such as dolls, puppets, and stuffed animals before questioning a young child directly.

• Give older children the opportunity to talk without the parents present.

• Assume a position that is at eye level with child 

• Speak in a quiet, unhurried, and confident voice.

• Speak clearly, be specific, and use simple words and short sentences.

• State directions and suggestions positively.

• Offer a choice only when one exists.

• Be honest with children.

• Allow them to express their concerns and fears.

• Use a variety of communication techniques.

I the child has a special toy or doll, "talk" to the doll first. Ask simple questions such as "Does your teddy bear have a name?" to ease the child into a conversation.

• Children younger than 5 years are egocentric
• It is futile to use another child's experience in an attempt to gain the cooperation of small children.
• They have not yet acquired sufficient language skills to express their feelings and wants but can push away unwanted objects and pull an wanted object.
• Avoid using a phrase that might be misinterpreted such as "coughing your head off", they attach literal meaning to common phrases and may think their head will fall off.

Communicating with children in School-Age Years

• They want explanations and reasons for everything but require no verification beyond that.
• They are interested in the functional aspect of all procedures, objects, and activities. They want to know why an object exists, why it is used, how it works, and the intent and purpose of its user.
• For example, to explain a procedure such as taking blood pressure, show the child how squeezing the bulb pushes air into the cuff and makes the “silver” in the tube go up. Let the child operate the bulb. An explanation for the procedure might be as simple as “I want to see how far the silver goes up when the cuff squeezes your arm.” Consequently, the child becomes an enthusiastic participant.

Build a Foundation

• Spend time together.

• Encourage expression of ideas and feelings.

• Respect their views.

• Tolerate differences.

• Praise good points.

• Respect their privacy.

• Set a good example

Communicate Effectively

• Give undivided attention.

• Listen, listen, listen.

• Be courteous, calm, and open minded.

• Try not to overreact. If you do, take a break.

• Avoid judging or criticizing.

• Avoid the “third degree” of continuous questioning.

• Choose important issues when taking a stand.

• After taking a stand:

• Think through all options.

• Make expectations clear.

Type

Be as specific as possible. With young children, asking the parents how they know the child is in pain may help describe its type, location, and severity. For example, a parent may state, “My child must have a severe earache because she pulls at her ears, rolls her head on the floor, and screams. Nothing seems to help.” Help older children describe the “hurt” by asking them if it is sharp, throbbing, dull, or stabbing. Record whatever words they use in quotes.

Location

Be specific. “Stomach pains” is too general a description. Children can better localize the pain if they are asked to “point with one finger to where it hurts” or to “point to where Mommy or Daddy would put a Band-Aid.” Determine if the pain radiates by asking, “Does the pain stay there or move? Show me with your finger where the pain goes.”

Severity

Severity is best determined by finding out how it affects the child’s usual behavior. Pain that prevents a child from playing, interacting with others, sleeping, and eating is most often severe. Assess pain intensity using a rating scale, such as a numeric or FACES scale (see Chapter 30).

Duration

Include the duration, onset, and frequency. Describe this in terms of activity and behavior, such as “pain reported to last all night, child refused to sleep and cried intermittently.”

Influencing Factors

Include anything that causes a change in the type, location, severity, or duration of the pain: (1) precipitating events (those that cause or increase the pain), (2) relieving events (those that lessen the pain, such as medications), (3) temporal events (times when the pain is relieved or increased), (4) positional events (standing, sitting, lying down), and (5) associated events (meals, stress, coughing).

The birth history includes all data concerning (1) the mother’s health during pregnancy, (2) the labor and birth, and (3) the infant’s condition immediately after birth.

• Has your child ever taken any drugs or tablets that have disagreed with him or her or caused an allergic reaction? If yes, can you remember the name(s) of these drugs?

• Can you describe the reaction?

• Was the drug taken by mouth (as a tablet or syrup), or was it an injection?

• How soon after starting the drug did the reaction happen?

• How long ago did this happen?

• Did anyone tell you it was an allergic reaction, or did you decide for yourself?

• Has your child ever taken this drug, or a similar one, again? If yes, did your child experience the same problems?

• Have you told the doctors or nurses about your child’s reaction or allergy?

• Behavior patterns such as nail biting, thumb sucking, pica (habitual ingestion of nonfood substances), rituals (“security” blanket or toy), and unusual movements (head banging, rocking, overt masturbation, walking on toes)

• Activities of daily living, such as hour of sleep and arising, duration of nighttime sleep and naps, type and duration of exercise, regularity of stools and urination, age of toilet training, and daytime or nighttime bed-wetting

• Unusual disposition; response to frustration

• Use or abuse of alcohol, drugs, coffee, or tobacco

• Approximate weight at 6 months, 1 year, 2 years, and 5 years of age

• Approximate length at ages 1 and 4 years

• Dentition, including age of onset, number of teeth, and symptoms during teething

Developmental milestones include:

• Age of holding up head steadily

• Age of sitting alone without support

• Age of walking without assistance

• Age of saying first words with meaning

• Present grade in school

• Scholastic performance

• If the child has a best friend

• Interactions with other children, peers, and adults

Ages 12 to 14 Years

• Have adolescent identify supportive adult to discuss sexuality issues and concerns with.

• Discuss advantages of delaying sexual activity.

• Discuss making responsible decisions regarding normal sexual feelings.

• Discuss role of gender, peer pressure, and the media in sexual decision making.

• Discuss contraceptive options (advantages and disadvantages).

• Provide education regarding sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection; clarify risks, and discuss condoms.

• Discuss abuse prevention: avoiding dangerous situations, role of drugs and alcohol, and use of self-defense.

• Have adolescent clarify values, needs, and ability to be assertive.

• If adolescent is sexually active, discuss limiting partners, use of condoms, and contraceptive options.

• Have confidential interview with adolescent (including a sexual history).

• Discuss the evolution of sexual identity and expression.

• Discuss breast examination or testicular examination.

Ages 15 to 18 Years

• Support delaying sexual activity.

• Discuss alternatives to intercourse.

• Discuss “When are you ready for sex?”

• Clarify values; encourage responsible decision making.

• Discuss consequences of unprotected sex: early pregnancy, STIs, including HIV infection.

• Discuss negotiating with partner and barriers to safer sex.

• If adolescent is sexually active, discuss limiting partners, use of condoms, and contraceptive options.

• Emphasize that sex should be safe and pleasurable for both partners.

• Have confidential interview with adolescent.

• Discuss concerns about sexual expression and identity.

Performed if a child abuse is suspected

Perform a comprehensive assessment on:

• Children receiving comprehensive well-child care

• Children experiencing major stressful life events (e.g., chronic illness, disability, parental divorce, death of a family member)

• Children requiring extensive home care

• Children with developmental delays

• Children with repeated accidental injuries and those with suspected child abuse

• Children with behavioral or physical problems that could be caused by family dysfunction

• Estimated average requirement (EAR)—Nutrient intake estimated to meet the requirement of half the healthy individuals (50%) for a specific age and gender group.

• Recommended dietary allowance (RDA)—Average daily dietary intake sufficient to meet the nutrient requirement of nearly all (97% to 98%) of healthy individuals for a specific age and gender group.

• Adequate intake (AI)—Recommended intake level based on estimates of nutrient intake by healthy groups of individuals.

• Tolerable upper intake level (UL)—Highest average daily nutrient intake level likely to pose no risk for adverse health effects. As intake increases above the UL, risk for adverse effects increases.

Upper arm circumference

Muscle