,2
,Telephone Triage
Protocols
for Nurses
Fourth Edition
Julie K. Briggs, RN, BSN, MHA
Providence Health & Services
Portland, Oregon
3
, Staff
Publisher
J. Christopher Burghardt
Acquisitions Editor
Bill Lamsback
Product Director
David Moreau
Product Manager
Rosanne Hallowell
Copy Editor
Tricia Mulvihill McShane
Proofreader
Jerry Altobelli
Editorial Assistants
Megan L. Aldinger, Karen J. Kirk,
Jeri O’Shea, Linda K. Ruhf
Creative Director
Doug Smock
Vendor Manager
Cynthia Rudy
Manufacturing Manager
Beth J. Welsh
Production Services
Thomson Digital
The clinical treatments described and recommended in this publication are based on research and consultation with nursing, medical, and legal
authorities. To the best of our knowledge, these procedures reflect currently accepted practice. Nevertheless, they cannot be considered absolute
and universal recommendations. For individual applications, all recommendations must be considered in light of the patient’s clinical condition
and, before administration of new or infrequently used drugs, in light of the latest package-insert information. The authors and publisher
disclaim any responsibility for any adverse effects resulting from the suggested procedures, from any undetected errors, or from the reader’s
misunderstanding of the text.
© 2012 by Lippincott William & Wilkins. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any means—electronic, mechanical, photocopy, recording, or otherwise—without prior
written permission of the publisher, except for brief quotations embodied in critical articles and reviews, and testing and evaluation materials
provided by the publisher to instructors whose schools have adopted its accompanying textbook. For information, write Lippincott Williams &
Wilkins, 323 Norristown Road, Suite 200, Ambler, PA 19002-2756.
Printed in China.
10 9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Briggs, Julie K.
Telephone triage protocols for nurses / Julie K. Briggs. — 4th ed.
p. ; cm.
Includes bibliographical references and index.
Summary: “Performing telephone triage requires the ability to make quick and effective decisions based on limited information. This rapid-
access resource delivers over 200 triage protocols for evaluating patients’ symptoms over the telephone. Each symptom entry lists questions,
grouped by urgency level, to determine whether the caller should seek emergency care immediately, seek medical care the same day, call back for
appointment, or follow home care instructions. Detailed home care instructions are then provided. Simple, direct, and useful, it is the most
4
,Telephone Triage
Protocols
for Nurses
Fourth Edition
Julie K. Briggs, RN, BSN, MHA
Providence Health & Services
Portland, Oregon
3
, Staff
Publisher
J. Christopher Burghardt
Acquisitions Editor
Bill Lamsback
Product Director
David Moreau
Product Manager
Rosanne Hallowell
Copy Editor
Tricia Mulvihill McShane
Proofreader
Jerry Altobelli
Editorial Assistants
Megan L. Aldinger, Karen J. Kirk,
Jeri O’Shea, Linda K. Ruhf
Creative Director
Doug Smock
Vendor Manager
Cynthia Rudy
Manufacturing Manager
Beth J. Welsh
Production Services
Thomson Digital
The clinical treatments described and recommended in this publication are based on research and consultation with nursing, medical, and legal
authorities. To the best of our knowledge, these procedures reflect currently accepted practice. Nevertheless, they cannot be considered absolute
and universal recommendations. For individual applications, all recommendations must be considered in light of the patient’s clinical condition
and, before administration of new or infrequently used drugs, in light of the latest package-insert information. The authors and publisher
disclaim any responsibility for any adverse effects resulting from the suggested procedures, from any undetected errors, or from the reader’s
misunderstanding of the text.
© 2012 by Lippincott William & Wilkins. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any means—electronic, mechanical, photocopy, recording, or otherwise—without prior
written permission of the publisher, except for brief quotations embodied in critical articles and reviews, and testing and evaluation materials
provided by the publisher to instructors whose schools have adopted its accompanying textbook. For information, write Lippincott Williams &
Wilkins, 323 Norristown Road, Suite 200, Ambler, PA 19002-2756.
Printed in China.
10 9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Briggs, Julie K.
Telephone triage protocols for nurses / Julie K. Briggs. — 4th ed.
p. ; cm.
Includes bibliographical references and index.
Summary: “Performing telephone triage requires the ability to make quick and effective decisions based on limited information. This rapid-
access resource delivers over 200 triage protocols for evaluating patients’ symptoms over the telephone. Each symptom entry lists questions,
grouped by urgency level, to determine whether the caller should seek emergency care immediately, seek medical care the same day, call back for
appointment, or follow home care instructions. Detailed home care instructions are then provided. Simple, direct, and useful, it is the most
4
