In this lesson, we review a case study of an 8-year-old boy named Joseph who is experiencing an acute cough and runny nose that started about a week ago. His mother, Kendra, has called the triage line to determine whether she should bring Joseph to the hospital because his nasal drainage, while clear, is now thicker and harder to blow out. His cough has gotten worse, and he’s started to bring up phlegm, which is also making it difficult for him to sleep. You can tell from the tone of her voice that Kendra is tired and anxious.

Following the 10 Critical Steps, you know to use empathic language and ask open-ended questions to learn more about Joseph’s symptoms. This includes a full respiratory assessment that addresses:

• Any changes in skin color.
• Wheezing, grunting, or other audible noises of concern.
• Possible retractions.
• Speed of respiration.

Using Kendra’s answers, you begin to estimate and categorize Joseph’s level of respiratory distress on a scale of mild to severe*, where:

• Mild can mean rapid respiratory rates, mild stridor, or wheezing.
• Moderate can mean labored breathing, some retractions, nasal flaring, stridor, or wheezing.
• Severe can mean marked respiratory effort, struggling to breath, retractions, or cyanosis.

*Note: fevers can minimally affect the respiratory rate.

You also know that information about Joseph’s activity level, fever, overall appearance, and any sick contacts are important when determining how to proceed.

Which protocol(s) would you choose?

Based on his symptoms, you’ll likely select a cold or cough protocol for Joseph. Because you need the one that will give you the highest acuity, cough is your best option.

Getting Joseph the right level of care requires a few additional questions, including those that address his ABCs and any neurologic problems. You ask Kendra:

• Is Joseph having any difficulty breathing, or any chest pain?

• Does he have a blueish face or tongue?

• Does he seem to be struggling to breathe or speak?

Consider additional factors like:

• The color of Joseph’s sputum.
• Breathing sounds.
• Respiratory rate and presence of fever.
• Ability to swallow.
• Quick review of any pertinent, past medical history.

Here are the results of your assessment:

• Joseph is still active and playful.
• Cyanosis is not present.
• No retractions.
• No wheezing, stridor or grunting.
• No pain when coughing.
• No ear or nose pain.
• His cough is productive with clear, thick sputum.
• He is eating and drinking about 75 percent of his normal intake.
• He is afebrile.
• His cough wakes him frequently during the night.
• He seems slightly more tired.

You assign a disposition of home care. This means you must give specific and detailed care instructions and callback advice, as well as ensure the caller/patient understands everything you have discussed.

You keep the advice short and relevant, and encourage Kendra to write everything down. Kendra calls the nurse line the following night to say thanks, as Joseph has responded well to home care.

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TriageLogic is a URAC-accredited, physician-led provider of top-quality nurse telehealth technology, remote patient monitoring, and medical call center solutions, all for the purpose of encouraging positive patient behavior and improving access to healthcare. Founded in 2007, the TriageLogic Group now serves more than 9,000 physicians and covers over 25 million lives nationwide. They continue to partner with private practices, hospitals, and corporations throughout the U.S.