Nurse Triage Advice for Dehydrated Patients

As we celebrate July 4th and spend more time outdoors, one thing to be particularly aware of is the risk of becoming dehydrated. Even for the portions of the US that aren’t affected by dangerous heat waves, hot weather can still pose a risk. For triage nurses, it’s also vital that they know what protocols to use when this condition may be affecting their patient callers. Here’s our advice for how they can assist dehydrated patients.

Nurse Triage Protocols

Triage nurses and medical professionals have long looked to Schmitt-Thompson protocols as the gold standard for assisting patients over the phone. These protocols form a checklist that prompts nurses with a series of questions for evaluating all patient symptoms and their severity, as well as determining which providers patients should contact, if any. Assigned protocols can be documented and then shared directly with those providers to improve continuity of care.

Protocols undergo updates by a panel of medical professionals. This happens annually, after major medical events, and upon review from doctors’ recommendations.

Different versions of protocols exist depending on the needs of a practice. Those include daytime and after-hours versions, as well as those for pediatrics and adults.

Dehydration for Children

Symptoms

For children, initial signs of dehydration include dizziness or light-headedness, nausea, as well as dry lips and mouths. As symptoms worsen from mild to moderate dehydration, children may become extremely thirsty, lethargic, irritable, or pale, and experience faster-than-normal heart rates and high blood pressure. 

While it’s important that parents know the best ways their children can avoid dehydration in the future (more on that below), triage nurses need a timely, efficient means of identifying whether a specific child may be experiencing one of several heat-related reactions, including heat cramps, heat exhaustion, and heatstroke (or sunstroke).

Heat cramps are when muscles become tight due to lack of fluids and salt. They aren’t usually a serious medical condition, but could be indicative of the beginnings of heat exhaustion. 

Heat exhaustion usually involves heavy sweating, dizziness, nausea, and vomiting. Fevers are atypical, but body temperatures may become elevated between 100 and 102 degrees F.

Heatstroke or sunstroke involves flushed skin, a high-grade fever over 105 degrees, and shock or confusion which can be life-threatening if not addressed. 

Protocols

Nurse triage protocols evaluate dehydrated patients by inquiring about their behavior and related symptoms. For instance, if a child experiences:

Difficulty staying awake, confusion when trying to talk or move, a possible seizure, signs of shock (weakness or gray, cool skin), or a fever above 105 degrees, the parent is advised to call 911 immediately.

Faintness or the inability to stand, or a fever greater than 104 degrees, the parent is advised to take their child to an emergency department.

The inability to walk, or may sound sick to the triage nurse when speaking with them, the parent is advised to take their child to the ER or to a primary care physician.

Vomiting when trying to drink fluids, or they’re under 90 days old and not acting normal after being exposed to the heat, the parent is advised to take their child to a PCP office as soon as possible.

Understandably, less severe symptoms may still involve seeing a PCP (albeit not immediately), or may be treatable with home-based care.

Click here to request your full copy of pediatric triage protocols.

Dehydration for Adults

Symptoms

While dehydration can affect everyone, AARP notes how older adults, particularly those over 65, are more vulnerable. Symptoms for dehydration in adults are very similar to those in children, but their different physiologies mean that adults may exhibit additional symptoms that require ruling out other conditions. 

While symptoms of heatstroke and heat cramps are very similar, fever may be higher for heat exhaustion (up to 104 degrees). Adults may also experience other conditions like heat syncope (dizziness from standing up too suddenly) or heat edema (mild swelling of the feet and ankles, along with puffy fingers).

Protocols

In adults, heatstroke may be characterized by a fever over 103 degrees, difficulty staying awake, feeling disoriented, unable to stand, or a possible seizure. Any of these would prompt a triage nurse to advise the patient to contact 911.

Fevers of 103 degrees, combined with the inability to walk, would indicate the need to go to an emergency department.

Vomiting, dizziness, long-lasting muscle cramps, or indications from the patient that they sound very sick would prompt a nurse to advise them to seek out an emergency department or their PCP.

Adults may differ from children when it comes to:

Swelling of the ankles (pedal edema), which may require a more appropriate protocol under leg swelling instead of heat exposure.

The need to go to a PCP’s office when the patient is experiencing a fever and is either over the age of 60, has a chronic disease, or is bedridden, as these need to rule out the possibility of bacterial illness.

Click here to request your full copy of adult triage protocols.

Preventing Dehydration in the Future

Dehydrated patients may benefit from being advised on how to avoid similar conditions in the future. 

For children, it’s usually best if they wear loose, light-colored clothing, make sure to drink enough fluids, and avoid ingesting items that are heavy in sugar (like fruit juice). 

For adults, the same applies to fluid intake — especially making the time for water breaks. Those who exercise in the heat are advised to shorten their workout sessions if it’s 82 degrees or higher, particularly in humid weather. Those who choose to utilize hot tubs on warm days should also be aware of the potential risks, limit their exposure to 15 minutes, and have someone with them in case they experience any negative reactions.

Do You Need Nurse Triage Protocols?

Do you need copies of nurse triage protocols, or do you have any questions about how they can help your dehydrated patients? Contact us today to discuss, as well as learn more about our other services that are available for improving your patient health and engagement.