Triage Nurse Case of an Adult with Acute Pain
In this lesson, we review a case study of an anxious 75-year-old female named Paula. She has called the triage line over the weekend after a bad fall. This case involves multiple injuries, requiring multiple protocols. You use the same 10 Critical Steps to talk her through her symptoms and encourage her to seek the appropriate care.
Besides Paula’s age, you learn that she has been married to her husband, John, for 55 years, and is a retired school bus driver. Her current medications include metoprolol, enalapril, ASA, and Lipitor. She’s 5’11”, 180 lbs., and has both hypertension and high cholesterol.
(It’s important to note that most older adults have at least one chronic condition, and many have multiple conditions which can both cause pain and complicate its identification and treatment.)
Because Paula sounds anxious and you hear her moaning, it’s better to ask her an open-ended question first before confirming that she’s able to continue the assessment, such as: “What prompted you to call me this afternoon?” or “You sound as if you might be in pain. Tell me how I may help you?”
Paula says she was walking her dog, the leash tangled, and she fell on her left side, hurting her hip. She tells you it’s painful for her to walk, and that she can’t lift her left arm up very far before she feels shooting pains in her shoulder. Paula doesn’t want to bother her doctor on the weekend, and she’s worried about whether her insurance will cover a hospital visit, which causes her to start crying.
In order to reassure and comfort Paula, it’s important to empathize with her condition by saying something like, “I am so sorry you are in so much pain. Let’s see how I can help you.”
Which protocol would you choose? When you have more than one injury, or more than one symptom, you must triage all symptoms.
While you would need to address protocols for hip pain and shoulder pain, the hip injury likely takes priority. It’s still important to ask some additional questions to evaluate whether Paula needs to be evaluated in an emergency room, including ABCs and neuro symptoms:
- Are you having any difficulty breathing, or any chest pain?
- Did you hit your head when you fell?
- Are you feeling confused or disoriented?
- Are you bleeding anywhere?
- Do your toes look blue on the injured side?
- Is there any numbness anywhere?
- Are you able to bear weight on your injured leg?
- Is your hip deformed?
Paula says she has tried several times to bear weight on her injured leg, but that it’s too painful. You want Paula to initiate 911 and get to the hospital as quickly as possible, but you remember her concerns about her insurance and finances.
To communicate this to Paula without causing more anxiety, try saying:
“Paula, I’m glad you called me tonight. With your symptoms of not being able to bear weight on your leg, you will need to be seen in an emergency room now. I’m concerned about your safety, and I want you to stay off your leg until you are seen by the emergency room doctor. The safest way for you to get help tonight is to call 911. Are you willing to call them right now?”
This statement lets Paula know the seriousness of her injury, your care advice, and your recommendations on where she needs to be seen and how to get there.
Your last question – “Are you willing to call them right now?” – is confirmation that Paula is willing to follow your plan.
Paula’s husband calls back later that evening and thanks you for encouraging her to go to the ER, as she has a hip fracture that will require surgery.
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