Triage Nurse Case Study: Protocol and Disposition for a Crying Newborn

As most people know, a nurse triage line is an important resource to help parents navigate early childhood.  Still, it is sometimes difficult for parents to understand when calling a triage nurse is necessary for the safety of their children. In this article, we detail a case study for a call during the evening shift from a concerned mother for her 6-week-old baby. Her child has been inconsolable most of the day and the mother needs to know her next step. Using the 10 Critical Steps in a triage call process, we illustrate how a triage nurse will handle the case of the mother and her child to determine the best path to care. 

The ten critical steps include the nurse introducing herself, collecting demographic information, collecting a brief patient medical history, letting the patient talk, documenting an assessment, choosing the correct protocol, getting the patient to the appropriate level of care, giving relevant care advice, ensuring the patient knows when to call back, and offering reassurance while confirming the patient is able and willing to follow the discussed plan.

In this case, the nurse is working the evening telephone triage shift. The first call of the evening is from a mother with a 6-week-old baby, Laura. The nurse begins the call by introducing herself and verifying the patient’s demographic information. Laura has been crying more than usual since six a.m., and her mother goes as far as to say that Laura is inconsolable for about an hour at a time. When the nurse takes the call, it is about 5:30pm, and the mother is worried about going through the night with Laura’s symptoms, which appear to be getting worse.

After the nurse confirms that Laura is stable, she asks a few questions about her past medical history. By asking the right questions, the nurse finds that Laura was a full term infant, has no chronic conditions, no allergies, and is not taking any medications. Her birth weight was six pounds, and she weighed in at 7 pounds, 2 ounces at her four week check up.

After that, it is the mother’s turn to talk. The nurse asks her open-ended questions, such as “Tell me what’s going on today.”

Mom tells the nurse that Laura’s crying is getting louder, more frequent, and for longer periods of time as the day goes on. Mom also says that there is something white and sharp sticking out of Laura’s mouth on the right side. Laura is irritable unless a bottle is in her mouth, but she is feeding well, does not have a fever, and mom has not given her anything for pain. Laura has passed two normal bowel movements, and mom has changed seven wet diapers — both of which are normal for Laura.

The nurse enters all of the caller’s information into a brief, concise note in our   center software. With this information, the nurse has enough information on the symptoms to understand why Laura’s mom called the triage nurse. The nurse selects the best Schmitt-Thompson protocols based on the symptoms presented. In this case, the nurse will address Laura’s new onset of crying fits, as it is most likely to have the highest acuity.

The nurse will enter a keyword “crying” and a protocol will be suggested for treatment recommendation. The nurse will use her critical thinking skills to identify the worst-case and best-case scenarios for the case before assigning a disposition. After the most extreme cases are ruled out, the nurse will go through secondary scenarios that are less extreme.  

The nurse decides that Laura’s symptoms, while not urgent, will need attention from a pediatrician. The nurse will give Laura’s mom instructions to schedule an appointment plan for the next few days, and will page the on-call physician.

Our triage nurses use the Schmitt-Thompson protocols to address patient symptoms. The top five symptoms that infants, 17 weeks to one year, were told to go to the ER or urgent care were cough, vomiting (with or without diarrhea), wheezing (non-asthma), and head injury. The symptoms that lead to newborns being directed to the ER or urgent care were slightly different. They included fever, acting sick, crying, head injury, and vomiting without diarrhea. These symptoms could be due to something as simple as a common cold or something life-threatening that needs immediate professional attention.  Our triage nurses do a thorough assessment in conjunction with standardized protocols to direct the parent to the best next steps to take. We will be elaborating on the different conditions that could be present with these symptoms in future blogs to help office nurses guide parents.


Telephone nurse triage is a perfect bridge to provide 24/7 access for patients and parents to ask questions without adding a significant burden for the doctors. In addition, parents are sometimes more comfortable calling a nurse because they feel that they can call the nurse even if the symptom doesn’t seem life-threatening. Triage nurses are trained to provide comfort and evaluate if a symptom even requires a doctor visit. Using the telephone triage service can either save a family from needlessly going to the ER or urgent care, or ensure that the patient seeks immediate care in order to prevent further complications.   Click here for a 30 day free access to the full spectrum of telephone nurse triage protocols software.

Contact us today to set up a nurse triage system for your patients. We will discuss your needs and set up a customized plan that works best for your organization and your patients.

Learning Center: courses and videos, learn more about telephone triage

Download E-Book “Revolutionizing Care – Technology and Telehealth Nurses in Remote Patient Care”

Download E-Book “A Provider’s Guide To Remote Patient Monitoring”

Download E-Book “Telehealth Trends During COVID-19”

DOWNLOAD E-BOOK “Telephone Nurse Triage Handbook”