ASSESSMENT

The telephone triage process often begins with a rapid assessment to determine and prioritize how urgently the patient should be seen. The telenurse identifies and prioritizes the patient’s needs though “questioning, information interpretation, symptom review, and skillful assessment of the urgency and level of care necessary to safely and effectively meet the caller’s needs” (Mataxen & Webb, 2019).

This key contextual information can quickly identify high-risk patients or problems. This process, while appearing superficial, yields valuable information and often takes as little as 60 seconds.

Using critical-thinking skills, the nurse must quickly recognize when collection of more data is appropriate. In the case of a potential life-threatening, emergency situations such as loss of consciousness, head trauma, or chest pain, the nurse may quickly elicit key data and make a decision. But a case of vague abdominal pain requires gathering larger quantities of detailed information.

Rapid assessment and prioritization is referred to as a global assessment, intended to quickly recognize an emergent situation that requires aborting the formal assessment process and directing the caller to the emergency department (see “SAVED” below). However, most calls are not emergent and require eliciting an adequate symptom and patient history.

SCREENING FOR SUSPICIOUS CONDITIONS

Screening questions are used to quickly identify or rule out these suspicious conditions that require additional evaluation onsite:

  • Alcohol/substance abuse
  • Chronic disease
  • Dehydration
  • Domestic violence
  • Emotional problems
  • Exposure (toxins, new medication, adverse drug reaction)
  • Infection
  • Possible pregnancy
  • Possible early sepsis symptoms
  • Smoking
  • Suicide/emotional distress
  • Trauma

(Wheeler, 2017a)

The history-taking process begins by verifying the patient’s contact information (address and phone number). The nurse reminds the patient that this information is important in case the call is disconnected (especially since many patients’ only or primary phone is a cell phone, which can disconnect at a critical moment).

SAVED: Identifying High-Risk Patients and Symptoms

Quickly identifying and prioritizing high-risk situations is a critical skill in telephone triage. Research has identified several broad categories of high-risk (red flag) patients and symptoms, signified by the mnemonic SAVED.

SAVED
S Severe, strange, or suspicious symptoms
A Age
V Veracity
E Emotional state
D Debilitation and distance

These are “red flag” symptoms and populations that should raise suspicions and of which all clinicians should remain aware (Wheeler, 2009, 2013, 2017a).

Using this broad, global approach has several advantages. It supports clinical prioritization of patients and symptoms that are at high risk as a quick “first pass” in the assessment process. It expedites data collection and decision-making and quickly establishes acuity. In general, high-risk symptoms and patients with several risk factors must be treated more conservatively (i.e., by appointment rather than advice).

SEVERE, STRANGE, OR SUSPICIOUS SYMPTOMS

Severe pain (9 on scale of 10), severe bleeding (spurting, bright red), or severe trauma (falls from a height over 15 feet) are all conditions that the average layperson could identify as urgent. Strange symptoms include ill-structured, vague, atypical, or unusual presentations—symptoms that astute professionals typically recognize as urgent.

Sudden, unexpected, or new symptoms; recurrent symptoms; or a marked change in the patient’s condition all qualify as suspicious or strange. Also included as strange are symptoms that are atypical, novel, or silent presentations—often present in persons with compromised immune systems, such as older adults or young children.

Three descriptive methods can help establish acuity:

  • Compare current symptoms to normal ADLs (see also “ADLs” later in this course).
  • Quantify symptom severity. Measure symptoms in terms of numbers, frequency, size, or duration. For example, pain described as an 8, 9, or 10 on a scale of 1–10 (10 being the worst pain ever experienced) is quantitatively severe. Other examples of severe are:
    • Vaginal bleeding of more than one pad per hour (females)
    • Urine output less than one scantily wet diaper per eight hours (infants)
    • More than six to eight large, watery stools in eight hours
    • Swelling of wrist that is twice the size of a normal wrist
  • Qualify symptom severity. Qualitative severity refers to descriptive terms or characteristics that indicate extreme symptoms. A headache described as sudden, splitting, throbbing, blinding, or “the worst headache I’ve ever had” is considered qualitatively severe. Other examples are:
    • Crushing chest pain
    • Sudden, localized, sharp abdominal pain
    • Sudden onset, widespread, unusual rash
    • Intense itching, sudden onset
    • Severe difficulty breathing

Suspicious symptoms also apply to situations where the nurse has a “gut feeling” or an intuition about a problem. In such situations, if the nurse is uncomfortable with the guideline disposition, it is important to upgrade a problem or bring the patient in sooner.

SEVERE/STRANGE/SUSPICIOUS SYMPTOMS (INCLUDING SEPSIS)
(Wheeler, 2009, 2013, 2017a)
  • Severe pain, bleeding, trauma, diarrhea, vomiting, rash, etc.
  • In older adults, severe diarrhea or dehydration
  • Novel, atypical, unusual presentations (worst, new, sudden, unexpected, recurrent, silent)
  • “Big six” (head, chest, respiratory, abdominal, “flu,” dizziness); often missed/delayed diagnosis of stroke, myocardial infarction, pulmonary embolus, appendicitis, ectopic pregnancy

AGE

Age is one of the most important pieces of data obtained. The very young, very old, and women of childbearing age are typically regarded as high-risk populations. Due to immature immune systems, premature infants and those under 3 months of age are at highest risk. The “frail elderly” (anyone over 75 years of age or suffering from multiple or chronic diseases, functional disability, or psychosocial problems) are vulnerable due to failing immune responses. The childbearing years—always a high-risk period—may extend from age 11 to 60+ years.

Age information is typically readily available in the EMR. If the EMR is unavailable, always elicit and document the age; for infants and newborns, indicate in days, weeks, or months.

Some diseases are age-related. For example, women of reproductive age have a higher incidence of ectopic pregnancy, birth control side effects, and sexually transmitted infections. Extremes of age increase vulnerability to acute illnesses. All infants under 6 months (especially newborn and premature infants) as well as frail elderly are more vulnerable to infections and risks of sepsis.

A = AGE (HIGH-RISK POPULATIONS)
(Wheeler, 2009, 2013, 2017a)
  • All children, especially newborns; then under 3 months; then under 6 years
  • All older adults, especially frail elderly
  • Men over 35, women over 45 (in relation to cardiac symptoms)
  • All women of childbearing age
  • Teenagers who may be depressed (in relation to risk for suicide attempts)
  • Persons with intellectual and developmental disabilities (may experience accelerated aging)
CASE

An elderly man called the primary care nurse line, insisting on speaking with his doctor. The nurse responded that the doctor was on vacation until the following week. The nurse further inquired about the reason for the patient’s call, and the man stated that he was “probably fine and just needed to have his blood pressure checked.” As the nurse explored the patient’s symptoms further with more structured assessment questions about symptoms, severity, etc., she discovered that the patient had a history of high blood pressure and heart disease. Based on the assessment, the nurse recommended an urgent disposition to the ED.

Discussion

In this case, the patient may not have recognized his symptoms as serious; indeed, he may not have experienced anything that he would even have considered a symptom. In older adults, symptoms may be subtle or even silent. Perhaps, in this patient’s mind, he was simply calling to talk to his doctor, a trusted advisor, about the fact that he had been feeling tired.

If the nurse had not explored this patient’s symptoms further but simply arranged an appointment with the doctor for the next week, a delay in care may have ensued, and the patient could have suffered further damage to his heart.

VERACITY

Veracity refers to the ability to describe facts of the situation accurately. In the context of telephone triage, impaired veracity refers to the compromised ability to communicate accurately. Typical populations who have obstacles to communication include children under age 8, poor historians, extremely young or very inexperienced mothers, individuals with limited health literacy, or caregivers unfamiliar with the patient.

Information relayed through second or third parties (as with calls about children) may be incomplete or erroneous. A cardinal rule of thumb is “speak directly with the patient,” but this is not always possible. Third-party calls may occur when a working parent receives a report of the child’s condition from the onsite caregiver and then phones the telenurse. In the case of language barriers, using certified medical interpreters may improve communications but will double the length of the call.

These patients will likely require an appointment because communications are impaired and potentially inaccurate. A prudent policy is to see the patient in a timely fashion rather than to attempt to evaluate symptoms by phone. However, in all cases, it is important to attempt to ascertain if any emergency exists by performing a basic “rule-out” of urgency before advising an appointment.

V = VERACITY (IMPAIRED COMMUNICATION)
(Wheeler, 2009, 2013, 2017a)
  • Second- or third-party calls
  • Child under the age of 8
  • Extremely young or very inexperienced mother
  • Limited health literacy
  • Language barrier (best practice is to use a certified medical interpreter to translate rather than a family member)
  • In older adults:
    • Suspected adverse drug reaction/substance abuse/overmedication by caregiver (“chemical restraints”)
    • Incoherent or slurred speech in patient/caregiver
    • Caregiver unfamiliar with patient

EMOTIONAL STATE

Emotional status is a major factor in assessing acuity. Research on calls to emergency medical dispatchers found that when callers were extremely emotionally distraught and individuals were 50 years of age or older, 96% of the individuals were having a cardiac arrest (Clawson & Democoeur, 2020).

Nurses can discern subtle cues through careful attention to the words, tone, and pacing of the caller’s voice. There may be hysteria or denial, inappropriate affect in the caretaker or parent, confusion, or a history of psychiatric problems or substance abuse. Anxiety is always a red flag. When possible, telenurses attempt to gauge whether emotions are a temporary reaction to the current illness or long-standing emotional patterns. Call acuity is upgraded when extreme emotional reactions are present. In other words, if the symptoms indicate home care, the patient’s or caregiver’s emotional state may require a clinic appointment or urgent care visit.

It is important to ask how often and when the patient has called in the recent past. Frequent calls in a brief period of time are an indicator of both caller anxiety and may be an indicator of symptom urgency. Frequent calls are a red flag and indicate the patient should be seen urgently. Malpractice cases often involve encounters in which multiple phone calls were ignored, causing a delay in care (Wheeler, 2016, 2017a).

Documentation should include patient hostility or legal threats, inappropriate or extremes of affect, confusion, multiple phone calls, and patient statements of emotional state, to assure that calls are placed within the proper context and not disregarded.

E = EMOTIONAL STATE
(Wheeler, 2009, 2013, 2017a)
  • Multiple calls, anxiety
  • Hysteria or denial
  • Inappropriate affect in caretaker
  • Emotional distress
  • Parent or caretaker with history of abuse (e.g., physical, sexual, financial, emotional), psychiatric problems, or substance abuse

DEBILITATION AND DISTANCE

Generally, the term debilitation refers to chronic illness. Chronic illnesses may include (but are not limited to) cancer, diabetes, heart disease, hypertension, mental disorders, asthma, or chronic obstructive pulmonary disease (COPD). For the immunocompromised, debilitation may involve lack of adequate immunizations, chemotherapy, HIV, splenectomy, steroid therapy, transplants, or nephrotic syndrome. Debilitation is also related to risk of sepsis.

D = DEBILITATION AND DISTANCE
(Wheeler, 2009, 2013, 2017a)
  • Chronic illnesses (asthma, depression, diabetes, cancer, cardiac symptoms, congestive heart failure, COPD, dementia, hypertension, inflammatory bowel disease, kidney disease, liver disease, neurologic symptoms, rheumatologic disease, Sickle cell disease)
  • Smoking, substance abuse
  • Immunocompromised (chemotherapy, HIV/AIDS, nephritic syndrome, splenectomy, steroid therapy, transplant history)
  • Developmentally disabled (typically age prematurely)
  • Frail elderly (over 75 years; over 65 years with functional impairments, with physical or mental disabilities)
  • Parent/caretaker calling from remote location over one hour from hospital
  • Reliance on public transportation that is sporadic or nonexistent at certain hours
  • In emergent situation, patient unable to reach care within one hour due to traffic or lack of available transportation

Medically complex patients are defined as those with comorbidity of several medical conditions that significantly compromise the ability to function (IOM, 2015). Medically complex patients may require upgraded acuity. For example, “flu symptoms” might represent early sepsis symptoms in patients with HIV, cancer, hemophilia, congenital defects, alcoholism, substance use, or multiple surgeries. Homeless and mentally ill (including posttraumatic stress disorder) patients may have higher rates of chronic illness, as will those who are immunocompromised and frail elderly.

Telephone triage is “time sensitive”; time to treatment (distance) influences triage disposition and can affect continuity and result in a delay in care. A patient/caregiver calling from a remote location several hours from a hospital or patients who depend on public transportation to travel may be at risk for delays in care. Delays may be typical of rural areas but may also apply to urban settings where rush-hour gridlock may impede arrival. Upgrading by calling paramedic transport can have the advantage of bringing access to the patient, thereby reducing a delay in care.

To summarize:

  • Quickly prioritize by using the high-risk categories within SAVED on the documentation form.
  • Ask questions in any order, or simply let the caller tell their story at first.
  • Use open-ended questions where possible.
CASE

A spouse calls regarding her husband, age 65, who has a history of hypertension and smoking. His chief complaints are nausea, sweating, pallor, dizziness, and a “pulled muscle” after lifting weights. The wife is very worried and says her husband is “too sick to talk to the nurse.”

Discussion

The nurse recognizes red flags in all five SAVED categories:

  • Severe symptoms (chest pain, soft cardiac signs)
  • Age and gender (65-year-old male)
  • Veracity (second-party call)
  • Emotional state (worried wife)
  • Debilitation (chronic health risk, smoking history)

In this particular case (emergent symptoms), based on five criteria (as a form of standard), the nurse is able to determine that such a patient will require immediate transport to the nearest emergency department.

Elicit the Problem and Patient History

When a problem does not appear urgent, the telenurse performs a more detailed assessment of symptom and patient history. This begins by eliciting the patient’s primary reason for calling. A patient’s first utterances are very important, and the patient’s first few descriptions can be key to zeroing in on the problem. Information can be collected in any order that seems appropriate to the patient and the situation.

Obtaining a brief patient history creates context and an immediate sense of patient risk. It includes verifying recent injury or illness, chronic illness, current daily medications, pregnancy status, and drug allergies.

It is not necessary to let a standard data collection form dictate the order of collection. In real-world situations, people volunteer information initially. It is important to find a safe balance between listening to a patient’s explanation and communicating the need to gather information in a timely fashion. Data is recorded into the appropriate field as the patient volunteers information; any information gaps are filled in later with follow-up questions from the guideline.

Patients often present symptoms in erratic and disorganized ways. They may focus on one symptom to the exclusion of other, more important ones. An example might be the parent who is concerned about a child losing a tooth due to trauma, when the more serious problem is possible head injury. A critical step in data collection is to avoid being caught up in the patient’s perception and to initiate the triage process with assessment questions and the documentation form. The rationale is to quickly sketch an outline of the problem.

If protocols are used as part of the nurse’s process or workflow, selecting a protocol too quickly in the call can lead to inaccurate advice. The nurse should perform thorough assessments as a “first pass” to reduce the risk of jumping to conclusions. As uncomfortable as uncertainty may be, choosing a guideline prematurely may lead down the wrong path.

CASE

At 3 a.m. a mother called a pediatric nurse triage line regarding her 3-month-old infant, who had a fever of 103 °F. The nurse did not obtain a complete symptom history and gave the mother routine advice for fever control. The nurse then directed the mother to an ED that was in network for their insurance coverage about 45 minutes away. (The nearest ED was about 15 minutes away.) En route, the child experienced a cardiac arrest due to hypoperfusion syndrome and meningitis. Because of impaired circulation, the child’s hands and feet had to be amputated.

Discussion

In this case, the nurse should have performed a thorough assessment and directed the mother to bring her infant to the nearest ED.

PROBLEM-FOCUSED MNEMONICS

Researchers (Graversen et al., 2022; Gustafsson & Eriksson, 2021) have consistently pointed out the need to collect essential information related to the problem and patient histories. The mnemonic SCHOLAR lists key questions to elicit data on the problem history, and the mnemonic RAMP lists key information about the patient history.

USING SCHOLAR FOR ELICITING PROBLEM HISTORY
(Wheeler, 2009, 2013, 2017a)
S Symptoms and associated symptoms
  • Is it an isolated symptom or complex of symptoms?
  • Course of symptoms: Is it better? Worse? The same?
C Characteristics (aids in precise description)
  • Quantitative (e.g., scale from 1–10)
  • Qualitative (e.g., sharp, dull, pounding)
H History of complaint
  • In the past, what was done? By whom? When? What were the results?
O Onset of symptoms
  • When did they start? How long have they been present?
  • Was the onset sudden or gradual? (sudden = higher acuity)
L Location of symptoms (strive for precision, e.g., right upper quadrant, left lower quadrant, etc.)
  • Localized?
  • Generalized?
  • Radiation?
A Aggravating factors
  • What activity, foods, positions, etc., make it worse?
R Relieving factors
  • What activity, foods, home treatment, positions, etc., make it better?
USING RAMP FOR ELICITING PATIENT HISTORY
(Wheeler, 2009, 2013, 2017a)
R Recent
  • Injury
  • Infection
  • Illness
  • Invasive (post-procedure, postoperative, postpartum)
  • Implant
  • International travel
  • Immunocompromised (chemotherapy, HIV/AIDS, nephrotic syndrome, splenectomy, steroid therapy, transplant)
  • Ingestion (accidental or intentional ingestion/exposure, adverse drug reaction, new medication, drug-disease / drug-drug / drug-food interaction)
A Allergies Any exposure to foods, chemicals, drugs, insect bites, cosmetics, or other substance (new or existing)?
M Medications Current or new over-the-counter, prescription, birth control, or recreational drugs?
P Pregnancy / breastfeeding For all women 12 to 50 years of age, any possibility of pregnancy or unprotected intercourse?

The mnemonic POSHPATE may also be used in the assessment of a symptom-based call to obtain detailed information about the problem and to determine the appropriate level of care and provide appropriate advice (Rutenberg & Greenberg, 2012).

USING POSHPATE FOR ELICITING PROBLEM HISTORY
(Rutenberg & Greenberg, 2012)
P Problem
  • What is the patient’s main problem or chief complain?
O Onset
  • How long has the patient had this problem, or when did it start?
  • Was it a gradual onset or sudden?
S Symptoms
  • Allow the patient to talk freely about what they are experiencing
  • Ask open-ended questions
H History
  • Has the patient been ill or seen a care provider recently?
  • Are symptoms related to recent care (e.g., new medication, treatment, procedure)?
  • Is the problem old, ongoing, or new?
  • Has the patient/family called for advice about this same problem?
P Precipitating Factors
  • Can any particular circumstances be identified that precipitated the problem?
A Alleviating or Aggravating Factors
  • What treatments has the patient tried?
  • What interventions make symptoms reduced or eliminated?
  • What actions/activities make the symptoms worse?
T Timing
  • Are symptoms specific to a time of day or particular day?
  • Are symptoms annual or seasonal?
  • If patient is female, are symptoms linked to a menstrual cycle?
E Etiology
  • What are the potential causes or contributing factors?

After completing the assessment using the POSHPATE approach, the nurse then delves into the possible etiologies of the problem in order to determine the nature and urgency of the problem with greater accuracy.

The mnemonic TICOSMO helps the nurse tap into their existing knowledge (Rutenberg & Greenberg, 2012).

USING TICOSMO FOR CLINICAL REASONING
(Rutenberg & Greenberg, 2012)
T Trauma
  • Did an injury occur?
  • Any sort of trauma?
  • Work-related injury?
I Infection
  • Is an infection possible?
  • Fever?
  • Localized signs and symptoms of an infection?
  • Exposure?
C Chemical
  • Is a chemical exposure a possibility?
  • Occupational hazards?
  • Household chemicals?
  • Prescription medications?
  • Alcohol or illicit drugs?
  • Lethal gases (e.g., carbon monoxide)?
  • Herbals or homeopathic products?
  • Endogenous chemicals (e.g., insulin, thyroid hormones)?
  • Electrolyte imbalances?
O Organ
  • What organ or system could be involved?
S Stress
  • Is there a possibility that stress is contributing to the problem?
M Musculoskeletal
  • Is there a potential musculoskeletal issue?
  • Localized or generalized?
O Other
  • Is there anything else that needs to be considered?
  • Allows for consideration and query of the unique and obscure possibilities.

Activities of Daily Living (ADLs)

Although a systematic approach in an assessment is highly effective in obtaining accurate information, there are times when the symptom presentations are vague, incoherent, or nearly absent. When this occurs, a clear picture of the current situation is difficult to discern, and determination of degree of illness or impairment may be a challenge. In these cases, inquiring about activities of daily living can be an effective approach to determine the urgency of the situation.

Determining what a typical day is for the individual who is experiencing the symptoms and then comparing to current level of activity brings clarity to the situation. Comparing current ADLs with baseline ADLs provides a mental image of how ill a patient might be now. This includes asking how the patient is functioning compared to their normal routines in the areas of eating, drinking, sleeping, playing, working, eliminating (urine output and bowel movements), general appearance, and demeanor. A second party (such as a parent or caregiver) can also evaluate this baseline state. Activities of daily living provide a concrete picture of the patient when other data are sketchy.

Questions such as the following can be adapted for all ages and involve comparing current level of activity to the patient’s baseline:

  • Is the newborn sleeping/feeding as usual?
  • Is the child playing?
  • Has the school-age child been able to keep up with extracurricular activities (e.g., sports, dance)
  • Is the teen texting?
  • Has the individual been able to go to work?
  • Has the older adult been able to leave their home?
USING ADLs FOR BASELINE COMPARISON
(Wheeler, 2013, 2009, 2017a)
Intake Fluids, food
Output Urine, emesis, bowel movements, diaphoresis (quantity and quality)
Sleeping Too much, too little
Activity level Compared to normal activity levels or routines
Mood Marked change (any)
Color Pale, red, blue, grey, ashen
Skin Turgor; lips/tongue

For newborns, infants, older adults, aphasics, extremely poor historians, or severely disabled patients, the mnemonic A DEMERIT can also be used to assess demeanor/mood.

USING A DEMERIT TO ASSESS DEMEANOR/MOOD
(Wheeler, 2013, 2009, 2017a)
A Any extreme behavior (irritability, inactivity, disengagement, inconsolable crying)
D Difficult to awaken or keep awake
E Expression (decreased)
M Movement (little or no spontaneous movement on own)
E Eye contact/focus decreased
R Recognition of caregiver/parent (decreased)
I Interactivity (decreased)
T Talking (decreased)

Pain Assessment

Pain—a common presenting symptom—requires patient self-assessment. The telenurse instructs patients how to use landmarks to identify the location of pain (e.g., in relation to nipples, sternum, umbilicus, and pelvic bones). The analogy of a clock is helpful to estimate the location of a foreign body in the eye, abdominal pain, or lump in the breast. Pain may be diffuse or localized. If the patient can point with one finger to the location, it may indicate localized pain (thought to be more serious), whereas if they cannot, it may indicate diffuse pain (thought to be less serious). Sudden onset of pain is thought to be more serious than gradual onset.

If patients cannot adequately relate the severity of their pain, another way to estimate pain intensity is to systematically ask about its effect on their ability to function as normal or perform ADLs. If pain is moderately impactful, it will require a same-day appointment.

Sepsis Recognition

With high-risk or any sick patient, the clinician remains suspicious for the often subtle symptoms of sepsis. This includes performing early sepsis recognition by taking into account contextual details that are associated with sepsis—previous (any chronic illness) and recent medical history (recent injury, infection, invasive procedure, implant, immunocompromised, international travel). This information can be combined with age and current symptoms to form a pattern of risk.

Early sepsis recognition can be made using the mnemonics SAVED, RAMP, and SEPSIS. (See also “Pediatric Sepsis and Dehydration Guidelines” below.)

USING SEPSIS
(Bradford, 2016)
S Shivering, fever, or feeling very cold
E Extreme pain or general discomfort
P Pale or discolored skin
S Sleepy, difficult to rouse, confused
I “I feel like I might die”
S Shortness of breath

Assessing by Proxy

Unless telehealth and biotelemetry (measuring physiologic functions from a distance by telemeter) are available, telephone triage clinicians must enlist the aid of patients to assess by proxy. Traditionally, clinicians use vision, touch, hearing, and smell to assess symptoms. In telephone triage, the patient must serve as eyes, ears, nose, and hands to the clinician, who elicits data. (Auscultation by phone—gross respirations, emotional tenor, speech patterns, background sounds—is sometimes feasible.)

Methods available to gather information by proxy include:

  • A visual assessment of a possible fracture can include comparing extremities (fingers, hands, feet, ankles) for swelling, discoloration, or deformity (e.g., “How do your two wrists compare to each other?”).
  • Tactile information can be elicited (e.g., “Touch the area and tell me what happens. Is there tenderness in one particular area?”).
  • In the case of a possible chemical ingestion, olfactory data can be elicited (e.g., “What does the child’s breath smell like?”).

With some exceptions, patients are subject to many of the same cognitive errors as clinicians: stereotyping, inadequate data collection, erroneous self-diagnosis, over-reacting, under-reacting, and fatigue. It is important to alert patients to these possibilities (e.g., “Is there a chance that you might be underestimating your symptoms?”).

SELF-ASSESSMENT TECHNIQUES

To assess for a range of specific symptoms or functions, patients can be asked to follow these actions and describe the results:

  • Blanching rash: Press area for 2 seconds.
  • Circulation: Squeeze finger between finger and thumb for 2 seconds. Release.
  • Costochondritis pain: Press with one finger on area of chest that hurts.
  • Dehydration: Pinch skin over top of hand for 5 seconds and release.
  • Fetal activity: Count the number of kicks in 30 minutes at a time when the baby is normally active.
  • Level of consciousness: Press down firmly on nail bed with thumb.
  • Pitting edema: Press firmly on the bony area of the ankle for 1 to 2 seconds.
  • Point tenderness: Gently press along length of bone to locate injury.
  • Postural hypotension: Cautiously rise from sitting to standing (perform only with another adult present).
  • Pulse: Gently place four fingers in groove alongside of “Adam’s apple” or place finger on thumb-side of wrist. (Tell patient when to start counting; time pulse for 1 minute.)
  • Respirations: Remove the shirt and observe chest movement, counting each time the chest rises. (Tell patient when to start counting; time respirations for 1 minute.)
  • Tenderness to touch: Touch the area.
  • Weight-bearing ability: Cautiously attempt to stand, then cautiously attempt to bear weight or walk on the affected limb with an adult nearby.
    (Wheeler, 2013, 2017a)