Vous êtes sur la page 1sur 22

Triage Checklist

Obtain pt name/DOB
Have pt change into gown
Obtain clean catch urine sample
Arrive pt into Epic (O2)
Device select monitor
Admit pt into Obix
Place OB Triage Order
Obtain/Review Prenatal Records
Print/Place ID bands (pt and allergy)
Print labels
Complete urine dipstick
Complete Patient Profile: Important to first ask
about ROM, fetal movement, contractions, and
bleeding.
Assessment (w/in 10 min of arrival)
Assess heart tones w/in 10 min of arrival
Notify doctor
New pt education assessment/teaching
Care plan

Triage Charting

Profile
Assessment
Confirm vitals (must have vitals w/in 30 min of
DC)
Heart tones
Care Plan (Discharge care plan)
Education
D/C tab under L&D (ask when follow up appt.)

Krames Teaching for D/C


Pt>37 weeks: Recognizing Labor, Kick
Counts, Benefits of Breastfeeding, Delivery
Prep sheet (add whatever other teaching pt
needs - i.e. medications, condition specific
Pt<37 weeks: Understanding Preterm Labor,
Kick Counts, Benefits of Breastfeeding (add
whatever other teaching pt needs - i.e. medications, conditions specific

Triage Vital Signs


Upon Admission to triage:

Assess and document routine vital signs which include


HR, BP, RR, SpO2, and pain.
Obtain temp at admission and q1hr if febrile
Assess and document Pulse, BP, SpO2, & RR q1hr
Notify physician and assess V/S q15min x1 hour if any
of the following are met:
Pulse > 120
SBP < 80, > 140
DBP < 50, > 90
RR > 20
SpO2 < 95%

Triage Fetal Heart Tone


Assessment

Assess FHR w/in 10 min of pt arrival to unit. Follow guidelines for gestational age:
< 20 weeks - doppler FHR upon presentation
20-24 weeks - attempt to obtain 20 min of continuous monitoring. If unable, notify physician
and doppler FHR upon presentation is this
right? 20-24 weeks?
> 24 weeks - obtain 20 min of continuous fetal
monitoring
If we have never seen the pt, obtain 40 min of continuous fetal monitoring
If pt has category I strip, absent vaginal bleeding,
and apparent latent phase of labor, switch to intermittent monitoring or auscultation. Allow pt to
walk as appropriate between sessions.
Category II Strip: Notify Physician and obtain order for auscultation , continuous or intermittent
fetal monitoring
Category III Strip: Notify physician immediately
and prepare patient for possible expedited delivery

Triage Notes:

Make sure to place OB Triage order - Indicate Pregnancy as reason for admission

Make sure to order NST and complete NST


form, if applicable.
Have the resident sign off the NST
before pt is discharged.

If urine drug screen is necessary:


Obtain and document verbal consent
for UDS

Triage
Common Triage Pt complaints:
R/O Labor
R/O PTL
R/O ROM
R/O Preeclampsia
Decrease Fetal Movement
Pelvic Pain
Special Notes for consideration
If you are unsure of pt history, have no prenatal
records, or are suspicious, ask for order to send
a UDS. However, you must get permission
from the pt to send the UDS, and you need to
document that the pt gave you permission in a
note.
Always remember OB Triage Order.
Urine dipsticks are very important. Please
document urine dipstick results on all patients.
This could help us identify a preeclamptic pt
early on.

Triage Cont.
Special Notes for consideration Cont.

Dont be afraid to make suggestions to the residents about sending labs. Better to suggest
sending them early, rather than waiting until
the pt has been here for two hours, then sending labs.

For any pt complaining of vaginal bleeding: Do


NOT perform a SVE until you verify there is
not previa.

DO NOT perform SVE on preterm pts unless


you are the only person on the floor and it is
ABSOLUTELY necessary.

DO NOT perform SVE on: bleeding, preterm,


or R/O rupture

Swab and Culture Info Cont.:


Amnisure ROM
To be used if other methods of ruling out ROM are
inconclusive
Supplies: Amnisure packet
1)
2)
3)
4)

Physician will swab for 1 minute to collect sample


RN will swish swab in the solution for 1 minute
Remove swab and throw away
Label specimen and send to lab.

**Call and alert lab that the swab is coming. The test
must run w/in 15 min of collection for accurate results**
*Results are not affected by blood, semen, or urine

Swab and Cultures:


FFN - Fetal Fibronectin
MUST be collected before anything else is placed in
the vagina
Supplies: FFN packet (swab & tube)

The physician will swab under SSE for 10 seconds,


put swab in container, break off, cap tube, label,
send to lab
May have false + if anything has been in the vagina over the past 48 hours. May have false + with
urine, blood, or vaginal mucous
Done for 24-34 weeks gestation

Swab and Culture Info Cont.:


GBS
Supplies: White Culture Collect Swab

Swab around the vagina and then down to the rectum. Place swab into container and snap the lid in
place. Label and Send

Swab and Culture Info Cont.:


Gonorrhea/Chlamydia
Supplies: Orange top tube Gonorrhea/Chlamydia
packet - use applicator in package

The physician will swab under SSE. They will use


1 swab and place it into the orange top vial. Make
sure the lid is screwed onto the vial tightly. Label
and send.

**Gonorrhea and Chlamydia are two separate orders make sure you put in both orders when sending down
this specimen

Swab and Cultures:


Nitrazine
Tests for the pH in vaginal fluids. Tests for Rupture of
Membranes
Supplies: Nitrazine swab

PH indicator on nitrazine swab will change color


with the presence of amniotic fluid
Green - Black indicates presence of amniotic fluid
Yellow - Orange indicates absence of amniotic
fluid
Equivocal is not an acceptable result per manufacturer
Avoid blood, urine, and cervical mucus - these
may result in a false positive reading

R/O Labor

What is gestational age? How were dates determined? Does she have a prenatal care provider?
Assess FHR and contraction pattern
Is she high risk?
Does she look uncomfortable?
Is she ruptured?
Is there vaginal bleeding?
Have resident examine pt, or ask if they want you
to check pt
Follow orders given
Probable cultures
GBS (if not available)
Wet prep if any signs of infection/abnormal
discharge
Nitrazine if any report of loss of fluid

R/O Pre-Term Labor


What is the pt gestational age? How were dates
determined? Does she have a prenatal care provider?
DO NOT check a preterm pt!! (Unless absolutely
necessary). Get DRs
Assure that she has had nothing in her vagina for
24 hrs (intercourse, digital exam, etc.) Have physician perform SVE (No gel on speculum). The first
swab will be FFN.
Prepare supplies:
Speculum
Flashlight
Sterile gloves
Swabs/cultures (see below)
FFN
Wet Prep
GC/Chlamydia
GBS
Assess FHT and contraction pattern
Follow orders as given
Mag is used for CP ppx, not to stop labor

R/O Rupture

Dont check your patient


Assess for visible fluid
Is she contracting? Is she bleeding? How long has
she been ruptured? What color is the fluid? Any
odor?
Assess FHR and contraction pattern
Follow orders given
Prepare for SVE
Speculum
Flashlight
Sterile gloves
Swabs/cultures (see below)
FFN
Look for Pooling
Amniswab, Smear Amniswab on slide and give
to resident to assess for ferning under microscope
Amnisure needed?
GC/Chlamydia
Wet Prep

R/O Preeclampsia

Apply EFM and assess vital signs


Test for clonus and DTRs
Labs: CBC, CMP, LDH, Uric acid, Clotting Factors, U/A, Protein Creatinine Ratio
Supplies needed: Straight Cath, purple top lab
tube, mint top lab tube
If pt has treatable pressures (systolic over 160/
diastolic over 105), get IV access immediately.
Potential IV meds: Hydralazine, Labetalol,
Magnesium
Foley if starting Magnesium
Order pumps immediately if starting Mag.

NEVER start Mag w/o a pump!!!!

Decreased Fetal Movement

Place pt on monitor ASAP


If no FHR, ask resident to verify FHR via ultrasound
If positive FHT, obtain NST
Highly consider BPP, especially if pt is close to
term

Complaint of Pelvic Pain

Clean catch urine w/ dip. If absolutely normal,


straight cath with U/A & C&S
What is GA?
If term, contractions?
If preterm, round ligament pain? Pain with movement? Pre-term labor?
UTI: Itching/Burning? Pain or burning with urination?
Other infection: abnormal discharge? Pain/
burning?
PTL: Contractions? Dehydration? Infection?
Is there any vaginal bleeding? Abruptions/previa?
Monitor FHR and contraction pattern
Cultures:
FFN if PTL is suspected
Amniswab if ANY report of fluid loss
Wet Prep
GC/Chlamydia
GBS if appropriate

Triage:
Pt w/ abdominal trauma

Initiate peripheral IV

Obtain the following labs:


FDPFibrin Deg. Products
Kleihauer Betke Fetal HGB ST (KB) - purple
top tube

Saline lock IV

Notify physician

ADD that we need 4 hours CEFM after


trauma? Is that right?

Triage:
Pt w/ BP above SBP>140 or DBP>90

Initiate peripheral IV
Obtain the following labs
CBC w/ diff
CMP
Uric Acid
LDH
ALT (in CMP)
AST (in CMP)
UA - straight cath sample
Spot CheckUrine Protein/Creatinine Ratio
Saline lock IV
Notify physician

Need straight cath, purple top tube, mint top tube

Triage:
Pt w/ dysuria

Obtain the following labs:


U/A and urine culture/sensitivity per straight
cath
CBC w/ diff

Notify physician

Triage:
Pt w/ large vaginal bleeding

Initiate peripheral IV
Obtain the following labs:
Protime (PT)
INR
PTT (APTT)
Fibrinogen
FDPFibrin Deg. Productions
Kleihauer Betke Fetal HGB ST (KB) purple
top tube
Type and Screen
Urine drug screen
Saline lock IV
Notify physician
Possibly an H&H and CMP, also but these 2 labs
are not included under the triage protocol.