Resident Condition Change: Should I Call 911?
Article Outline
- Abstract
- Background
- SPICES: An Ounce of Prevention
- Case Study Utilizing SPICES
- FANCAPES: Including DELIRIUM, PQRST, and COLDSPA
- Case Study with FANCAPES
- When Should I Call the Doctor, Nurse Practitioner, or 911?
- Communication
- Transfer Information
- Conclusion and Summary
- References
- Biography
- Copyright
Identifiers of illness, including catastrophic change, are based on a set of assumptions that are not always true or accurate for older adults. Atypical findings in combination with the more subtle or different presentation of illness can result in missed opportunities for early treatment and prevention of more dire consequences. Assessment instruments described in this article can guide the investigation and communication of a resident’s change in status: SPICES (Sleep; Problems with Eating and Feeding; Incontinence; Confusion; Evidence of Falls; Skin Breakdown), FANCAPES (Fluid; Aeration; Nutrition; Cognition/Communication; Activity/Abilities; Pain; Elimination; Skin/Socialization), DELIRIUM (Drug use: Electrolyte imbalance; Lack of scheduled meds; Infection; Reduced sensory input; Intracranial problems; Urinary problems; Myocardial problems), PQRST (Provokes/Palliates; Quality/Quantity; Region/Radiates; Severity; Timing) and COLDSPA (Character; Onset; Location; Duration; Severity; Pattern; Associated Symptoms), (for pain assessment). “Should I call?” scenarios are described using case studies. A systematic approach to assessment, recognition of change in functional status, protocols to guide calling for emergency assistance, and structured communication are essential elements of early recognition of illness, can reduce caregiver anxiety, and improve the health care outcomes for the resident.
Imagine you or one of your staff standing in the dining room of your residence and looking at the residents for whose health and well-being you are responsible. Could you spot someone who was not doing well? Who might be ailing? If you saw 2 residents who looked ill, whom would you assess first? How would you decide?
Identification of illness, including catastrophic change, is based on a set of assumptions that are not always true for older adults and can result in a set of findings that does not fit with our conventional understanding and knowledge of illness presentation. All too often, these atypical findings in combination with the more subtle presentation of illness in older adults results in missed opportunities for early treatment. A systematic approach to assessment, recognition of change, protocols to guide calling for emergency assistance, and communication with other health care providers are essential elements of early recognition of illness that can decrease health care provider anxiety and improve outcomes.
This article describes 2 evidence-based assessment instruments: the SPICES tool, which should be used routinely as a first-line method for recognizing change and preventing deepening complications or acute illness, and the FANCAPES tool, which evaluates change in condition. In addition, several acronyms that can guide symptom assessment are provided. Immediately life-threatening conditions and 3 “don’t miss” signs of emergencies are discussed, as are nursing interventions for the geriatric emergency. “Should I call?” scenarios are presented in a table that includes common signs and symptoms and recommended nursing actions of who to call. Two case studies illustrate the assessment instruments and analysis of data. Basic information that should be included in a transfer document is described. The article includes a communication model known as SBAR (Situation, Background, Assessment, Recommendation) that can be implemented and used by all staff of the assisted living residence.
Ethel Mitty
Sandi Flores
Background
The first sign of illness in older adults is often a subtle change in cognition, function, or both. This across-the-room assessment is often described by experienced nurses and nursing assistants as “something is just not right.” Concern may be triggered by a usually meticulously well-dressed resident coming to breakfast looking disheveled or someone who is active suddenly unable to ambulate independently to the dining room. Knowing that the most susceptible and likely areas of illness presentation in the elderly are the neurological (brain), genitourinary (bladder), and musculoskeletal systems reinforces the need to investigate even small changes.1, 2
Vital signs are a first source of information regarding life-threatening problems.3 Potential airway compromise due to foreign body obstruction can present as stridor. Severe respiratory distress is signaled by a respiratory rate <10 or >29, oxygen saturations <93%, or both, with no history of chronic obstructive pulmonary disease (COPD).4 Classic clinical signs of shock are a pulse rate of <50 or >120 or a systolic blood pressure less than 90 mm Hg (or both).2 Yet presentation of acute illness in the older adult is rarely so clearly defined as these parameters. Depending on the resident’s baseline chronic illness(es), these vital signs may not be signs of acute illness. Two evidence-based tools for geriatric assessment, SPICES and FANCAPES, guide the investigation of a resident’s change in status.
SPICES: An Ounce of Prevention
The SPICES tool is an overall assessment tool that should be used routinely with older adults.5 It is based on the scientific evidence that normal aging is associated with irreversible physiologic changes that predispose the older adult to increased risk or hardship in maintaining health, wellness, and the ability to continue their pursuit and enjoyment of goals and interests (i.e., their quality of life). How often SPICES should be “used” might depend on the resident’s illness history, including current conditions and stage of illness (e.g., think of COPD trajectory) and the ability of the resident to describe himself or herself as “not feeling well.” Familiarity with the commonly occurring disorders that constitute the SPICES instrument can help prevent avoidable challenges to the older adult’s well-being and can focus nursing interventions.
SPICES is an acronym for the most common syndromes afflicting older adults:
The SPICES instrument continues to be used extensively in acute care, in some cases with additional letters added to the acronym for other syndromes. Depending on the characteristics of your resident population, it may be helpful to add or modify letters. For example, you might want to change it to SPICIEST wherein the second “I” stands for Infection (important for the resident with diabetes mellitus or HIV) and the “T” might be for “tenderness or pain” – a major comfort and quality-of-life issue for older adults.
Probing questions associated with each SPICES letter can be revealing. For example, an older adult female who denies incontinence says that she gets short of breath when going to the bathroom at night. What does one make of this information? Should we be as concerned about dyspnea on exertion as about nocturia? The psychometrics of SPICES (i.e., its reliability and validity) have not been reported; however, the instrument has great value and utility for both healthy and frail older adults. In long-term care, such as assisted living, SPICES is an “alert system” that can be used by personal care staff followed by a complete assessment of triggered conditions or suspicious happenings. The Resources section (Box 1) of this article identifies the location of a free video on how to administer the SPICES assessment; it is recommended viewing.
Resources: Assessment Instruments
Data from reference.13
Case Study Utilizing SPICES
Ms. J is a mildly confused at baseline, 83-year-old assisted living resident whose personal care assistant, after helping her with bathing and getting dressed as per her usual routine, comes to you and describes Ms. J as being “different.” She was slightly more confused than usual, said she was too tired to bathe, complained of increased back pain, and slept intermittently in her chair throughout the night. You go to Ms. J’s room and find her sitting in her chair in no obvious distress but telling you that she was “not feeling well.” She is more confused and states that her back hurts more today than usual and that she is tired. When asked why she didn’t go to bed, she says it was “too uncomfortable.” Ms. J denies shortness of breath, chest pain, and has no cardiac history; her breathing is even and unlabored. When asked, Ms. J says, “everything is fine; I’m just feeling a little down.” It is at this point that the SPICES tool is used to probe into “Ms. J is different.”
Sleep: Ms. J did not sleep well last night, which is unusual for her. An aspirin did not relieve her back pain. Asked why she slept in her chair, Ms. J said that it kept her from coughing—something else that was new. The cough was nonproductive; Ms. J denied feeling ill and said that the coughing seemed to “just come on.”
Problems with Eating and Feeding: Ms. J normally eats well if the food is cut into small pieces and is fairly soft. Ms. J has not eaten breakfast or lunch because her “stomach is upset.” She described a gradual onset of nausea that did not get worse, but said, “Boy, I couldn’t eat a thing.” Nothing made it better or worse.
Incontinence: Ms. J denies changes in her bowel or bladder pattern, and the care assistant confirms this. However, she had an episode of urinary incontinence the previous night when she attempted to make it to the bathroom but was hampered in doing so because it was “hard” to get out of the chair.
Confusion: Ms. J denied confusion: “I’m a little off, but not confused.” However, her care assistant emphatically states that something is different: “She is usually sharp as a tack.” Ms. J was alert to person and place but not time. This is a change from her baseline impairment, which includes difficulty with new names, planning for trips, and managing her finances. It was noteworthy that she kept going off track during the assessment and talking about things that did not appear to be relevant to the situation “I’m not eating, but I’m not really a fan of pumpkin pie anyway—did we have pumpkin pie last night?” Redirection would bring her back, but she would quickly go off track again. An evidence-based tool for identifying acute confusion that may be useful here is the Confusion Assessment Method (CAM). (See the Resources section in Box 1.)
Evidence of Falls: There is no evidence of falls on physical examination. Ms. J denied falling, and there is no documentation of her needing assistance to get up from the floor or ground.
Skin Breakdown: Ms. J denies sores and has no history of skin breakdown problems. This portion of the assessment is an opportunity to do a brief physical assessment. She appears slightly pale; skin and mucous membranes are dry; no stomatitis or thrush is found on examination. Although she denied being short of breath the night before, she is notably short of breath even with limited movement. Pulse: regular sinus rhythm, strong. Peripheral pulses: intact, though weak. Range of motion: full.
Based on the SPICES assessment findings, what decision would you make regarding emergency room transfer or contacting a physician? How could the information from the SPICES assessment be helpful in clarifying your concerns about Ms. J? What follow-up questions might you like to ask?
FANCAPES: Including DELIRIUM, PQRST, and COLDSPA
The 3 “can’t miss” signs of emergencies – delirium, pain, and falls – require effective and efficient assessment and communication.
The FANCAPES assessment tool1 should be used when there appears to be an actual problem or something is brewing—something is wrong, but what exactly is wrong is unclear. Developed in acute care but appropriate for long-term care, the FANCAPES acronym is as follows:
Assessment does not conclude with simply stating the finding. Each finding or data bit has to be followed up with key considerations for further investigation as discussed below.
Fluid: In addition to hydration assessment (orthostatic vital signs, appearance of mucous membranes, and presence of dry skin), this is an opportunity to consider common vascular system emergencies such as shock, acute coronary syndrome (ACS), and anemia. A first sign of shock may be narrowing pulse pressures: from 160/80 to 144/94 to 132/110. Congestive heart failure was the first sign of ACS in 20% of older adults presenting with cardiac symptoms. Despite electrocardiogram evidence of prior myocardial infarction, 38%–60% of elderly patients did not report a history of an acute episodic event.6 The Merck Manual of Geriatrics (2007) identifies chest pain as the primary symptom about which older adults will seek treatment, but in many cases the only symptoms of ACS are dyspnea, gastrointestinal problems (epigastric distress, nausea, vomiting, and heartburn), and neurological changes.7 Residents presenting with these symptoms require special attention immediately.
Aeration: A respiratory rate (i.e., aeration) of >20 for at least 1 hour is indicative of probable pneumonia.4 Even without the ability to listen to breath sounds (i.e., auscultation), what is heard simply by standing close to the resident? Is he or she in pain and unable to take a deep breath? Is breathing noisy? Moist?
Nutrition: Nutrition includes assessment of the oral cavity (e.g., for thrush, xerostomia), as well as overall nutritional status. Albumin level is a key indicator of adequacy of nutritional intake: <3.5 g/dL is associated with fluid shift, decreased bioavailability of certain medications such as Ativan and Coumadin, and reduced likelihood of tissue healing.8 If lab tests cannot be performed, it is still possible to assess for wounds that are not healing and edema.
Cognition (Delirium): Delirium can be life-threatening. Characteristically presenting as acute confusion, the following delirium mnemonic can guide assessment:
The signal criteria of delirium are acute onset and fluctuating course, inability to focus or maintain attentiveness, disorganized thinking, and altered level of consciousness. The Confusion Assessment Method (CAM) can specifically describe the observed changes and guide communication of these changes to the physician or nurse practitioner.
Activities: This is the domain of activities of daily living (ADLs) and changes in the older adult’s ability to do self-care. It also includes any recent falls and 72-hour follow-up. An elderly resident who trips and falls might exhibit no symptoms on the first day but is unable to provide baseline self care 2 days later.
Pain: Chronic pain and the emergence of acute pain needs to be described particularly with regard to its effect on self-care and restriction of desired activity. Consistent use of an accepted scale can help identify poorly controlled chronic pain or new onset acute pain.9 The Resources section (Box 1) contains evidence-based pain scales for use with cognitively impaired and cognitively intact older adults.
The PQRST mnemonic can help differentiate acute from chronic pain in both demented and cognitively intact residents and guide assessment, documentation, and communication.10, 11
Elimination: Assessment considers changes in continence and bowel pattern. Mental status change, typically confusion, is associated with constipation. For new-onset abdominal pain, a first consideration would be impaction or lack of movement of the intestinal wall, known as an ileus. Appendicitis or an inflamed gall bladder must be considered as well.
Skin and Socialization: This domain covers a multitude of grave scenarios, from decubiti and pressure ulcers to herpes zoster to suicide. It is alarming that suicidal ideation and prodromata to suicide attempts are poorly recognized.
Case Study with FANCAPES
Mr. O is a high-functioning, cognitively intact 99-year-old assisted living resident. His friend comes to you and describes what appear to have been 2 syncopal episodes that Mr. O has had in the previous 2 days. When you see Mr. O, he is in no apparent distress and is conscious, oriented, with no serious injuries from his falls other than a minor abrasion on his left arm. His first fall occurred while getting tangled in his sheets when rising from bed, and the second occurred while he was using the toilet. Mr. O has no focal neural changes and refuses any treatment, including transfer to the hospital emergency department.
Two days later, dining room staff report that Mr. O dropped his water glass twice and seemed “a little out of it – you know, just not the same.” You go to see him, and he tells you some “weird things have been happening.” He describes what now appear to be focal neural changes: dropping glasses, a weak grip, and a “clumsy left arm.” Mr. O denies other weakness, lower extremity changes, chest discomfort, or palpitations. Vital signs are normal; pulse strength is equal bilaterally; no abnormal movements are noted. Again, Mr. O refuses hospital transfer but agrees to make an appointment to see his physician.
One day later, Mr. O falls again. His friend feels that Mr. O is increasingly confused because he is saying that people have been visiting when they have not. Mr. O denies confusion but says he is feeling anxious. Although conscious and alert, Mr. O is not answering all questions at his usual baseline. Physical assessment is only remarkable for left arm weakness. Vital signs: increasing blood pressure from a baseline of 116/66 to 134/64, and most recently to 154/74. Having made clear his wishes for minimal medical intervention, it is agreed to monitor him more closely without transfer to the hospital.
F: Fluid-related orthostatic hypotension is not causing his problem: his first fall was the result of environmental events, and the second occurred while sitting on the toilet. It may be an acute coronary event, but this seems unlikely given the presentation. Mr. O denies palpitations, shortness of breath, and chest pain. The fact that he “dropped his water” indicates he is at least trying to drink; skin and mucous membranes appear well hydrated. Is this a cardiac event in the presence of, or masquerading as, syncope?
A: Although Mr. O’s increasing confusion could be related to a worsening pneumonia or other pulmonary etiology and hypoxia, he has no cough; lungs are clear on auscultation, and no cyanosis is noted.
N: There is little to discuss regarding nutrition, although it is possible that a change in dietary habits may have altered the interaction of certain medications and led to a fall. Long-term malnutrition can certainly precipitate falls, but that seems unlikely in Mr. O’s case. Mr. O also denies changes in swallowing, and assistive personnel confirm this finding.
C: Mr. O’s speech is not slurred or otherwise changed. Although he is experiencing progressive change in cognition, Mr. O still has decisional capacity and wants minimal medical intervention. Do we know what is going wrong, or how much medical intervention would be required? The continued left arm weakness, increasing blood pressure, and increasing confusion are key findings. Assessment continues with the DELIRIUM mnemonic:
D: No new or changed medications; thorough review reveals no relationship between medication ingestion and symptom onset.
A: Mr. O has an apparent accidental, explainable fall followed by increasing falls over a 1-week period. Additionally, he is unable to participate in normal activities, such as drinking a glass of water with his left hand. He does not report increasing shortness of breath with baseline activities.
P: Mr. O denies pain other than discomfort from his falls and that it is “no big deal.” He does not appear to be in pain.
E: As noted in the DELIRIUM mnemonic, there are no changes or difficulty with bowel or bladder habits.
S: Mr. O’s bruises and skin injuries are consistent with his falls, and no suspicion of abuse is present. Additionally, he is social and interactive with family and friends who are concerned about his well-being.
Based on the FANCAPES assessment, when should Mr. O be transported to the hospital or the MD or nurse practitioner contacted? Given his reluctance for intense medical intervention, should he be transported? What other information would you have liked to have?
The next day, Mr. O is clearly anxious and obviously confused. He fell again, sustaining a slight shoulder injury. Urine obtained by straight cath is clear. Vital signs reveal a hypertensive emergency, characterized by a blood pressure of 200/100. Fortunately, he is not hypoxic or tachycardic. Mr. O’s son is contacted, and the decision is made to transfer him to the local hospital.
When Should I Call the Doctor, Nurse Practitioner, or 911?
Condition change in older adults can signal imminent catastrophic events or less life-threatening changes in the trajectory of known chronic illness. The difficulty and challenge lies in differentiating between normal anticipated changes and those that are flashing red lights. Changes that are seemingly benign in one individual can be life-threatening in another. The severity of the change or its consequences can depend on the older adult’s comorbidities, treatment regimen, past history, frailty, and other characteristics. Table 1 lists several presenting situations or condition changes and the safest and most appropriate course of action given the available assessment information—that is, to call the physician or advanced practice registered nurse (MD/APRN) or 911 (emergency medical services). This table could be distributed to all staff every 6 months to maintain a level of sensitivity to changes but should be adapted to the particular assisted living residence setting and availability of the MD/APRN.
Table 1. Should I Call? Presentation and Action to Take
| Presentation/Condition Change | Call MD or APRN Immediately If: | Call 911 If: |
|---|---|---|
| Vital signs | •Systolic BP: >200 or <90 •Diastolic BP: >115 •Resting pulse: >130 or <55 •Oral temp: >101 •Rectal temp: >102 | •The vital sign changes are associated with altered and/or severe symptoms of other kinds of distress (e.g., airway obstruction or anaphylaxis) |
| Delirium | •Any sudden onset of change in mental status | •Change in mental status accompanied by suspected or possible airway obstruction •Severe respiratory distress •Clinical signs of shock |
| Edema | •Sudden fluid excess noted in associated shortness of breath (SOB), pink frothy sputum, possibly co-occurring with chest pain •Abrupt onset of edema in one leg only •Loss of sensation in swollen leg •Associated tenderness and/or redness in affected leg | •Suspicion of a cardiovascular event, such as syncope, tachycardia, or other symptoms of acute coronary syndrome (ACS) |
| Sleeping difficulties | •Only if associated with mental status changes | •Not applicable |
| Bleeding | •Uncontrolled bleeding or repeat episode (e.g., prolonged nosebleed) •Emesis with frank blood •Bloody stools •Vaginal bleeding, profuse | •Uncontrolled bleeding •Bleeding with symptoms of impending shock and/or VS changes •Trauma with or without evidence of overt injury |
| Falls | •Obvious deformity of limb or alignment of same •Joint or hip pain with reduced range of motion •Inability to bear weight •Laceration with uncontrolled bleeding | •Major trauma event, such as a fall of a significant distance with associated loss of consciousness or VS changes |
| Chest pain | •New-onset or recurrent pain not relieved in 20 min with previously ordered nitroglycerine ×3. •Chest pain accompanied by VS changes, dyspnea, diaphoresis, nausea/vomiting. | •Complaints of chest pain associated with or followed by LOC changes or obvious arrhythmia with pulse check such as severe bradycardia (<40) or tachycardia (>150) |
| Medication error | •Resident is symptomatic because of the error | •Resident is symptomatic and there are VS and/or LOC changes |
| Constipation/diarrhea/emesis | •Severe abdominal pain •Rigid abdomen or extreme tenderness on palpation •Bowel sounds absent •Guarding (tensing of abdominal wall to protect inflamed underlying organs) | •Only when associated with other symptoms such as mental status changes or in conjunction with other cardiovascular symptoms that would necessitate transfer |
| Pain | •Associated with a fall/trauma •Noticeable and new inability to perform ROM •Headache with altered vision and/or LOC | •Severe, uncontrolled pain |
| Dehydration | •More than 1 episode of vomiting in 24 hours and decreased fluid intake •Less than 50% of normal fluid intake over 24 hours | •VS abnormalities •LOC change •Suspected sepsis such as narrowed pulse pressures, tachycardia, fever, mental status changes. |
| Pressure ulcers/skin rash | •Stage II, III, or IV receiving no treatment and no protocol to cover the condition •Signs of wound infection: purulent discharge, erythema, odor •Fever | •Not applicable |
| Depression/suicidal ideation | •Expression of suicidal ideation that contains a plan for carrying it out in the assisted living residence (e.g., “I have a lot of medications hidden away to use when I think my time has come.”) | •Expressed suicidal ideation with a plan and inability to monitor resident in the assisted living residence |
| Seizures | •New onset •Status epilepticus | •New onset or status epilepticus associated with: possible airway compromise - severe respiratory distress - signs of shock |
| Visual changes | •Associated stroke symptoms (e.g., hemiparesis, slurred speech, headache, facial drooping) •Complaints of seeing “halos” (a person will look at a light and see a halo or rainbow-colored circle around the light) •Any abrupt onset •Suspected trauma with severe pain | •Suspected stroke/CVA |
| Shortness of breath | •VS changes or suspected cardiovascular involvement •Labored breathing •Ashen appearance •Cyanosis | •Evidence of inadequate oxygenation (cyanosis, increased respiratory rate, paradoxical chest movement, diaphragmatic breathing, use of accessory muscles) despite interventions, such as Egan’s Fundamentals of Respiratory Care (2003): Oxygen via nasal cannula: .25 to 4 L/min; via simple mask: 5-12 L/min |
In thinking about Ms. J and Mr. O, when should the MD/APRN have been called? 911? Using Table 1 as a guideline, the first indication in both cases that warrant a call to the MD/APRN or transfer for further evaluation in a hospital setting is an acute change in mental status. Additional findings of changes in functional abilities reinforce the need for evaluation by an MD/APRN, but the initial red flag is the subtle change in mental status. Subsequent follow-up for Ms. J revealed an acute anterior wall myocardial infarction; Mr. O had suffered an intracranial hemorrhage. Use of either the SPICES or FANCAPES tool and Table 1 might have resulted in timely and crucial intervention for these residents.
Communication
A requirement of the Joint Commission’s National Patient Safety Goals states that health care facilities must have a standardized “hands-off” communications structure and process that includes the opportunity to ask and respond to questions.14 Standardization of communication can improve patient safety by reducing, if not eliminating, variations in communication style and content.15 The SBAR communication model is a structured communication process that can be used in all health care settings in keeping with the “culture of safety.”16 It encourages and supports (and, arguably, requires) open and honest information sharing, asking questions without recrimination, and providing suggestions without fearing an attack on one’s ability, preparation, and credentials to do this. SBAR is a description of the Situation, Background, Assessment, and Recommendations about and for a patient or resident. The communication must be informed by data that describes the patient’s current and previous status (S and B), the probable meaning of the new information or data (i.e., the A), and suggestions for next steps that respect the patient or resident’s wishes and best interests (i.e., the R).
The nurse transmitting the resident’s descriptive data would state what assessment instrument(s) she or he had used, why, and the findings. The nurse must state what is happening that precipitated the SBAR communication. Background information is contextual and includes the physical environment (if appropriate), comorbidities, resident preferences, and past decision making. In the example of Ms. J, the presentation of situation and background tells us that she is a pleasant, mildly confused 83-year-old assisted living resident who is acutely functioning below her baseline. Ms. J becomes short of breath with minimal exertion, is displaying increased confusion, and is complaining of new-onset back pain. These data will inform the assessment: this is what seems to be the problem. In thinking about Ms. J, the decrease in functional ability, increasing confusion, new-onset shortness of breath and back pain lead to a statement such as “I think this is evidence of an acute coronary syndrome.” Management or correction of the problem (i.e., the R) draws from the prevailing evidence of best practices. Indeed, the nurse can say, “Based on the report I found in the online Merck Manual of Geriatrics, with a similar patient population, we might want to do a cardiac workup.”
To some extent, the SBAR model invokes the SOAP note paradigm for the nursing process: Subjective, Objective, Assessment, and Planning. The virtues of the SBAR are that it uses language that virtually all health care disciplines are comfortable with; it avoids jargon. The resident’s current status can be described using one of the assessment tools previously described: SPICES, FANCAPES, DELIRIUM, PQRST, COLDSPA.
Transfer Information
Waiting for transport is, of course, a critical time. Communication with the resident’s physician or primary provider, family, receiving acute care facility, and the resident, who is likely in desperate need for reassurance, all demand skilled attentiveness. An effective transfer information document should include the resident’s normal or baseline data, as well as the current data that, in part, contributed to the decision to transfer.
The information and data listed below should be included in any transfer document that accompanies the resident.2 Some of this information can be entered in anticipation of a possible transfer and have it available at all times. The absence of any of this information can delay treatment.
Conclusion and Summary
In the absence of a systematic approach to assessment, the initial reaction to a resident who is described as “just not right” can be anxiety and confusion. Traditional nursing education is based on a series of assumptions about the presentation of illness that may be incorrect for older adults. The tools described in this article can help the assisted living nurse probe the change in a resident’s condition for indications of onset of a more significant disease process. Findings from these assessment instruments can be organized and relayed using the SBAR mnemonic, an evidence-based tool for improving communication among all health care providers. We strongly recommend developing and using a transfer information document for each resident that contains the his or her baseline “normal” status; this can be filled in advance of a medical crisis. The document should have space to describe the changes that precipitated the transfer. We further suggest that the resident’s goals for his or her health care be expressed in the document or by an individual speaking on the resident’s behalf (i.e., a proxy or agent) so that unwanted medical interventions are not initiated. The authentic voice of the resident needs to be elicited, heard, and respected (Figure 1).
Figure 1.
Assessment and communication acronyms.
References
- . Age-related changesToward healthy aging: human needs and nursing response. In: Toward healthy aging: human needs and nursing response. 5th ed.. St Louis: Mosby; 1998;p. 101–106
- . Taking charge in a geriatric emergency. Nursing. 1999;29:41–47
- . Emergency problems in older people. J Emerg Med. 2005;22:370–374
- . Egan’s fundamentals of respiratory care. 8th ed.. St Louis: Mosby; 2003;
- . Fulmer SPICES: an overall assessment tool for older adults [revised] (Try This No. 1). New York: Hartford Institute for Geriatric Nursing, College of Nursing, New York University; 2007;
- Prevalence of cardiovascular diseases among older adults (The Cardiovascular Health Study). Am J Epidemiol. 1993;137:311–317
- Merck manual of geriatrics 2000. Whitehouse Station, NJ: Merck; 2000;
- Peralta R, Rubery B. Hypoalbuminemia. emedicine from WebMD. Available: www.emedicine.com/med/topic1116.htm#section∼medication. Cited September 18, 2007.
- . Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. J Am Med Direct Assoc. 2003;4:9–15
- . Pain: the 5th vital sign. Alzheimer’s Association Newsletter (Massachusetts Chapter). 2002;22(1):
- . Using pain assessment tools. Nurse Pract. 2002;27:54–56
- . Health assessment in nursing. 2nd ed.. Philadelphia: Lippincott Williams Wilkins; 2003;
- Joint Commission Perspectives on Patient Safety. 2005;5(2):
- Joint Commission National Patient Safety Goals. Available: www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_ome_npsgs.htm. Cited November 22, 2007.
- . The human factor: The critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(suppl 1):185–190
- . SBAR: a shared mental model for improving communications between clinicians. J Qual Patient Saf. 2006;32:167–175
ETHEL MITTY, EdD, RN, is an adjunct clinical professor of nursing at the College of Nursing, New York University, and Consultant in Long Term Care at the Hartford Institute for Geriatric Nursing, College of Nursing, New York University.
JUSTIN B. MONTGOMERY, RN-BC, BSN, is the associate project manager for The Competency for Geriatric Nursing in Rural New England Project at the Dartmouth-Hitchcock Medical Center.
PII: S0197-4572(07)00371-0
doi:10.1016/j.gerinurse.2007.11.009
© 2008 Mosby, Inc. All rights reserved.
Refers to erratum:
- Correction
