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Team Essentials for Preventing Acute Deterioration Reference Guide for Learners Version 1.0 March 2016

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Prepared by the Baycrest Centre for Learning, Research and Innovation in Long Term Care as part of

Team Essentials: Leading Practices for Long-Term Care.

This reference guide supports learners who have participated in the 1-day module on

Team Essentials for Preventing Acute Deterioration.

For more information, please contact the Lead Interprofessional Educator:

Jennifer Reguindin at [email protected]

Prepared by:

Jennifer Reguindin BScN MScN RN GNC(c)

Reviewers (alphabetically):

Faith Boutcher MN RN

David Conn MB BCh BAO FRCP

Shoshana Helfenbaum MSW RSW

Paul Katz MD

Monika Keri BScN MScN RN

Joyce Kuang BKin

Raquel Meyer PhD RN

Maria Nelson BScN RN GNC(c) ABA(c) CPMHN(c)

Disclaimer: This reference guide is not binding for users . It neither consti tutes a liability nor a discharge from

liability. While every effort has been made to ensure the accuracy of the contents at the time of publication,

nei ther the authors nor Baycrest Geriatric Centre give any guarantee as to the accuracy of the information

contained in the guide, nor accept any liability, with respect to loss , damage, injury or expense arising from any

such errors or omissions in the contents of this work. Any reference throughout the guide to specific products as

examples does not imply endorsement of any of these products.

Supported with funding from the Government of Ontario.

The views expressed are the views of the authors and do not necessarily reflect those of the Province.

© 2016 Baycrest Geriatric Centre. For indvidual use only.

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CONTENTS

Foreword ................................................................................................................................................................ 4

Introduction......................................................................................................................................................... 4

Core Frameworks ................................................................................................................................................ 6

The 3Rs Clinical Framework ............................................................................................................................. 6

SBAR Reporting Framework............................................................................................................................. 7

Abbreviations ...................................................................................................................................................... 8

A. BASELINE ............................................................................................................................................................ 9

Health History...................................................................................................................................................... 9

Social & Family History ...................................................................................................................................... 10

Personhood ....................................................................................................................................................... 10

Continuous Monitoring or Trending ................................................................................................................. 10

B. RECOGNIZE ....................................................................................................................................................... 11

Objective Observation....................................................................................................................................... 11

Common Conditions .......................................................................................................................................... 11

1. Delirium .................................................................................................................................................. 12

2. Dehydration............................................................................................................................................ 13

3. Urinary Tract Infection ........................................................................................................................... 14

4. Respiratory Infection .............................................................................................................................. 15

5. Chronic Obstructive Pulmonary Disease (COPD) Exacerbation ............................................................. 16

6. Septicemia .............................................................................................................................................. 17

7. Decompensated Heart Failure ............................................................................................................... 18

8. Myocardial Infarction (Heart Attack) ..................................................................................................... 19

9. Ischemic Stroke ...................................................................................................................................... 20

10. Diabetes: Hypoglycemia ..................................................................................................................... 21

10. Diabetes: Hyperglycemia .................................................................................................................... 22

Prioritize ............................................................................................................................................................ 23

A Note on Risk ................................................................................................................................................... 25

Basic Information for Any New Situation.......................................................................................................... 26

C. REFLECT............................................................................................................................................................. 27

Critical Thinking: Considerations with Any Change .......................................................................................... 27

Which Systems are Affected? ........................................................................................................................... 28

1. Safety ...................................................................................................................................................... 30

2. Neurological – Head, Nerves, & Pain ..................................................................................................... 31

3. Mood & Behaviour ................................................................................................................................. 34

4. Sensory – Eyes, Nose, Ears, Tongue ....................................................................................................... 36

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5. Respiratory – Breathing & Lungs............................................................................................................ 38

6. Cardiovascular – Heart & Circulation ..................................................................................................... 40

7. Integumentary – Skin & Touch............................................................................................................... 42

8. Gastrointestinal – Mouth, Digestion & Elimination ............................................................................... 45

9. Genitourinary – Renal & Elimination ..................................................................................................... 48

10. Musculoskeletal – Muscles & Bones .................................................................................................. 50

11. Function – ADLs, IADLs, Programs & Roles......................................................................................... 52

Systems Observed (Look & See) by Task........................................................................................................... 53

Considerations: Using SOS as a Reflective Checklist ......................................................................................... 54

D. RESPOND .......................................................................................................................................................... 55

Actions in the Moment ..................................................................................................................................... 55

Critical Sign or Symptom – Personal Support Staff ........................................................................................... 56

Critical Care Path – Nursing Staff ...................................................................................................................... 56

Sharing Actions & Assessments ........................................................................................................................ 57

Asking for or Recommending What is Needed ................................................................................................. 57

SBAR & Asking for Help: What to Include in Your Report................................................................................. 58

Introduction ................................................................................................................................................... 58

Situation ......................................................................................................................................................... 58

Background .................................................................................................................................................... 58

Action & Nursing Assessment........................................................................................................................ 59

Recommendations & Requests ..................................................................................................................... 59

Appendix A: SBAR Work Sheets........................................................................................................................... 61

PSW Worksheet................................................................................................................................................. 61

Nurse Worksheet .............................................................................................................................................. 62

Appendix B: Head-to-Toe Report Example ......................................................................................................... 63

Systematic Reporting Approach .................................................................................................................... 63

Sensory Observation Reporting Approach .................................................................................................... 63

Appendix C: What Does “OK” Mean?.................................................................................................................. 65

Neurological, Mood, Senses, Musculoskeletal & Function ........................................................................... 65

Respiratory..................................................................................................................................................... 65

Cardiovascular & Integumentary ................................................................................................................... 65

Gastrointestinal & Genitourinary .................................................................................................................. 65

References ............................................................................................................................................................ 66

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FOREWORD

Introduction

This reference guide was designed for staff and student healthcare providers who have participated in Team

Essentials – Leading Practices for Long-Term Care: Preventing Acute Deterioration. The purpose is to help long-

term care healthcare providers recognize, prioritize, reflect and respond to acute changes in the health status

of residents. Being more attuned to the changing needs of frail elders will improve the care provided and the

resident-provider relationship.

Some elderly residents have atypical signs or presentations of deterioration. To assist in identifying early acute

changes, this reference guide includes signs and symptoms of common conditions that may lead to the

transfer of elderly residents from long-term care to acute care emergency departments. This list of conditions

is specific to the geriatric population. The reference guide is based on current best and clinical practice

guidelines.

The Sensory Observation System (SOS) was created to help healthcare providers and students recognize,

prioritize and respond to subtle and acute changes in the health status of elderly residents. The SOS consists of

a head-to-toe assessment whereby senses (i.e., sight, touch, hearing and smell) are used to identify

observations and assessments which are grouped by system. It provides a systematic checklist to use when

observing and assessing physical, cognitive, emotional and functional changes in residents, in order to prevent

worsening of their condition.

The reference guide includes examples of:

Which systems may need to be considered

What information may need to be included

How the reporting term “OK” can be used by a team in a way that supports objective, specific and

concrete observations and reporting

The SOS requires baseline knowledge of the resident and is used with a 3Rs clinical framework. The 3Rs ask

the healthcare provider to: Recognize, Reflect and Respond. Each step is based on professional readiness and

accountability. Figure 1 below depicts this process:

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Self/ Professional Readiness

Find Baseline

Continuous Monitoring

RECOGNIZE Priority

REFLECT

RECOGNIZE Change or Distress?

RESPONDEffective?

Team/SBAR Report

NO

YES

RESPOND: Pharm or Non-Pharm

Figure 1. Process Flow for the 3Rs Clinical Framework

All healthcare providers need to develop an understanding of the resident’s background and relevant

information in order to establish a baseline for future observations. Ensuring that the resident is safe in his or

her environment is always essential when observing or assessing a resident, but when a change in health

status is recognized, SOS is used systematically from head-to-toe starting with the neurological system and

ending with integumentary system. If the changes are localized to a system, SOS guides clinicians to perform a

focused system assessment. Finally, function, which is a great indicator of an elderly resident’s health

condition, is incorporated into the report to complete a picture of the resident’s situation.

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Core Frameworks

This module incorporates a clinical framework and a reporting framework.

The 3Rs Clinical Framework

Recognize: the signs, symptoms, risk and priority

Reflect: knowledge, observations and assessments

Respond: pharmacological, non-pharmacological or relational interventions and reporting

The 3Rs is a foundational clinical framework for healthcare providers to use in the face of any clinical situation

– whether it is responding to an acute emergency, understanding a resident’s responsive behaviours or

interacting with a concerned family. This framework is sequential, whereby healthcare providers are

encouraged to first recognize and understand the situation, then to reflect upon their observations and finally,

to respond appropriately.

Step 1 is to Recognize by:

i. Observing and assessing the change(s) based on risk and priority

ii. Identifying what may have triggered change(s).

iii. Identifying safety concerns that affect the resident and others.

Step 2 is to Reflect on:

i. The resident's known background and history to form a baseline.

ii. Systematic changes which may be connected to the original concern.

iii. The resident's function to create a fuller picture of the resident's current situation and overall health

condition.

Step 3 is to Respond by:

i. Providing appropriate interventions (pharmacological, non-pharmacological, relational).

ii. Describing the effectiveness of actions taken.

iii. Determining if further clinical diagnostic testing is needed.

iv. Reporting situation, background, actions and recommendations to the team.

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SBAR Reporting Framework

Situation – concern, risk/urgency

Background – baseline, observations/assessment

Action (unregulated & regulated staff) – intervention, outcomes

Assessment (regulated staff) – ruled out, overall picture

Recommendation/Request

The SBAR is a structured communication tool that is used to communicate any resident or family concerns

between team members. It has been tailored to allow personal support workers in long-term care to share

their knowledge, interventions and requests with the team. SBAR offers healthcare providers a thorough,

systematic and effective way of providing accurate information to the care team and beyond. This framework

allows information to be shared clearly and comprehensively in a short amount of time, thus making it critical

for urgent and emergency concerns. However, because clear communication is necessary for efficient

teamwork, SBAR is also suitable for non-urgent situations (e.g., action needed within hours, team rounds).

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Abbreviations

The following abbreviations are used in this Reference Guide.

ADLs Activities of Daily Living

3Rs Recognize, Reflect and Respond

BM Bowel Movement

Ca2+ Calcium

COPD Chronic Obstructive Pulmonary Disease

Fe+ Iron

GERD Gastroesophageal Reflux Disease

IADLs Instrumental Activities of Daily Living

kg Kilograms

LOC Level of Consciousness

PSW Personal Support Worker

SBAR Situation, Background, Action/Assessment, Recommendation/Request

SOS Sensory Observation System

UTI Urinary Tract Infection

VS Vital Signs

In this reference guide, the term ‘resident’ is used (instead of client or patient) to reflect the population living

in long-term care (i.e., persons who ‘reside’ in long-term care homes).

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Team Essentials for Preventing Acute Deterioration

A. BASELINE

In order to identify changes in a resident, there must be an initial reference point for comparison. This

reference point is referred to as the resident’s baseline. To establish a baseline, healthcare providers must

understand the resident’s background, health history and social history and must obtain relevant information

about the resident using a head-to-toe approach. All time spent with a resident is an opportunity to build on

or confirm baseline knowledge. The longer a healthcare provider knows a resident, the more comprehensive

baseline knowledge.

How do you get to know your resident?

What do you need to know?

Health History

Health history information is needed to establish baseline knowledge of your resident. Knowing this

information will allow you to anticipate what may go wrong when the health of the resident deteriorates or

what conditions may develop in the future. It also allows healthcare providers to understand the goals of care

that the healthcare team sets for the resident.

Questions to consider are:

What is the primary diagnosis?

What is the past medical history?

Are the changes being reported relevant to the primary diagnosis or to past medical history?

Does the resident have any allergies?

What is the resident’s code status?

Is there an advanced care plan?

What are the resident’s treatments and therapies?

Are there any recent changes?

Is it relevant to the advanced care plan?

What is written in the kardex? Is it up to date?

What is the care plan for this resident?

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Social & Family History

Social and family history can help healthcare providers to understand the resident’s current or past

environment. Some resident responses and interactions may be more easily understood in the context of this

information.


Is there a relevant family practice or tradition that is important to the resident?

What stories do your colleagues, family members, volunteers or visitors share about the resident that are

significant to the care you are giving?

Personhood

For residents with cognitive decline or impairment such as Alzheimer’s Dementia, knowing the story of the

resident is key to creating solutions or interventions to many behaviours and psychological symptoms; also

known as “responsive behaviours”.


Who was the resident before they came to the nursing home? What makes them tick?

What are their interests, needs, abilities and skills?

What are the resident’s culture, childhood, work life and education?

Are there any relevant or important stories or events?

Can you engage the resident in any activities based on this knowledge?

What would allow you to relate well with the resident?

How do you present yourself when relating with the resident?

Are there techniques that are relevant to caring for the resident?

Are there environmental factors that the resident prefers?

What is the resident able to do for him or herself?

Continuous Monitoring or Trending

Remember that the longer a healthcare provider knows the resident, the more the healthcare provider will

have developed a comprehensive baseline. Any time spent with a resident is an opportunity for the healthcare

provider to add to or confirm baseline knowledge of the resident. Each healthcare provider should consider the

trends observed in their own practice and by the team.

Consider what you know about the resident, from your baseline observations vs. over t ime.

Is there a trend?

Report any change.

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B. RECOGNIZE

This section will cover:

Recognizing and describing specific concerns objectively

Prioritizing new changes

All healthcare providers must be skilled in recognizing changes in resident condition. Communicating this

knowledge in a concise and specific manner is essential. In order to develop this skill, this section describes the

presentation of acute deterioration related to several conditions in the geriatric population. Also, prioritization

of these new changes will be discussed. Signs and symptoms that are localized (system-specific or easily

identifiable towards a body system) and general (non-localized) will be covered.

Objective Observation

It is important to maintain objectivity when noting signs and symptoms in order to plan and implement

interventions. The Sensory Observation System (SOS) developed for Team Essentials can guide healthcare

providers in determining the best method of assessment and encourages systematic observation. Based on

the senses, SOS directs the healthcare provider to:

Look and see

Listen and hear

Touch and feel

Smell

And consider further knowledge gathered

Common Conditions

Listed below are ten common conditions that may lead to an acute change in a resident’s condition. Note that

deterioration of chronic conditions in the frail elderly may present very differently compared to the general

population. Thus, the signs and symptoms listed below are specific to the elderly population. Many resources

were used to compile these signs and symptoms. In particular, practice guidelines from the former American

Medical Directors Association (now The Society for Post-Acute and Long-Term Care Medicine) were followed

and information from various sources was then added to complete the list (see References).

As a note, behavioural changes, mental status changes and change in functional status may be cues to

delirium, dementia or depression. Further assessment and intervention will only happen if changes are

recognized, prioritized and shared with the team.

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1. Delirium

Delirium is sudden change or acute disturbance of consciousness. A resident with delirium may show signs

such as reduced ability to focus, organize thoughts, or shift attention that may not be accounted for by a pre-

existing cognitive impairment like dementia. Most conditions that will be discussed may have signs of a mental

status change and appear as confusion but there are different types of delirium to consider. Note that if there

is a change from baseline behaviour, this may be related to a change in condition that needs to be addressed.

Signs of Delirium

Sudden onset or change in behaviour, symptoms come and go and is a change from baseline

Change in mental status or cognition (organizing information, planning, sequencing, perception,

memory, language)

Inattention, no focus

Easily distracted

Disorganized thinking

Disorientation (confusion)

Altered level of consciousness

Memory impairment (long-term and short-term memory problems)

Psychomotor changes or ADL function

Visuospatial problems (less able to see and understand the world around them)

Perceptual disturbances

Reports of feeling “cloudy”

Labile (always changing) affect

Hyperactive-Hyperalert Delirium

Sleep/wake cycle disturbance (most common)

Agitation, restlessness

Paranoid

Delusions or hallucinations

Hyperreactivity

Speech incoherence

Hypoactive-Hypoalert Delirium

Decreased level of consciousness and lethargy

Sluggish

Inactive or few spontaneous movements

Apathetic

Quiet, responds slowly to questions

Loss of facial reaction

Mixed Delirium

Shows and changes between hyper- and hypo- signs

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2. Dehydration

Elderly residents who are dehydrated are at higher risk for delirium and infection. Age-related changes, some

disease processes and medications also affect how water is retained or eliminated.

General Signs & Symptoms

Change in:

ADL function or engagement in activities

Intake of food or fluids

Mental status (increasing confusion and/or lethargy)

Skin temperature

General malaise

Dizziness

Fall or deterioration in balance or gait

Other Signs & Symptoms

Constipation

Decreased urine output

Postural hypotension

Postural pulse difference

Tachycardia

Weight loss (3-5 pounds in a 24-hour time frame)

Elevated body temperature

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3. Urinary Tract Infection

Urinary tract infections (UTIs) are common in long-term care residents. Although localized symptoms allow for

easier recognition and assessment, at times general signs are seen first.


Change in:




Skin temperature and/or color

Sleep pattern

Vital signs

Increased or excessive perspiration

General malaise

Dizziness

Nausea and/or vomiting


Fever or hypothermia

Generalized pain, myalgia

Localized Signs & Symptoms

Suprapubic or flank pain or tenderness

Painful urination

Gross hematuria

Foul smelling urine

Change in continence level (e.g., urgency or functional)

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4. Respiratory Infection

Recognizing respiratory signs is very helpful when addressing respiratory infections. Keep in mind the

differences in signs based on the location of infection.


Change in:





Sleep pattern

Vital signs

Tachypnea with or without shortness of breath


General malaise

Dizziness






Pneumonia

Tachypnea

Unlike the general population, coughing may be mild and without copious, purulent

sputum, especially in dehydrated elderly residents

Upper Respiratory Infections

Congestion

Sore throat

Nasal purulence

Lower Respiratory Infections

Increasing and/or productive cough

Shortness of breath

Adventitious lung sounds

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5. Chronic Obstructive Pulmonary Disease (COPD) Exacerbation

Residents with COPD may have acute exacerbation of the disease and if not treated early enough may lead to

a transfer to acute care services.


Change in:


Behavioural changes (irritability and anxiety)


Sleeping pattern (chronic change or observed change over a prolonged period)


Vital signs

Oxygen saturation < 88%

Respiration > 28 breaths per minute

Fever

Peripheral edema

Acute Changes Likely When

Dyspnea is present

Increased cough

Increased sputum production, change in color or thickness

Chest tightness

Wheezing

Accessory muscle use

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6. Septicemia

The frail elderly with multiple comorbidities, decreased immunity, dehydration and other risk factors have a

higher chance to develop an inflammatory body response. These signs may be missed if the diagnos is of is not expected (Nasa et al., 2012).


Change in:





Sleep pattern

Vital signs


General malaise

Dizziness





Fever, Infections & the Elderly

The febrile response is usually blunted in the elderly. However, using this guideline may

indicate fever in the elderly (AMDA, 2011):

Increase in temperature of equal to or greater than 1.1 oC from baseline

2 or more measurements of oral temperature equal to or greater than 37.2oC

Single measurement of temperature equal to or greater than 37.8oC

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7. Decompensated Heart Failure

A gradual onset of signs and symptoms of heart failure may lead to emergency transfers and hospitalizations.


Change in:





Vital signs

General malaise (lethargic, less active, weakness)

Nocturia or nocturnal incontinence

Sleep disturbance

Increased potential for falls

New or increasing edema

Lower-extremity swelling


New or increasing edema

Sacral edema for bedbound residents

Abdominal swelling

Increased shortness of breath with or without exertion

Dyspnea (less likely if patient is sedentary)

Unexplained cough

Sudden night time dyspnea (difficulty breathing) during sleep

Orthopnea (breathing comfortably only when standing or sitting up)

Unexpected and sudden weight gain (example is 2 kgs over 3 days)

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8. Myocardial Infarction (Heart Attack)

Signs and symptoms of a heart attack may present as “atypical”, which means the classic signs of chest pain

that healthcare providers wait for may not be present.


Change in mental status (increasing confusion and/or change in level of consciousness -

syncope)

Fatigue or weakness

Dizziness


Increased or excessive perspiration, cold sweats

Common Manifestations

Dyspnea

Upper abdominal distress

Syncope

Vomiting

Chest pain

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9. Ischemic Stroke

There is a higher incidence of stroke in the elderly population and knowing these signs may allow a healthcare

provider to recognize a change.

Acute Stroke

Sudden confusion, difficulty speaking (slurred), or difficulty understanding speech

Sudden difficulty seeing out of one eye

Sudden difficulty walking, severe dizziness, or loss of balance or coordination

Sudden numbness or weakness of face, arm, leg – confined to one side of the body

Sudden severe headache with no other readily identifiable cause

Subtle or Non-Specific Signs of Ischemic Stroke

Dramatic decline in muscle strength, speech, or level of consciousness

Decline in function

Difficulty judging distance or depth

Difficulty recognizing or paying attention to one side of the body

Difficulty with new learning

Impulsiveness or poor planning

Poor judgment

Poor safety awareness

Short attention span

Change in mental status (increasing confusion and/or lethargy)

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10. Diabetes: Hypoglycemia

The elderly population present differently when blood glucose levels decrease. The neuroglycopenic

symptoms listed below are more common changes in the elderly as opposed to the neurogenic symptoms that the younger diabetic population may present with (Clayton et al., 2013).

Neuroglycopenic Symptoms*

Change in mental status (cognition, increasing confusion and/or delirium)

Difficulty speaking

Weak, drowsy, lethargic

Change in psychomotor skills or function

Lack of coordination

Dizziness (increased potential for falls)

Headache

Vision changes

*Neuroglycopenic symptoms are more common in the elderly .

Neurogenic Symptoms

Trembling

Palpitations

Sweating

Anxiety

Hunger

Nausea

Tingling

Asymptomatic hypoglycemia occurs in the frail older resident.

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10. Diabetes: Hyperglycemia

Undiagnosed diabetes leads to further complications (AMDA, 2010b).


Change in mental status (new or increasing confusion or delirium)

Weak, drowsy, lethargic

Blurred vision

Worsening incontinence

Fruity breath odour

Thirstier than usual

Hungrier than usual

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Prioritize

Prioritizing changes makes good use of team resources, time and interventions. Knowing the resident’s

baseline, making observations and conducting assessments are necessary to prioritize a change as an

emergency, urgent or non-urgent. Prioritizing concerns determines how quickly to respond to a concern. A

stoplight system of red, yellow and green can be used to help visually flag the priority (Table 1).

Table 1. Prioritization of Concerns

Priority Level Response Time Stoplight

Colour

Emergency Address Immediately Red

Non-Urgent Address Within Hours Green

Emergency concerns need to be addressed immediately to preserve life (or limb). For example, when a

resident presents with new signs of facial drooping, one-sided limb weakness and slurred speech, these would

be considered signs of an Ischemic Stroke and call for an immediate transfer.

. This prioritization refers to situations where a

resident’s status will not improve or will deteriorate if further interventions are not provided. For example,

consider a resident who continues to be short of breath upon exertion but remains on room air with no

oxygen support and only non-pharmacological interventions have been used. If oxygen saturation of greater

than 92% there are other interventions that could be used to ensure the resident remains stable like applying

oxygen by nasal prongs or giving medication. This is considered urgent because the resident saturation may

not improve if further interventions are not provided.

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Figure 2 provides examples of emergency and urgent concerns by system.

Musculoskeletal

• Dramatic decline in muscle strength

• Falls

Integumentary

Skin looks gray or blue compared to

earlier appearance

Safety

Fall with fracture

Neurological

Sudden pain

Cardiovascular

Sudden edema or extensive bleeding

Function

Sudden decline in function compared

to earlier status

1

Neurological • Sudden change in LOC• Weakness on one side or seizure

Sensory

Sudden eye pain

Cardiovascular

• New/unrelieved chest pain,

tightness, pressure, discomfort with

known cardiac condition

• Hemodynamically unstable

Respiratory• Sudden or increased effort to

breathe at rest

• Respiration rate >28

• Obstruction

Gastrointestinal

• Rapid onset of abdominal pain or

distention

• Sudden weight gain

Genitourinary

Bleeding significantly

Mood & Behaviour

Sudden behaviour change

Photo Acknowledgement: Allen Cooper

Figure 2. Emergency and Urgent Concerns by System

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A non-urgent concern needs to be addressed within hours. Note: A non-urgent concern is still an important

concern (for example, you may take hours to further observe, assess, intervene and evaluate the change).

Prioritizing a concern as non-urgent allows the care team time to gather more information and to come up

with appropriate interventions. In some cases, non-urgent concerns may escalate if not addressed in a timely

manner. For example, when a stage 1 pressure ulcer is recognized and reported, the team then has time to

assess the new sore, identify contributing factors that led to the pressure sore and intervene as appropriate.

Figure 3 identifies some examples of non-urgent concerns by system (note: this is not a fully inclusive list).

Neurological• Lethargic

Sensory• Can’t perceive the same

Cardiovascular

• More swollen

Respiratory• Breathing faster (24-30), increased

secretions

Gastrointestinal• Decreased intake, change in continence

level

Genitourinary• Change in continence level or urine output

Musculoskeletal• Decline in muscle strength

Integumentary• New pressure ulcer, wound

Neurological

• Chronic painMood & Behaviour • Withdrawn

Function• Change in function compared

to earlier status

1

Figure 3. Non-Urgent Concerns by System

If the baseline established for the resident is known, then determining the priority of concerns is clear. If the

resident baseline is not known, a nurse should perform a head-to-toe assessment or focused assessment

(system specific assessment) to determine the priority.

A Note on Risk

Risk assessment of behaviors is necessary to keep residents and staff safe. It must be noted though that some

acute changes of conditions present as a sudden change in behavior. In this case, the sudden change must cue

a clinician into the urgency of the situation or a possible delirium. In some instances, these changes in

behavior may be seen as a responsive behavior due to dementia if a resident has this comorbidity. If so,

further assessment must be done by the team especially if new behaviours appear.

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Basic Information for Any New Situation

Table 2 can help organize communication about a concern and make it specific. Having this information right

at hand helps the healthcare provider highlight critical signs or symptoms and decide what additional

information is needed. See Appendix A for the full worksheet.

Table 2. RECOGNIZE: Situation Situation: What change requires the most attention?

Priority: Non-urgent, urgent or emergent Risk: Low, slight, moderate, high, potential to escalate

Trigger/Antecedent: What happened prior?

After reviewing Table 2, healthcare providers are encourage to practice using it with past clinical situations

experienced.

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C. REFLECT


Thinking critically to compare the resident’s current status to background and baseline

Thinking critically to identify the potential source of the changes observed

Organizing signs and symptoms observed in a systematic manner

Critical Thinking: Considerations with Any Change

Drawing on the knowledge of the resident and his/her background and baseline, makes an important

difference in the care provided and allows healthcare providers to build a professional relationship that is

resident-centred.

When observing a change, consider:

1. Vital Signs (VS)

a) Are there significant changes in VS compared to the baseline?

b) If any of the VS are in the range listed in Table 3 below, act immediately, as the resident may be

hemodynamically compromised. If this is the case, the situation may be prioritized as urgent or

emergency.

c) With no change in VS, a healthcare provider has time to gather more data and the situation may be

prioritized as non-urgent.

Table 3. Critical Vital Sign Changes in the Elderly

TEMPERATURE 37.8 oC or 100.0oF

> or equal to 1.1oC from baseline

2 or more measurements of oral temperature = or >37.2oC

BLOOD PRESSURE Systolic: < 90 mmHg or > 200 mmHg

HEART RATE < 50bpm or >100 bpm

RESPIRATORY RATE <10/min or >28/min

OXYGEN SATURATION <90% (less than 88%, if COPD) or a 3% decrease from baseline

BLOOD GLUCOSE <3.9mmol or >16.6mmol

2. Is it delirium or delirium on dementia? Remember, there are numerous sources for delirium in elderly

residents.

a) Are basic needs being met?

Unmet needs may include: lack of food, lack of fluids, inability to void or defecate, lack of

sleep, presence of pain, or inability to breathe comfortably.

For example, a change in appetite may trigger hypoglycemia if food is not consumed but

diabetic medications are provided to the resident.

3. Is this a change due to disease progression or a new disease?

Some diseases have complications as it progresses. Also decompensations or deteriorations

happen in diseases such as heart failure or chronic obstructive pulmonary disorders.

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4. What other systems are affected or affecting the resident? Localized signs and symptoms may affect

other systems.

5. What is relevant about the change? Other considerations? Are there changes to treatment plans,

medications, any recent transfers or stressors?

6. Is it an increase in frailty or an age-related change?

Which Systems are Affected?

If a system is affected, you will find a signs and symptoms that can be grouped together. Organizing

observations by system may be helpful when working or communicating with the resident and the team. The

following section describes relevant information for each system in terms of:

Age-related changes

Systematic observations that healthcare providers may observe when working with the elderly

Examples of observations that require urgent attention

Examples of observations according to systems

Each system is reviewed as listed in figure 4 below:

1

Genitourinary

Kidneys, voiding

Neurological

Brain, mind, pain

Sensory

Eyes, ears, touch, taste,

smell

Cardiovascular

Heart

Respiratory

Breathing, lungs

Gastrointestinal

Mouth, digestion,

bowels

Mood & Behaviour

Musculoskeletal

Muscles, bones

Integumentary

Skin

Cardiovascular

Circulation

Function

ADL, IADL, programs,

roles

Safety &

Environment

Neurological

Pain

Background &

Baseline

Photo Acknowledgement: Allen Cooper

Figure 4. Review of the Descriptions of Each System

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With any changes to the resident, ask and consider, and then document and communicate: What is the change?

Be objective and specific

PSWs: What do you see, hear, smell, and feel that is different?

Nurses: What relevant systems are affected?

A sample head-to-toe report is found in Appendix B.

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1. Safety

Look & See

What does your safety environmental scan show?

Call bell in reach? Side rails up?

Non-slip shoes on resident?

Bed is low/near the ground?

Does the head of the bed facilitate better breathing and prevent skin breakdown?

Environment suited to reduce behaviours?

Feels like home?

How is the lighting?

Any excessive noise that may irritate the resident?

Bed/chair alarms on and working?

Restraints used?

Hip protectors on?

Could team offer more support for the resident’s memory?

Non-Urgent Concern (Act within Hours)

Reaction new to the environment

Reaction to sounds and loud environment

Reaction to warmth or coolness of environment

Reaction to new staff working with him or her

Some Safety Observations

Unable to follow safety precautions

Falling frequently

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2. Neurological – Head, Nerves, & Pain

Age-Related Changes

Less blood flow to brain leads to a decline in executive function – e.g., planning, attention and

problem solving abilities

Smaller and less brain size and neurons leads to slower speed of thinking, poorer short-term

memory, and a need for more time to reason things out

Slower nerve impulse (sensory and motor) changes movement and motor control

Slower movements, are not as balanced or coordinated

Bone thinning of the spine leads to less bones structure and may increase pressure to the spinal

cord and may lead to decreased response to stimuli and a need for a longer reaction time

Harder to choose words

More memory distraction

Less able to regulate heat

Less likely to show signs of elevated temperature typical of fevers when having an infection

Look & See

Level of consciousness?

Alert

Drowsy – lethargic, more tired or sleepier than usual

Confused - disoriented to person, time, place, altered perception

Drowsy and responding only to strong touch and verbal stimulation – stuporous

Not rousable and not responding - comatose

Mental responsiveness and orientation (name, time, place and purpose)?

Face even from left to right?

Listen & Hear

What is the resident saying?

Cognition - memory, recall, and identification

Complete and organized thoughts, understandable

No change in how the resident speaks

No word finding difficulty finding

Is there a positive or a negative theme?

Has sound judgment

Touch & Feel

Does not show new or sudden weakness

No reports of numbness to face, arm, trunk and/or leg

Equal strength and movement from both left and right limbs

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Ask & Consider Further

If there is pain present, consider the following:

Is it new or chronic?

What started it?

Where is the pain?

How long has the area been painful?

How much pain is the resident in?

What is the pain quality?

What treatment worked before?

Does the resident report any dizziness or lightheadedness?

If there are changes to energy levels:

How many hours of sleep has the resident had?

Was it enough for the resident to feel rested?

If the resident is non-verbal and/or cognitively impaired, consider history of painful chronic

disease and observe for:

Decreased interaction

Decreased food intake

Rocking movements

Grimacing

Negative language used

Physical or verbal aggression

Increased irritability

Breathing faster

Consider if there are physical changes related to pain and observe the following:

Gait

Posture

Appetite

Sleep patterns

Elevated BP

Increased respirations

Diaphoresis

Note the use of restraints and consider if there is a continued need for them

Urgent Concern (Act within 1 Hour)

Sudden change in level of consciousness – reduction in level of consciousness for example, from

alert to stuporous or non-responsive

Sudden confusion

Sudden change in speech – slurring or garbled speech

Sudden numbness limited to 1 side

New facial droop

New onset seizure

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Suicidal or homicidal thoughts


Change in sleeping pattern

Worsening pain

New change in cognition

Decreased energy level—more lethargic, tired, weak, faint

Decrease in responsiveness

Chronic pain

Some Neurological Observations

Decreased alertness

Disoriented or confused

Pain present

Insomnia (not sleeping)

Fatigue

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3. Mood & Behaviour

Age-Related Changes

Less neurotransmitters and catecholamines that help with brain function such as cognition and

emotion

Poor sleep leads to an increased risk of major depression, memory problem and fewer social

interactions

Lethargy and hypo-alertness are NOT NORMAL in older adults with dementia

Look & See

Observe the resident’s affect (non-verbal reaction to environment)

Interactions with visitors, family, caregivers and staff

Positive or negative interaction?

Increased or decreased in quantity and/or quality?

Involvement in programs and activities

Is it more or less often than before?

Signs of boredom?

Is there any unexpected behaviour during care?

Is the resident hyperactive, more withdrawn (hypoactive) or resistant to care?

Listen & Hear

Interactions with visitors, family, caregiver and staff

Positive or negative theme when speaking?


What is the resident’s mood (what does resident say s/he is feeling)?

Is there a change?

Is there a presence or worsening of new responsive behaviours?

Is it: Delirium? Depression? Dementia?

Who is the behaviour affecting (staff, other residents, family)?

What is the behaviour and why might it be happening?

What happened beforehand?

What were the specific actions of the resident?

Describe and quantify

What or whom is around the resident at the time of the behaviour?

What is the resident saying?

When is this happening?

During the day or at night?

When is this NOT happening?

What can you do about it?

Has this behaviour occurred before?

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Which techniques were used? Which techniques were effective? Which techniques were

ineffective?

How long has this behaviour been happening?

Are there safety issues for staff, other residents, visitors, etc.?

Is there a behaviour that is now “normalized”?


New delusions, paranoia, hallucinations

Violence or destructive tendencies to self and/or others

Suicidal or homicidal ideation present with or without a plan


New onset behaviour or personality change or a significant change in behaviour:

Resisting or refusing care

Refusing to get up or move; staying in the same place

More withdrawn/sad or talking more than usual, negative themes

New or increased confusion/disorientation; delusions or hallucinations; severe depressed mood

Some Behaviour Observations

Increased motor activity or verbalization

Decreased interactions and participation

More withdrawn or more active than usual

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4. Sensory – Eyes, Nose, Ears, Tongue

Age-Related Changes

Eyes

Lens less flexible, which leads to decreased ability to focus on close objects (presbyopia)

and less able to adjust to changes in bright lighting (glare prevents seeing clearly)

Poorer night vision

Less sensitive cornea and conjunctiva

Less tear production

Less able to see colour differences

Cholesterol deposit lead to visual haziness

Ears

Outer ear enlargement

More ear wax impaction

Less elastic ear canal

Thinning and stiffening of the tympanic membrane

Less able to recognize speech

Less able to hear higher tones

Less able to follow conversations

Slower brain processes of auditory information

Inner ear structure – changes in vestibular system lead to more dizziness and falling

Nose

Less smell leads to less taste, which may lead to decreased appetite

Less able to identify odours

Higher chance of nose bleeds

Tongue

Less taste

Less saliva production

Look & See

Vision

Visual aids used – glasses, etc.?

Trouble seeing surroundings?

Blurred vision

With Hearing Aids

Comfortable fit

Batteries changed recently

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Listen & Hear

Hearing Deficits

Resident is responding to you

Ability to Communicate

Verbal or non-verbal


Vision

When was vision last checked and followed up on?

Seeing double?

Can’t see the same: decreased, blurry or lost vision?

New decreased or lost vision?

Any strain to see out of 1 eye?

Severe eye pain present?

Touch

Are there known tactile/touch risk issues?

Is there a loss of tactile sensation?


Sudden change in vision (example, sudden change in visual fields or sudden inability to see out

of one eye)

Severe ear pain and bleeding or discharge from ear canal

Fast onset of hearing loss

Non-Urgent Concern (act within hours)

Seeing halos

Increasing glare from lights

Experiencing eye pain

Can’t see the same: new vision loss

Can’t hear, smell or taste the same

Some Sensory Observations

Can’t see, hear or taste the same

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5. Respiratory – Breathing & Lungs

Age-Related Changes

Stiffer chest wall and less lung muscle strength and elasticity

Decreased gas exchange

Drier mucus membranes

Decreased cough reflex leads to less ability to clear mucus/foreign matter and an increased risk

of infection and spasm of airway

Easier to lose breath when working harder than normal, which leads to less to tolerate exercise

Look & See

Depth

Deep or shallow

Rhythm

Regular or not

Respiratory rate

Fast or slow

Mouth breather

Discomfort when breathing

Any increased effort to breathe at rest or with activities

New or worsening shortness of breath only with activity

Increased need for more pillows to sleep in bed or a need to sit up to sleep

Listen & Hear

Wheezing

Coughing

Sneezing

Congestion


Is there a new cough?

How much and how often is the resident coughing?

What is the colour and quantity of sputum?


Struggling to breathe

Short of breath at rest

Coughing up copious amounts of blood

Sudden or increased effort to breathe at rest


Shortness of breath with activity or a change in breathing pattern

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Irregular or breathing fast

Slow breath recovery after an activity – e.g., ADLs or walking

New increased sputum production

New or worsened cough, wheezing

Sore throat

Some Respiratory Observations

Increased work of breathing at rest or during activities

New cough

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6. Cardiovascular – Heart & Circulation

Age-Related Changes

Thicker heart muscles, stiffer arteries and heart valves, thicker arterial walls and more fat

around the heart lead to more work for the heart

Less blood flow lead to cool arms, hands, legs and feet

Decreased number of white blood cells and decreased immune response resulting in higher risk

of infections

Lower maximum heart rate during exercise and a high risk of heart rhythm changes

Less cardiac reserve leads to more tiredness, shortness of breath and slower recovery from

higher heart rate – e.g., after exercise

Higher risk for a drop in blood pressure when changing positions (postural hypotension) – e.g.

Switching from laying down to sitting or sitting to standing

Look & See

Observe the overall colour of the resident

DIAPHORETIC – sweating too much

Edema or swelling

Where?

Legs, arms, sacrum, face, eyes and/or scrotum

How much?

Compare from left to right?

If subcutaneous lines are in use:

Where is it located?

What does the skin look like at the insertion site?

Is the dressing holding up?

Touch & Feel

Is the resident warm to touch?

Temperature – new fever?

Axilla drier than usual


Does the resident report:

Palpitations

Chest pain, chest tightness, pressure, discomfort and/or unusual sweating

(diaphoresis)?

Location of discomfort: neck, jaw, shoulder, arms, back and/or abdomen?

Some describe chest pressure as the sensation that “someone is sitting on my chest”

If needed, are the compression stockings on?

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New or unrelieved chest pain, discomfort, pressure, heaviness or tightness with known cardiac

concerns

Sudden edema in only 1 leg with tenderness and redness

More than 5 lbs. weight gain in 3 days

No able to feel or sense touch in swollen legs


Signs of dehydration:

Increasingly tired, sleepy, dry axilla

Signs of fever

Worsening edema in arms, legs, abdomen, sacrum or genitalia

Unable to sleeping laying down flat

Unable to stand without severe dizziness

Some Cardiovascular Observations

Chest pain or heaviness

Edema

Irregular heartbeats

Dizzy

Bleeding

Fatigued

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7. Integumentary – Skin & Touch

Age-Related Changes

Drier, more scaly and wrinkled

Less subcutaneous fat (under the skin) leads to less ability to stretch, and decease skin integrity

More visceral fat (deep)

Less able to sweat

Thinning and shrinking of the top layer of skin (epidermis) leads to slower healing

Fewer nerve cells leads to less ability to feel and sense

Less contact between dermis and epidermis (skin layers) lead to less nutrients exchange

Thinner scalp, pubic and axilla hair; also changes in colours

Higher risk of infection, trauma, cancerous les ions, and pressure ulcers

Thicker nasal and ear hair

More facial hair in women

Nails thicker, grow slower, become brittle and yellowed

Increased risk of splitting and infections of the nails due to less blood supply to nails

Look & See

Colour of skin

Pale, pink, yellow, flushed or bluish

Dry or DIAPHORETIC (excessive sweating)

Colour of legs

Pale, red, mottled

If there are wounds:

Is it a pressure ulcer? Rash? Hives? Blisters?

Boggy and/or red areas?

Is there any hardened skin around?

Any new changes to existing wounds?

Where is it?

Is there pain due to the wound?

How large is the area or wound?

What does it look like?

Red, yellow, black

Wet or dry

If there is drainage, what is its:

Quantity

Colour

What does the skin around the wound (PERIWOUND) look like?

Is there a dressing on it?

Dry and intact?

How often is it changed?

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Observe for:

Redness over pressure spots that does not blanch when touched

Visible scars

Bruises

Skin tears

New changes to moles

Touch & Feel

Warmth of skin

Drier or more clammy than usual

Smell

Any unusual smell to resident’s wound?


Are there positioning plans?

Is there use of special mattress or specialize cushions?

Presence of pressure sores depends on:

The ability to feel pressure-related changes

How often skin is wet

How often resident gets up and/or does physical activity

How much resident is eating and drinking

The risk of rubbing on a surface when being lifted or boosted


Wound from a fall or trauma with significant bleeding

Colour of skin – gray or blue


Some signs of dehydration

Tired or sleepy, dry skin, poor turgor in central locations (late sign)

Redness on and around pressure areas that don’t blanche when touched

A larger or worsening pressure ulcer or existing wound

A new skin tear

A lump that is felt in the breast area

Changes in skin colour – blue or yellow

Signs of chills

Showing excessive moisture due to incontinence

Diaphoresis – excessive sweating

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Some Integumentary Observations

Axilla drier than usual

Wounds larger and/or more drainage

Warm to touch

New reddened areas

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8. Gastrointestinal – Mouth, Digestion & Elimination

Age-Related Changes

Less able to taste

Diminished thirst drive

Less calories needed but same nutritional needs

Teeth sockets wearing away and decreasing gums leads to tooth loss

Risk of chewing problems contributing to poor nutrition

Decreased strength of chewing muscles

Thinner mucus lining in the mouth (less protection) leads to dry mouth

Weaker mucosal barrier lead to more risk of infection

Swallowing muscles are less effective leading to risk of swallowing difficulty (dysphagia)

Weaker peristalsis and weaker esophageal sphincters lead to GERD (heartburn)

Change in ability to absorb nutrients (Ca2+, Fe2+) and medications leads to further

considerations for pharmacological interventions

Higher risk of adverse drug reactions due to decrease in liver size, blood flow and cardiac

reserve

Less able to digest starch

Less bile production leads to less tolerance for fats

Less able to feel the need to defecate BUT constipation is NOT normal

Risk of fecal incontinence with disease (not when resident is healthy)

Look & See

Nutrition

Appetite (meals and snacks)

Appropriate diet and texture

Able to eat independently

Drinking enough

Intake is the same as usual

Oral condition

Condition of membranes in the mouth, lips and tongue

See if appearance is dry or moist, and pink or covered in white

Teeth (own or dentures)

Dentures fit comfortably

Appearance of abdomen

Not unusually bloated (DISTENDED)

Rounded

Flat

If there is nausea or vomiting:

How much, how often and what is vomited?

Elimination

Size and quality of stool

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No change in frequency, size, type and consistency of bowel movement

Ostomy: stoma, appliance, skin, effluent

Touch & Feel

Pain is present when touching abdomen

Listen & Hear

Voice is clear and there are no changes such as gurgling or wet voice

If there is a concern with swallowing

Coughing before, during or after swallowing

Pocketing food in mouth when eating

Choking concerns are addressed

More flatus (gas)

Smell

No unusual smell to resident’s breath (e.g., fruity odour)

No unusual smell to resident’s BM


Nutrition:

Too much salt or sugar or fat intake?

Indigestion

Appearance:

Sudden distention of abdomen?

Unexpected weight gain or loss?

Any sudden onset of abdominal pain or cramps?

If there is a feeding tube, consider:

Location

Placement of the tube

Amount of feeds

Type of feeds ordered

Volume and rate of feeds

If resident is diabetic:

How often do they have signs of hypoglycemia or hyperglycemia?

When was the date of last bowel movement?

Is a bowel routine needed?

Are laxatives used?

Change in frequency, size, type and consistency of the bowel movement?

Change to the continence level?

Toileting plan? How often?

Any unplanned weight loss or weight gain in the last month or quarter to consider?

Need Registered Dietitian or Speech Language Pathology assessment?

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Rapid weight gain or weight loss (example 2 kg over 3 days)

Coffee ground-like or bloody emesis

Rapid onset of abdominal pain, distention, weight gain and rigid stomach, with or without

vomiting, but with known constipation

Choking during meals


Change in appetite or intake pattern – decreased oral intake over past 24-48 hours

Dry mouth, lips and tongue

Reporting denture pain or a burning sensation in mouth

Nausea and/or episodes of vomiting

Swallowing difficulty: coughing, wet voice, voice changes when eating; pocketing food in mouth

Blood in stool (without history of hemorrhoids)

Acute onset of diarrhea or multiple episodes

Change in stool pattern (frequency, size, type and consistency of BM)

New constipation or no BM for 3 days (start planning intervention)

Abdominal pain or any sign of pain when abdomen is touched, bloating

Weight loss or gain – 5% over last 30 days or 10% over last 6 months?

Some Gastrointestinal Observations

Not eating or drinking


Pain or stomach tenderness

No BM or watery BM

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9. Genitourinary – Renal & Elimination

Age-Related Changes

Kidneys

Decreased kidney size, less blood flow and function leads to lesser ability to clear body

of drugs and toxic substances, resulting in higher risk of electrolyte imbalance

Leaves body in a more acidic environment

Lead to more risk of kidney injury and significant reactions from drugs

Higher risk of water retention in body (in heart failure)

Higher risk of dehydration

Bladder

Less elastic, has less muscle tone and less capacity

Bladder volume decreases from 500-600 ml to 150-250 ml

More urine left in bladder after voiding

More night time urine produced and need to void (nocturia and polyuria) – higher

risk of urinary urgency

Incontinence is NOT a normal finding

In females

Shorter urethra in women lead to a higher risk of UTI

Remember the relationship between UTI and increased potential for falls

Decreased estrogen lead to tissue shrinkage and less lubricating secretions

In males

Prostate enlargement, testicular shrinkage, less sperm count and decreased

testosterone

Larger prostate in men compresses the urethra and leads to difficulty or painful voiding

Look & See

Method of urination

Spontaneous

Continent or incontinent

If incontinent, check size and fit of incontinence prevention tool

Foley catheter

Condom catheter

Suprapubic catheter

A leg bag is attached with catheters

The resident is not ANURIC (does not void)

No dialysis needed

Frequency of resident’s voiding

Frequency does not increase at night

No urgency, pain when voiding or straining to void

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Quality of urine

Amount

Colour

Odour

Clear

No signs of blood in the urine

Smell

No unusual smell to resident’s urine


If there is a change to continence level, is there a toileting plan?

Is there:

Vaginal discharge or bleeding?

Itchiness to pubic area?

Burning on urination?

Blood in urine?

Is there any history of:

UTI?

Urinary retention?


Bleeding significantly from vagina


Blood in urine or more sediments in urine

Change in urination pattern (urgency, frequency or continence level)

Foul smelling or concentrated urine

Reporting pain or difficulty when voiding

Pain in lower abdomen, flank

Less urine output than usual

Some Genitourinary Observations

Incontinence

Pain when voiding

Frequency and/or urgency of voiding

Unusual smell

Not voiding

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10. Musculoskeletal – Muscles & Bones

Age-Related Changes

Less muscle mass and coordination (sarcopenia) leads to weakness and poor exercise tolerance

Leads to less strength

Leads to higher risk of disability, falls and unstable gait

Less cartilage-forming cells leads to more joint damage

Less lean body mass, more fat and less able to absorb calcium leads to bone thinning

Bone loss in women and men (after peak mass at ages 30 to 35 years) leading to higher risk of

fractures and/or osteoporosis

Less ligament and tendon strength, elasticity and flexibility

Cartilage erodes and leads to changes in how resident stands and his/her height; range of

motion limited, more joint instability, higher risk of osteoarthritis, less flexibility and less

mobility

Look & See

If the resident has resident fallen before:

Any changes in balance and gait, weight bearing, transfer, ambulation, and posture?

Any dramatic or ongoing decline in muscle strength?

How often are these falls?

Is the resident able to weight bear?

Are transfers or mobility aids needed and within reach?

Movement

No change in exercise or activity tolerance

No shuffling when walking

No tremors, rigidity

Coordinated movement

Observe feet and toenails to see if there is anything that may cause pain

Touch & Feel

Compare limb strength from left to right

Limbs equal in strength

No 1-sided weakness to face, arm, truck and/or leg

Joints moving normally for the resident

No evidence of pain on movement or at rest

No increase in rigidity or decrease in coordination

No changes to muscle tone

No odd bumps on the joints


Is the resident part of a:

Physiotherapy program?

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Occupation Therapy program?

Exercise/cardiac rehabilitation program?

Could this resident benefit from more range of motion or joint loading exercises –

active/passive?

Are hip protectors on for high risk fallers who have a history of frequent falls?

Is there a falls prevention plan in place?

If the resident is on bed rest, is there a positioning schedule?


New onset one-sided weakness (face, arm, trunk, leg) – unequal limb strength

Fall with obvious broken bones or known blood thinner use

Dramatic decline in muscle strength


Change in balance, weight bearing, transfer, ambulation, postural ability or gait

Change when walking, moving or joint range of motion

Increased weakness, tremors or rigidity

Decreased exercise /activity tolerance

Repeatedly falling

Known unequal limb strength from left to right

Some Musculoskeletal Observations

Pain

Stiffer when moved or moving

Weaker strength

New or increasing tremors or rigidity

Falling (new or frequent)

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11. Function – ADLs, IADLs, Programs & Roles

Age-Related Changes

Function is a resident’s ability to carry out his/her activities of daily living (ADLs), instrumental

activities of daily living (IADLs) and roles

Increased engagement in ADLs prevents excess disability

Providing an agenda for the day or task breakdowns with cue cards leads to better engagement

and positive benefits

Ensure activities and roles are based on the assessment of resident’s needs, interest, skills and

ability


Is there a sudden decline in function?

Is there a decrease in tolerance for one or more activities?

Is the resident participating more or less than usual?

What is the resident’s ability to do an ADL independently? (capacity)

E.g., Toileting, feeding, dressing, grooming, teeth brushing, ambulation and bathing

Will you be able to support the resident with a task breakdown?

Is there a change in the level of assistance required for the activities?

What is the resident’s capacity for IADLs?

E.g., Shopping, meal planning and preparation, housekeeping, laundry, transit, financial

management, using a telephone, medication management and driving

What Therapeutic Recreation programs does the resident enjoy?


Sudden decline in function – ADLs, activity or engaging with others


Showing signs of boredom or loneliness

Hesitation to do a simple task

Refusing programs or activities

Showing a steady decline in function (ADLs) and requiring increasing help

Decreased exercise or activity intolerance

Some Observations about Function

Not able to function in ADLs as before

Not participating in activities as per usual

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Systems Observed (Look & See) by Task

Some healthcare providers have deemed that a systematic head-to-toe observation is not always feasible

unless time is set aside. This section categorizes some systems that may be observed during an activity of daily

living when a healthcare provider is continuously monitoring the resident and using these instances to build

up on or confirm baseline knowledge of the resident.

Table 4. Summary of Systems Observed by Activity of Daily Living Safety Neuro Mood/Behaviour Sensory Resp CV Integumentary GI GU MSK Function

Bathing

Feeding

Dressing

Oral Care

Toileting

Ambulation

Transfers

Activities

Periodic

Checks

Remember that if a resident is able to speak and respond, then healthcare provider is able to collect more

information to trend and observe the systems. This will lead to a comprehensive definition of what is “ok” for

a resident (See Appendix C: What Does “OK” Mean? for sample descriptions of an “OK” system).

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Considerations: Using SOS as a Reflective Checklist

Table 5 can be used as a reflective checklist to put together what is known about the resident. Remember to

prioritize the affected system and act on it based on your knowledge, skill, judgment and scope of practice as a

healthcare provider. Please see Appendix A for the full worksheet.

Table 5. REFLECT: Background

Background & Baseline (vs. Current Presentation)

Personal and medical history:

Basic needs (intake, sleep, toileting, pain):

Sensory Observation System

Which system(s) are affected? How? Local? Systemic?

Safety/Environment:

Vital Signs:

Neurological:

Mood, Affect or Behaviour:

Respiratory:

Cardiovascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary:

Function:

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D. RESPOND


Initiating appropriate actions and assessments

Highlighting needs, requests or recommendations to the team

Reporting systematically with SBAR

Planning for follow up

When encountering a resident with a change in condition, the healthcare provider must support the resident

to their best of ability in the moment so that the resident can be safe, supported and receive appropriate

interventions according to the care plan or level of care. Responding to a resident’s change, in the moment,

requires a few considerations, especially if the first observer is alone. If alone, consider the following:

Is the resident safe and comfortable before setting out to find a co-worker or equipment?

What resources are at available here/now?

Are there medications ordered for this specific event? If not know, does the nurse know?

Are there medical directives, policies, or orders that outline the diagnostics and laboratory testing

required?

Is there an advanced care plan that is documented that will prevent or guide further interventions?

Actions in the Moment

If providing a non-pharmacological intervention, consider the following:

Interventions – What was done?

Here are some examples:

If a resident is not waking up, was verbal communication or light touch tried?

If a resident is short of breath, are they safe and sitting? Were deep breathing exercises

tried?

How many times was the intervention tried?

For how long?

The number of attempts and duration of attempts are valuable pieces of information that may contribute to

the plan of care for a resident and should be shared with the team.

Outcome of Intervention (Consequences) – Did it work?

Effective: concern modified or stopped

Ineffective: concern accelerated or continued

Sharing the outcome of the intervention will be useful as the team changes or builds new interventions

based on the information shared.

Was there a noticeable trigger, antecedent or unmet need?

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Clinical interventions may vary between a medical condition and a concern based on a responsive behavior.

Consider these questions:

Is it an acute change due to a medical condition OR a delirium? Think about:

Medication, supplementary oxygen, increased VS checks, blood work, diagnostic testing,

consults or further observations by the team

Assess the need for transfer to acute care or further interventions

Is there a known responsive behaviour due to dementia or depression?

If yes, attempt the following non-pharmacological interventions: distract, engage in activity,

assist, redirect, instruct verbally, re-approach and monitor; if pharmacological intervention,

monitor

Consider milieu management

Critical Sign or Symptom – Personal Support Staff

When a PSW identifies multiple concerns, signs, or symptoms of a change in condition, it is imperative to be

precise and concise when reporting these changes to the registered staff. Highlighting the priority of the

change as non-urgent, urgent or an emergency will help registered staff pay attention to your concern.

If multiple concerns are present, use Figure 2to highlight and report observations to a nurse. This may assist in

the nurse’s further clinical assessment and intervention. If there is more than one emergent or urgent change,

list these systematically from head-to-toe, if possible. An example: A resident is coughing, breathing fast, has

repetitive vocalizations about not being able to breathe and appears anxious. The critical sign of breathing fast

and the symptom of repetitive vocalization about not being able to breathe should be reported first.

A carefully established baseline offers a clearer description of what changes are present in a resident.

Critical Care Path – Nursing Staff

After a registered nurse or physician completes an assessment, a critica l care path may be determined. All the

initial observations, prioritizations and interventions (pharmacological, non-pharmacological, relational) made

by the team lead to this determination.

After careful consideration of the change, identification of a care path provides guidance on how a resident

should be monitored and future monitoring and interventions that may be required as well as may set the

parameters for transfers to acute care emergency as needed.

For example, a new concern of a cough may lead to a respiratory infection, an exacerbation of chronic

obstructive pulmonary disorder or a decompensation of a congestive heart failure. Therefore, careful

assessment and evaluation are the keys to ensuring that the correct interventions are implemented by the

team.

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Sharing Actions & Assessments

Table 6 can help organize communication about specific actions or interventions taken and the resulting

outcomes. Nurses should provide an overall assessment of the potential critical care path. Please see

Appendix A for the full worksheet.

Table 6. RESPOND: Action, Safety & Assessment Interventions (Pharmacological or Non-Pharmacological)

• Number of trials • Duration of intervention

• Outcome (effective or ineffective) Nursing Assessment:

“I have ruled out …” (basic needs, delirium or other system change); “I think the problem may be …”

Asking for or Recommending What is Needed

Table 7 can help organize communication about any recommendations or requests. It helps you to be specific

about what the resident needs or what you need to help the resident. Please see Appendix A for the full

worksheet.

Table 7. RESPOND: Recommendation/Request PSW:

“I recommend …” (specific action, non-pharm interventions, further observation, monitoring and/or referrals); “Can I ask you to … / What can I do in the next __ minutes/hour?”

Nursing: “I recommend …” (non-pharm or pharm interventions, labs, consults,further assessment, review of medication side effects, monitoring and/or transfer); “Can I ask you to …?” (specific action)

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SBAR & Asking for Help: What to Include in Your Report

There are probably times when you ask for help, but you don’t get the response you desire. As a healthcare

provider, many elements need to be communicated concisely to help team members gain insight into your

knowledge of the resident. The SBAR communication tool has been tailored to assist healthcare providers in

long-term care in reporting to the team.

SBAR stands for:

Situation – concern, risk/urgency

Background – baseline, observations/assessment

Action (unregulated & regulated staff) – intervention, outcomes

Assessment (regulated staff) – ruled out, overall picture

Recommendation/Request

Introduction

When communicating with a new team member, be sure to introduce yourself. This will help avoid confusion

in the beginning. If on the phone, let the team member know where you work do they can identify your

specific location.

Situation

Always highlight the reason for the call according to priority, followed by specifics about the concern. This will

paint the picture for the other team member. Stating the priority helps team members to manage their time

and workload. If you were able to determine or observe what triggered the new concern, then share this too.

In short, let the team member know the main concern and whether it is an emergency, urgent or non-urgent?

Background

Share what you know in a systematic way using SOS. Pull together information from what you and the team

have observed and/or assessed and consider trends and relevant information. This is where systematic

observations or assessments and accurate prioritization are relevant. Comparing what is known from baseline

to how the resident is presenting now helps to figure out the next steps. Preparing this ahead of time

increases team efficiency and quality of care for the resident.

Always consider if basic needs are being met (e.g., eating, drinking, sleeping, toileting, oxygen, no presence

of pain). Pain is a common concern for the elderly. So with respect to basic needs, consider if the resident is

experiencing any pain, pressure, or discomfort that can be relieved without medications.

Pain is a commonly missed change that leads to complications, such as delirium.

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Action & Nursing Assessment

When you ask for help, always highlight some of the actions that you have done based on the signs or

symptoms that you’ve observed. Let the other team member(s) know if it was effective, so there is no

duplication of efforts.

Nurses should also communicate their overall assessment of the situation, which is the critical care path, to

ensure that the care provided is consistent and the goals of care are clear with the team. PSWs are

encouraged to share the critical sign or symptom observed.

Recommendations & Requests

It is always helpful for the other team member to understand why you need his or her help. In emergency or

urgent cases, relating what you need from your team also speeds up the process of achieving quality care for

the resident.

Consider the interventions listed below and your scope of practice. What clinical actions could another

member of the team assist, ordering, perform or evaluate?

Acute change due to a medical condition OR a delirium?

Medication, supplementary oxygen, increased VS checks, blood work, diagnostic testing,

consults or further observations by the team

Transfer to acute care

Responsive behavior due to dementia or depression?

Non-pharmacological interventions: distract, engage in activity, assist, redirect, instruct

verbally, re-approach and monitor

Milieu management, medications and monitoring, further consultation, organized assessments

and observations

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Table 8 summarizes the elements to be included in an SBAR report for acute deterioration.

Table 8. SBAR for Acute Deterioration in the Elderly

Introduction

Name, Position, Location, Resident

Situation (Recognize)

Situation: What change requires the most attention?

Priority: Non-urgent, urgent or emergent

Risk: Low, slight, moderate, high, potential to escalate


Background (Reflect)


• Personal and medical history

• Basic needs (example, intake, sleep, toileting, pain)


• Which system(s) are affected? How? Local? Systemic?

Action, Safety & Assessment (Respond)

Interventions (Pharmacological or Non-Pharmacological)

• Number of trials

• Duration of intervention

• Outcome (effective or ineffective)

Nursing Assessment:

“I have ruled out …” (basic needs, delirium or other system change);

“I think the problem may be …”

Recommendation / Request (Respond)

PSW:

“I recommend …” (specific action, non-pharm interventions, further observation, monitoring

and/or referrals);

“Can I ask you to … / What can I do in the next __ minutes/hour?”

Nursing:

“I recommend …” (non-pharm or pharm interventions, labs, consults, further assessment,

review of medication side effects, monitoring and/or transfer);

“Can I ask you to …?” (specific action)

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APPENDIX A: SBAR WORK SHEETS

PSW Worksheet

PSW Introduction Name, Position, Location, Resident

S


Current Concern: What change requires the most attention?

Priority: Non-urgent, urgent or emergency?



B



- Personal and medical history - Basic needs (intake, sleep, toileting, pain)


Which system(s) are affected? How? Local? Systemic? - Safety & Environment - Neurological - Mood & Behaviour - Sensory - Respiratory - Cardiovascular - Integumentary - Gastrointestinal - Genitourinary - Musculoskeletal - Function (ADL &IADLs)

A

Action & Safety (Respond)

Interventions

Number of trials

Duration of intervention

Outcome of intervention (consequence) Effective: concern modified or s topped

Ineffective: concern accelerated or continued

R Recommendation / Request (Respond) “I recommend … ” (specific action, non-pharm interventions,

further observation, monitoring and/or referrals)

“Can I ask you to … ” “What can I do in the next _____ min/hr?”

© 2016 Baycrest Geriatric Centre.

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Nurse Worksheet

Nurse Introduction

Name, Position, Location, Resident

S


Current Concern: What change requires the most attention?

Priority: Non-urgent, urgent or emergency?



B



- Personal and medical history - Basic needs (intake, sleep, toileting, pain)

Sensory Observation System Which system(s) are affected?

How? Local? Systemic? - Safety & Environment - Neurological - Mood & Behaviour - Sensory - Respiratory - Cardiovascular - Integumentary - Gastrointestinal - Genitourinary - Musculoskeletal - Function (ADL &IADLs)

A

Action & Safety (Respond)

Interventions

Number of trials & duration

Outcome of intervention (consequence) Effective: behaviour modified or s topped Ineffective: behaviour accelerated or continued

Nursing Assessment (Respond) “ I have ruled out …” (basic needs, delirium or other body

system change, deterioration of a chronic condition)

“I think the problem may be ________.”

R Recommendation / Request (Respond) “I recommend … ” (non-pharm or pharm interventions , labs,

consults , further assessment, review of medication side effects,

monitoring, and/or transfer)

“Can I ask you to … ?” (specific action)

© 2016 Baycrest Geriatric Centre.

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APPENDIX B: HEAD-TO-TOE REPORT EXAMPLE

Remember: Look up, down and around

The following examples are based on a case study shown during the education day. The first example is listed

in a systemic reporting approach and the second is arranged in a sensory observation approach. In both types

of reports, descriptions written in bold blue represent a sign or symptom that a healthcare provider might

report to the team.

Situation Description:

When it was time for activities, Mr. Smith was lethargic with negative affect and interaction with staff.

Resident declined participating in his usual programs and reports being uninterested in them. He is more

withdrawn than usual.

Patient Background:

Mr. Smith is an 85-year old resident, who likes to eat and attend sing-a-long activities. He is usually pleasant

and his wife visits regularly in the evenings.

Table 9. Comparison of the Systematic Reporting and Sensory Observation Reporting Approaches

Systematic Reporting Approach Sensory Observation Reporting Approach

Safety

Resident sitting in armchair with no safety issues

noted.

Neurological/ Psychological

Awake, lethargic, but converses appropriately. Face is

even from left to right. Complete and organized

thoughts, understandable but has negative theme.

Unable to observe limb strength. The resident was

not asked verbally if he was in pain, but no non-verbal

signs of pain were present.

Mood & Behaviour

Negative affect observed. Negative interaction with

staff. Resident declines to participate in the

programs he usually attends. No restlessness but

more withdrawn than usual.

Sensory

He does not wear glasses or hearing aids. He can hear

Look & See: (Neuro, Mood, Sensory, Respiratory, CV,

Integumentary, GI, GU, MSK, Safety)

Awake, lethargic but converses appropriately.

Non-verbal signs of pain not present but resident

was not asked verbally.

Negative in his affect and is interacting more

negatively with staff.

Regular breathing. No noted discomfort with

breathing.

No edema observed. Not diaphoretic.

Skin pink. No wounds seen at this time.

Resident sitting in chair. Able to turn his head

from side to side with no noted discomfort.

Resident sitting in armchair with no safety issues

noted.

Listen & Hear: (Neuro, Sensory, Resp, GI)

Complete and organized thoughts,

understandable but has a negative theme.

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well. No known tactile risk issues.

Respiratory

Regular breathing. No noted discomfort. No cough.

Cardiovascular

No edema observed. No subcutaneous lines. Not

diaphoretic. Unable to feel warmth of skin at this

time.

Skin

Skin pink. No noted wounds at this time. No excessive

sweating noted.

Gastrointestinal

Unable to observe oral mucosa, teeth, abdomen or

elimination.

Genitourinary

Unable to observe elimination at this time.

Musculoskeletal

Resident sitting in chair. Able to turn his head from

side to side with no noted discomfort.

Function: ADLs, IADLs, Programs, and Roles

Resident is reporting that he is not interested in his

usual activity at this time.

Smell: (Integumentary, GI, GU)

Unable to smell

Touch & Feel: (Neuro, Sensory, CV, Integumentary,

GI, MSK)

Unable to test limb strength.

Unable to feel warmth of skin at this time.

Consider Further: (Neurological, Respiratory,

Cardiac, Skin, Sensory, Musculoskeletal,

Gastrointestinal, Genitourinary, Mood/Behaviour,

Safety, ADLs)

Also, Mr. Smith...

Declines to participate in the programs he

usually attends.

Is reporting that he is not interested in his usual

activities at this time.

The systematic approach gathers all observable data under a system and the sensory observation reporting

allows for multiple systems observation grouped under how the resident was observed.

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APPENDIX C: WHAT DOES “OK” MEAN?

It is helpful for healthcare teams to establish normal baseline functioning of residents as a reference point for

reporting that they are “OK.” This allows caregivers to prioritize changes in residents as they occur. Below, one

such list of normal baseline functioning by system is suggested for a general resident population. It is

important that the team agrees on the meaning of “OK” and normal baseline functioning.

Neurological, Mood, Senses, Musculoskeletal & Function

Awake, alert, converses appropriately

Speaks in complete and organized thoughts

No behavioural or psychological symptoms of dementia observed

Positive affect, no sad mood reported

Using glasses, hearing aid, and mobility aids appropriately and safely

Moves without difficulty or discomfort

Equal limb strength from left to right

Steady gait

No dizziness when moving

Non-verbal signs of pain not observed, no pain reported

No change in ADL level

Engaging in activities as per usual

Respiratory

Breathing on room air

Equal rise and fall of chest

No cough or wheezing heard

No increased work of breathing observed

Cardiovascular & Integumentary

No change in skin color

No new swelling to arms, legs, abdomen

Denies chest pain, pressure or discomfort

No wounds, skin tears, pressure ulcers, bruises

No excessive sweating

Gastrointestinal & Genitourinary

No change in appetite

Mouth clear, no observed sores

Eating by mouth and taking in 100% of offered food and drinks

Abdomen not swollen; soft when touched

Passing flatus; last bowel movement less than 3 days ago

No changes to continence level

Toileting routine effective

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