Case Study: Ms. A
Ms. A is a mentally intact 79-year-old frail (in a weakened condition) woman who arrived at the Manor Nursing Center after a hip fracture at home. After a stay at an acute rehabilitation center, she is still not able to manage by herself. Ms. A walks with difficulty with a walker and needs help with daily living activities. Ms. A also has several other medical problems. She has high blood pressure, diabetes, and arthritis. She is also being treated for depression. Her family visits her regularly on weekends. She rarely participates in activities of the Manor Nursing Center; at mealtimes she tends to avoid conversation. Recently she had diarrhea, was incontinent of liquid stool, was placed in adult briefs, and nursing assistants had to change her adult briefs once or twice per shift. She began taking meals in her room. Stool tests showed that she had a bowel infection with Clostridium difficile. An antibiotic was started. Even with the antibiotic, her bowel movements continued to be liquid and frequent over the next week, and she was eating less. Her blood pressure had been normal for her at 130/80, but her pulse rate was higher than her usual 70-75 at 90-100. Yesterday, she had a fever of 102.5 and was transferred to the acute hospital, where she was admitted to the Intensive Care Unit.
How did Ms. A get so sick with only diarrhea? What changes might you have noticed about Ms. A? When might you have decided to do something about it? What could you have done?
We've all been in difficult situations that might have been avoided if we had noticed a problem early and dealt with it right away, before it got worse. These situations may happen when a person is ill, and even more so if that person is frail. When one thing goes wrong, it seems to lead to another thing going wrong, and that can continue until the person is dangerously ill. So noticing changes that might signal or lead to a serious condition is important. Often, the sooner something is done, the better it is for the person who is ill.
As nursing assistants and licensed nurses, your role in a long-term nursing center is very important. At home, people know each other well and notice changes in a friend or family member's condition or behavior. In a hospital or clinic, registered nurses, nurse practitioners, and doctors are there almost all the time, and they are trained to look for signs of illness and to be sensitive to changes in a patient. In nursing centers and other types of long-term care, nurse practitioners and doctors are there for much less time.
The providers who most often see the residents are the nursing assistants, and the ones who see them some of the time are the occupational and physical therapists and the licensed nurses. Unit administrators, clerks, and volunteers may also be there. Residents in long-term nursing centers depend on nursing assistants and these other providers to be the ones who notice change.1 Nursing assistants, in particular, become the eyes, ears, and hands of the care team. Residents depend on you to be alert and interested. They depend on you to talk with your team members so everyone is “tuned-in.” They also expect you to respond if something comes up. Nursing assistants are very busy and have many tasks, but detecting change is one of the most important.
Leaders and advocates in nursing center care believe that having the same staff consistently assigned to the same residents leads to better care for the resident and higher staff satisfaction.2
Role of Nursing Assistants and Licensed Nurses
Having consistent assignments is more likely to work when:
- Nursing center leadership educates staff on the benefits of consistent assignment.
- All members of the team participate in meetings about consistent assignment.
- There is a process to ensure that nursing assistants have input when assignments are given, with the goal of having everyone feel that their assignment is fair.
- Care team members meet regularly to discuss how the consistent assignment is working, including reviewing assignments to ensure that relationships with the residents are going well.
- Leadership invites suggestions from team members about improvements.
Know the Resident's Normal (Baseline) Condition
When you first meet residents you are responsible for, you should talk with other members of your team to find out everything you can about the residents. Your coworkers may have learned things you need to know from other care providers or from family members and visitors. This can help you establish what's normal and may be called "baseline" information. Try to stay with each new resident as long as possible, just getting to know him or her, so that changes don't get overlooked because you don't have enough baseline information. Establish a conversational relationship with the resident and family and stay in touch every day you are with the resident so that you are more "tuned in" to how he or she normally is and how long he or she has been at that baseline. A change of shift report is another good way to gather baseline information.
Be sure to note a resident's ability to move around; their usual method for getting from, say, bed to chair; and how they do with activities of daily living. For example, do they need to sit while they are in the shower? It helps to know their preferences for activities, eating, dressing, and so on. Changes from the baseline in a resident's routines or enjoyable parts of the day can signal a medical change. In addition, be aware if the resident seems to be uncomfortable. Many older adults will not be willing to talk about pain or discomfort unless you ask them about their pain. When you learn these important things about residents, make sure that you share the information with your coworkers.
Some care providers, such as the float nurse or new hires, don't know all they need to about the residents. Help them out by sharing relevant information and tips.
When something about a resident seems to have changed, you should always observe and document the following things:
- Look back at the previous shift notes and make a shift-to-shift comparison.
- Make sure that needed equipment is available—the blood pressure cuff and stethoscope, the pulse oximeter, and the thermometer.
- See if a change occurred in any of the resident's vital signs—blood pressure, pulse rate, breathing rate, and/or temperature.
- Check the resident's records of urination and bowel movements—a quick check by the licensed nurse of the resident's bladder with a physical examination (percussing or tapping over the bladder area to see if it sounds like it is full), or with an ultrasound if one is available, can be very helpful for the resident who has not urinated and may need a catheter. If your nursing center has a hand-held ultrasound, make sure it is present too.
When you have collected all the information you can, be sure to share it with a licensed nurse. The registered nurse may then decide to do a full assessment by reviewing the resident's condition to see if a different treatment is required.
Registered Nurse's Assessment
Registered nurses should follow prior training when conducting an assessment. This Workbook will not address in detail how registered nurses should assess change.
However, briefly, the registered nurse will do the following:
- Ask the resident how he or she feels even if the resident is confused or seems to be "out of it."
- Ask the resident how the symptoms began and when.
- Take the resident's vital signs again.
- Perform a general exam and assessment of the resident's level of consciousness or cognitive function and physical function, following the usual methods for resident assessment
- When the assessment is completed, the registered nurse will organize this information to report the change to the resident's nurse practitioner or doctor, if this is necessary.
Because older people may have a serious illness and the only sign of that illness is some confusion, assessment of confusion is important. Several tools to help with evaluating mental status are included in the MDS3 and are accurate for nursing center residents (go to the Additional Tools and Resources section), including:
- Brief Interview for Mental Status (BIMS), which evaluates the normal (baseline) mental function.
- Modified Confusion Assessment Method (CAM), which is a simple set of questions that help to identify the presence of confusion.
- PHQ-9 detects changes in mood, such as depression or anxiety.
Knowing how to administer each of these instruments is part of the licensed nurse's scope of work and may help to identify changes in mental function that could be a sign of serious illness.
Registered Nurse's Assessment
1. Boockvar K, Brodie HD, Lachs M. Nursing assistants detect behavior changes in nursing home residents that precede acute illness: Development and validation of an illness warning instrument. J Am Geriatr Soc 2000; 48:1086-1091.
2. Increasing use of consistent assignment. Advancing Excellence in America's Nursing Homes campaign. Available at http://www.nhqualitycampaign.org/files/factsheets/Staff%20Fact%20Sheet%20-%20Consistent%20Assignment.pdf [Plugin Software Help]. Accessed January 10, 2012.
3. Minimum Data Set 3.0: Brief Interview for Mental Status (BIMS), Items C0299-C0500; Confusion Assessment Method (CAM), Items C1300 and C1600; and the PHQ-9, Item D0200.