Doesn't Look Right, Not Themself, Participating Less, Nonspecific Change in Condition

Also Consider:  Confusion, Fever, Poor Oral Intake, Weakness 

1. Take Vital Signs

• Temperature:

• Blood Pressure lying:

• Blood Pressure standing:

• Heart Rate lying:

• Heart Rate standing: 

• Respiratory Rate:

• Oxygen Saturation:

2. Evaluate Symptoms and Signs

• Fingerstick glucose (patients with diabetes)

• Alcohol intoxication or drug use (if narcotic overdose is suspected, administer naloxone (Narcan) immediately)

• Injuries (bruising, laceration, fractures), head trauma

• Assess all joints for change in normal range of motion, weight bearing, etc

• Acute mental status change

• Negative Expressions:  Tearful, crying, irritable, scared, frowning

• Positive Expressions: Laughing, smiling

• Not eating or drinking as much as usual

• If Pain:  exact locations, pain scale, description (sharp, dull, burning), persistent or intermittent

• Fainting, dizziness or lightheadedness when standing up

• Acute decline in ADL abilities

• Thirst, signs of dehydration

• Jaundice

• Bleeding, hemorrhage

• Runny nose, sore throat, headache

• Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress

• Cardiovascular:  Chest pain, new irregular pulse, cyanosis, mottling, edema

• GI: Nausea, vomiting, diarrhea, constipation, heartburn, abdominal distention or tenderness, rebound tenderness, bowel sounds

• GU: New or worsened incontinence, pain with urination, blood in urine, urinary retention / bladder scan

• Neurologic  changes: consciousness/alertness, orientation, weakness, gait changes (unsteadiness, loss of coordination or balance)

• Very low urinary output (<30cc/hr)

• Skin: sweats (diaphoresis), cold/clammy/pale skin; any new skin condition, i.e., bruising (including potential head trauma), rash, infection/cellulitis

3. Take Action using SBAR Report:

• Presence of other, significant symptoms or signs of illness (look through list of any symptoms or signs you have observed, such as mental status change, weakness, fever, etc.)

  • Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.

• Notify medical staff & resident representative within the next 16 hours. 

  • Persistent AND significant change in condition that does not fit any of the situations listed

• Notify medical staff on the next business day 

  • Persistent mild change in condition that does not fit any of the situations listed

4. Implement Management Plan

• Monitor every 4 hours for new signs or symptoms of illness / situations

• Monitor vital signs every 4-8 hrs for 2-3 days

• Offer fluids frequently

• Place on Intake & Output monitoring

• Monitor meal acceptance

• Place on 24-hour report for 2-3 days

• Obtain lab results (if ordered), and notify medical as needed of significantly abnormal values in lab tests (refer to appropriate Situation)

• Update care plan regarding  fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs

• Review status and plan of care with designated representative daily or with any changes

• Update advance directives if appropriate

2025-04-26