Weakness (general), Needs more help
Also Consider: Mental Status Change, Weakness (one side - face, arm or leg)
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Causes
Common: infection, dehydration, metabolic disorders, anemia, neurologic diseases, stroke, medications/overdose
Less common: adrenal insufficiency, heart disease, lung disease, autoimmune diseases
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
Acute mental status change
Not eating or drinking as much as usual
Fainting, dizziness or lightheadedness when standing up
Acute decline in ADL abilities
Thirst, signs of dehydration
Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress, diminished respirations.
Cardiovascular: Chest pain, new irregular pulse, cyanosis, mottling, edema
GI: Nausea, vomiting, diarrhea, 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)
Skin: sweats (diaphoresis), cold/clammy/pale skin; any new skin condition, i.e., bruising (including potential head trauma), rash, infection/cellulitis
Fingerstick glucose (patients with diabetes)
3. Take Action using SBAR Report:
Presence of other, significant symptoms or signs of illness
Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.
Immediately notify the medical staff & resident representative
Abrupt onset of general weakness with fever, change in LOC, or other acute symptoms
Notify medical staff on the next business day
New onset of general weakness without any other symptoms
Notify medical staff at the next regular rounds
Gradually progressive general weakness
SBAR Report
Situation: "Generalized weakness associated with:" (acute symptoms)
Background:
Reason the patient is in the nursing home (rehab for___, long term care for __).
When the weakness started, how severe it is, getting worse or staying the same, any treatments that have been used.
Abnormal vital signs or changes with lying and standing
MOLST / Advance Directives
Recent illness, antibiotics, medication changes, surgery, falls
General observation of patient condition
Diuretic use & recent dose changes
Diet restrictions, fluid restriction, thickened liquids
Blood glucose, if elevated
Abnormal findings on lung, cardiovascular, abdomen, genitourinary,neurologic or skin observations.
Signs or symptoms of constipation, infection, dehydration, head trauma
Tube feeding rate, water flush orders, residual measurements, recent changes
Availability of IV or clysis hydration (i.e., PICC line)
Assessment: I am concerned about: __________
Recommendations/Requests:
Labs: CBC with manual diff, Lactic Acid, CMP/Chem14, Magnesium, Phosphorus, CK, Drug levels
INR if patient is on warfarin
Chest X-ray with lateral view if possible
EKG
Other:
Physical therapy evaluation
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
Monitor vital signs every 8 hrs for 2-3 days
Offer fluids frequently
Oral, IV, or subcutaneous fluids if needed for hydration
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
Update advance directives if appropriate
2025-04-27
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