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Standard of care for monitoring residents with an acute illness or infection

Long-Term Care Nursing Advisor, January 28, 2005

Nurses and paraprofessional nursing personnel are responsible for regular, ongoing monitoring of residents who have experienced an acute illness, infection, incident, or other event. Any change in condition, no matter how minor, falls into this category. The resident must be monitored for as long as necessary to ensure the event is resolved, and the resident's condition has stabilized. If abnormalities are noted, the licensed nurse must take the appropriate nursing action, providing the necessary interventions and notifications.

If a resident experiences a change in condition, nursing personnel should do the following:
1. Monitor the resident regularly on all shifts until at least 24 hours after the acute event is completely resolved. Monitoring may continue for days or weeks, depending on the nature of the precipitating occurrence, and resident's response.
2. Monitor vital signs (temperature, pulse, respirations, and blood pressure) at least once every eight-hour shift. Check vital signs more frequently if one or more of the values are abnormal, or the resident's condition warrants it.
3. Conduct a focused assessment of resident systems, based on the nature of the resident's problem at least once each shift. For example, for a resident with upper respiratory infection, the nurse should assess and document: 

  • Auscultation of lung sounds. Assess the nature of sounds and adequacy of chest expansion, rate, rhythm, depth of respirations, and use of accessory respiratory muscles.
  • Color of the resident's skin, lips, and fingernail beds.
  • Change in mental status or level of consciousness.
  • Increased restlessness.
  • Shortness of breath or other difficulty breathing.
  • Presence or absence of cough. If present, note whether productive or non-productive, with color, character, and amount of secretions.
  • Presence or absence of signs and symptoms related to the specific infection. For example, presence or absence of nasal drainage.

4. Report results of monitoring to the oncoming nurse in the change of shift report.
5. Notify the physician immediately if abnormalities are noted.
6. Update the care plan to reflect the additional observations, monitoring and care required because of the acute illness, infection, change in condition, or abnormal observation.
7. Document the results of monitoring, observations, nursing interventions, notifications, and the resident's response in the nurses' notes. If the resident is on antibiotics or other therapy, document the condition for which the antibiotics are being given. Avoid entries such as "no side effects to antibiotics." This is an appropriate entry in addition to other information, but absence of side effects can be easily noted on the medication record or flow sheet. Your nursing notes should address your assessment of the acute medical problem or injury and actions taken, as noted above.
8. If the resident is not responding to treatment for an acute medical problem, contact the physician.

Editor's note: The above information is excerpted from the new HCPro book, The Long-Term Care Nursing Desk Reference. For more information about this book, click here: http://www.hcmarketplace.com/prod.cfm?id=3152  .

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