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Standard of care for monitoring residents with acute illness or infection

Long-Term Care Nursing Advisor, September 22, 2006

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.

If a resident experiences a change in condition, nursing personnel should perform the following duties:

• 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.
• 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 is abnormal, or the resident's condition warrants.
• Conduct a focused assessment of resident systems, based on the nature of the resident's problem, at least once each shift.
• Report results of monitoring to the oncoming nurse in the change of shift report.
• Notify the physician immediately if abnormalities are noted.
• Inform the responsible party of the change and action taken.
• 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.
• 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.
• If the resident is not responding to treatment for an acute medical problem, contact the physician.

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