- 1 Recognising a Sick Patient in a Nursing Home Setting
- 1.1 Back to Basics: Vitals
- 1.2 Nursing Home vs Hospital
- 1.3 A Reasonable Approach
- 1.4 Common Conditions
- 1.5 What if the condition the patient has does not fall into these above categories?
- 1.6 Scoring systems
- 1.7 Questions?
- 1.8 References
Recognising a Sick Patient in a Nursing Home Setting
Patients in the nursing home are chronically sick. Most patients are admitted due to long-term medical problems that make them difficult to care for in their own homes. They are usually stable, but sometimes their conditions can flare up, requiring medical attention.
This article is to guide our nursing home nurses and nursing aides in recognising a sick patient.
Back to Basics: Vitals
How are we supposed to know what is abnormal when we do not know what is normal?
|Blood Pressure (Systolic)||120||160||90|
|Blood Pressure (Diastolic)||60||110||50|
Nursing Home vs Hospital
Are we a hospital?
This is the most important question to answer. The answer is invariably no. A nursing home is a long-term care facility where patients and staff live in a community in which their medical, nursing and therapy needs are being met in the same place.
We are not an acute hospital.
There is a lot of research originating from acute hospitals and critical care units about how to recognise sick patients with many complicated scoring systems and algorithms. Unfortunately, most of that is not going to apply to us.
Due to this, there is going to be very little research and data done in this field. I will have to try to summarise a solution that could be more relevant to our nursing home settings myself. Hence, it could be completely wrong. If you have any opinions on this, please leave your comments below.
A Reasonable Approach
Is the patient not his/her usual self?
If the patient is as per “usual”, and his parameters or behaviour have been like this since admission, then we should probably leave him/her alone.
If there is a new change in behaviour, then…
Is this a change that could signify that something dangerous is happening?
If yes, then escalate and ask someone. Otherwise, think through what a possible diagnosis could be.
Does this patient already have an ACP on this condition stating that he/she should not be transferred out?
Basically, we are trying to answer the question if escalating the care will improve the quality of life of the patient or potentially make it worse (see palliative lectures).
Does the patient need to be transferred out NOW?
We have to consider the urgency of the condition. Some conditions have to be treated early for a good outcome, while other conditions allow some leeway to let us try some treatment first. And while thinking about this question, we should also ask ourselves: can we adequately treat the patient in our current setting?
Most of the nursing home transfers to the hospitals comprise the following big diagnoses, so it might be worthwhile knowing them.
Overwhelming lung infection. Simple, right? If only it was.
Nursing home patients have multiple medical problems, most of which can make them immobile on their beds, impair their swallowing and weaken their immunity. Lung infections of varying degrees occur to most nursing home patients, if not all. Not all of them need urgent treatment.
Common symptoms: cough, fever, phlegm.
Urinary Tract Infection
Nursing home patients have high rates of urinary retention as well as asymptomatic pyuria (white cells) and bacturiuria (bacteria in urine). However, most of them do not have any symptoms and hence do not need treatment.
Some of these patients, however, do develop overwhelming infections.
Common symptoms: fever, tiredness, loss of appetite, pain when passing urine, unusual urine colour.
Nursing home patients tend to have poor skin condition due to age, as well as underlying medical problems such as diabetes, eczema, nail issues and immobility.
It is best to try to actively prevent it by applying emollients aggressively and treating active skin and nail issues. If cellulitis does happen, we should quickly pick up any areas of redness or swelling and immediately start an antibiotic.
Unfortunately, this condition can sometimes progress very quickly, and generally when the patient starts to have a fever, he/she will likely need a parental antibiotic (IM or IV).
“Sepsis” is the umbrella term for severe infections with bacteria in the blood. It is generally due to the above mentioned infections. The vital signs will unlikely be normal. These patients usually need parental antibiotics.
Congestive Heart Failure or Congestive Cardiac Failure or “Fluid Overload”
These patients’ conditions tend to be very chronic and relapse often. In fact, most of them should be offered palliative treatment instead due to the poor prognosis of any of these conditions. Transfer to an acute hospital should be done only when a trial of medical treatment at the nursing home has failed, since treatment at the acute hospital will not differ very much from what a nursing home can provide.
Most importantly, if it is a chronic terminal illness, aggressive treatment might not change the eventual outcome.
Diarrhea can be common in a nursing home. As long the patient is still able to replace the fluids that are lost, there is generally no need for transfer to an acute hospital. If intravenous fluids can be provided, there will be no difference in the care.
Chronic Obstructive Pulmonary Disease Exacerbation
These patients tend to be breathless all the time. It can be very difficult to estimate “how much more breathless” they need to be before they need to be sent to an acute hospital.
In any case, these patients should be offered palliative care as well since no amount of hospital stay will change the eventual outcome.
Patients who refuse to eat and drink either have a death wish or they have underlying reasons that render them unable to do so. Most of these underlying reasons will not be treatable by a hospital stay anyway. They should be offered palliative care.
No matter how well we care for them, falls will still happen, unfortunately. Most falls without head injury can be observed until the doctor sees the patient.
Falls with head injury should be triaged according to the “Canadian CT head rule”.
Unfortunately, based on this, most of our residents are above 65 anyway, putting them at “high risk” according to this guideline… However, if they do not fit any of these criteria, continue monitoring them at the nursing home for any acute changes.
Delirium and change of mental state
This is the “final common pathway” for any illness. It could be the only or even first presenting symptom for any of the illnesses given above. If we are unable to come to a reasonable diagnosis fairly urgently, then it is not unreasonable to refer the patient to the emergency to try to find out a cause, unless the patient has already recently had some workup done, and this has been deemed to be “the usual” (baseline) for this patient.
What if the condition the patient has does not fall into these above categories?
Sometimes, it could be a chronic issue that the patient has, which does not need urgent treatment. It is best to ask the doctor.
Or sometimes, it could be other issues that require a brief hospital stay for treatment. Again, try to apply the above questions. If you still cannot figure it out, escalate the question.
Again, we work in a community and as a team. Nobody has to shoulder all the responsibilities of all the above. Always share and in the process, learn good communication skills!
Use ISBAR – Identify, Situation, Background, Assessment and Recommendation
• Identify — Who are you and what is your role? Patient identifiers (at least 3)
• Situation — What is going on with the patient?
• Background — What is the clinical background/context?
• Assessment — What do you think the problem is?
• Recommendation — What would you recommend?
Risks- patient/occupational health and safety?
Assign and accept responsibility/accountability
A score of more than 5 indicates likelihood of death or ICU stay.