A nurse's quick assessment of an acute change in the condition of a nursing home resident, for example, development of breathing problems or a fever, can make the difference between a mild illness and a serious decline in health, or between a quick recovery with simple treatment and hospitalization and prolonged recovery. Although patient assessment and documentation are basic nursing practices, they are not always performed by nurses called on to assess the status of nursing home residents, according to a study supported in part by the Agency for Healthcare Research and Quality (HS08551).
If a resident develops an acute change in his or her condition—for example, difficulty breathing or an abrupt change in mental status or mobility—it is the responsibility of the nurse to perform and document an assessment. This assessment includes, but is not limited to, measurement of vital signs (temperature, pulse, and respiration) and examination of body systems, and it is supposed to be documented as a retrievable record of nursing care.
Missouri researchers evaluated the prevalence of vital sign assessments of 4,959 residents who developed symptoms of acute illness in 36 urban and rural nursing homes over a period of 38 months. They also evaluated the prevalence of body system assessments performed by nurses in a convenience sample of 289 residents at 12 nursing homes that participated in the larger study. Overall, 31 percent of residents did not have any vital sign assessments performed at the time of an acute change in condition, and only 36 percent had a complete set of vital signs taken (excluding blood pressure). About half (52 percent) of residents identified by the nursing home staff as acutely ill received some type of nursing physical assessment. Nurses documented 88 percent of lung assessments and 94 percent of body system assessments.
See "Nursing assessment of ill nursing home residents," by Cathy R. Barry, R.N., M.S.N., Kathy Brown, R.N., B.S.N., Debbie Esker, R.N., G.N.P., and others, in the May 2002 Journal of Gerontological Nursing 28(5), pp. 4-7.