The Deteriorating Residents Triage Tool has been piloted in several Residential Aged Care Homes across the North Coast and is currently being evaluated by Healthy North Coast.

If you wish to use the tool, please feel free to do so, understanding that it must be used under the governance of your organisation

NB: Always treat deterioration with suspicion. These parameters are a guide only and are not to replace clinical judgement. Triage abnormal vital signs against the resident’s ‘normal’ parameters (Adapted from Clinical Excellence Queensland ‘Management of acute care needs of RACF residents, 2019).

Clinical support guide for the triage and management of a deteriorating RAC home resident.

 

For effective use of the tool, current resident ACDs and the HNC Goals of Care tool (or equivalent) are recommended.

Currently in pilot phase with three participating RACHs, evaluation measures include effectiveness in building RN confidence and reported reduction in unnecessary hospitalisations. Findings will inform a future planned, region-wide implementation with specific nurse education offered by nurse education specialist Primary Care Innovation, commissioned by Healthy North Coast.

Using This Tool:

Detection of Deteriorating Resident

Nursing assessments: A-G assessment and vital signs

Check Goals of Care Directive (or Advance Care Directive)

Use deterioration symptom page to assess level of severity

Follow response pathway

Useful Contacts

n.b. RACH fast-track after hours – 1800 867 221 – available to all MNC & NNSW RACHs 24/7

or

Practice tools

Implement appropriate nursing interventions and escalate as indicated using ISBAR

Implement recommendations, notify family, document & update care plan as appropriate. If GP was not involved in management, notify GP next working day

Table of Contents

Deterioration Symptom

Practice Tools

Abdominal Pain

When to act
Resident's symptoms
Response
Act Now
Resident's symptoms

If bowels have not been open for 48 hours AND any of these symptoms:

  • Severe abdominal pain
    Nausea
  • Distended, bloated abdomen and no bowel sounds and/or unable to pass wind
  • Persistent vomiting and/or faecal vomitus
  • Increasing agitation or confusion
  • Abnormal vital signs

n.b. Abnormal vital signs, rapid onset of pain, and localised tenderness to right upper or lower quadrant of abdomen can be indicative of leaking aortic aneurysm

Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • If resident for hospital-level treatment, phone ambulance, prepare ISBAR handover and notify ED of transfer
  • If resident for RACH-based level of care, prepare ISBAR handover and escalate to GP via video-telehealth (or GP telehealth service) 
  • Contact family
  • DOCUMENT
  • If in last days of life – follow internal palliative pathways
Act Within 24 Hours
Resident's symptoms

If ONE of the following symptoms present:

  • Distended or bloated abdomen
  • Passing watery bowel motions
  • Bowels not open for 48 hours despite aperients
  • Nausea
  • Decreased oral intake 
    * If >1 of these symptoms are present, treat as ‘Act Now’
Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • Contact GP via video-telehealth (or GP telehealth service) if symptoms not resolving with anticipatory orders
  • Contact family
  • DOCUMENT
Nursing Interventions

Assessments

  • Conduct a comprehensive pain assessment and document 
  • Check and document all vital signs including urinalysis (MSU if possible), BGL, delirium screen, LOC

Interventions

  • Check medication chart for (and implement) anticipatory orders  
  • If in ‘red zone’ criteria, keep nil by mouth until medical review
       If passing wind and no ‘act now’ symptoms, 
  • Encourage oral fluid intake and provide prescribed or nurse-initiated aperients as appropriate
  • Refer to local bowel action protocol

Airway – Cough / Breathing Difficulty

When to act
Resident's symptoms
Response
Act Now
Resident's symptoms
  • If the resident has a change in breathing AND one of the following is present:
  • Chest pain
  • Unable to speak in full sentences
  • Bluish coloured lips and/or fingernails
  • Extra effort required to breathe – use of accessory muscles
  • Airway swelling, rash or itchiness
  • Change in level of consciousness
  • Respiratory rate < 8 or > 30 per minute
  • Physical exhaustion
Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • If resident for hospital-level treatment, phone ambulance, prepare ISBAR handover and notify ED of transfer
  • If resident for RACH-based level of care, prepare ISBAR handover and escalate to GP via video-telehealth (or GP telehealth service)
  • Contact family
  • DOCUMENT
  • If in last days of life – follow internal palliative pathways
Act Within 24 Hours
Resident's symptoms

If any of the following symptoms present:

  • Increasing shortness of breath
  • New coughing
  • Unexplained fever or sweats
  • Decreased food or fluid intake
  • Decrease in usual function or activities
  • Increasing confusion or change in level of consciousness
Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • Contact GP via video-telehealth (or GP telehealth service) if symptoms not resolving with anticipatory orders
  • Contact family
  • DOCUMENT
Nursing Interventions

Assessments

  • Check and document all vital signs including urinalysis, BGL and pain chart

Interventions

  • Check medication chart for (and implement) anticipatory orders  
  • Assist into upright position and provide 02, aim for oxygen saturations between either 92-96% or 88-92% if known underlying chronic airways disease which may cause CO2 retention. If unsure, aim oxygen saturations 88-92% until clarification. Refer to QLD CEC 2019 Management of acute care needs of RACF residents for further information
  • If resident uses CPAP or BiPap, apply as per orders.
  • If resident is using oxygen, check flow and tubing to ensure there is good oxygen flow with no kinks in tubing
  • Support resident in breathing exercises – slow, deep breaths, in through the nose, out through the mouth using pursed lips
  • Check COPD action plan and medication chart, and ensure optimal use of prescribed regular or PRN puffers or nebulisers

Chest Pain

When to act
Resident's symptoms
Response
Act Now
Resident's symptoms

If the resident has new chest pain or tightness AND one or more of the following symptoms:

  • Pain is not relieved by up to 2 doses of their prescribed medication such as Anginine or GTN spray
  • Requiring GTN with no reported history of angina
  • Pain is not relieved by antacid
  • Sweaty or clammy
  • Left arm, shoulder or jaw pain
  • Abnormal vital signs
  • Dyspnoea
  • Nausea & vomiting
  • Syncope
Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • If resident for hospital-level treatment, phone ambulance, prepare ISBAR handover and notify ED of transfer
  • If resident for RACH-based level of care, prepare ISBAR handover and escalate to GP via video-telehealth (or GP telehealth service)
  • Contact family
  • DOCUMENT

If in last days of life – follow internal palliative pathways

Act Within 24 Hours
Resident's symptoms

If any of the following symptoms present:

  • Chest pain (with history of angina) relieved by 1-2 doses of GTN or Anginine warrants a non-urgent medical review
  • Increasing episodes of chest pain brought on by exertion which improve with medication or rest
  • New chest pain or tightness at rest which improves with medication
Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • Contact GP via video-telehealth (or GP telehealth service) if symptoms not resolving with anticipatory orders
  • Contact family
  • DOCUMENT
Nursing Interventions

Assessments

  • Check and document all vital signs and perform chest pain assessment
  • Perform full chest and abdomen examination to look for non-cardiac causes

Interventions

  • Provide reassurance and comfort, this may be either by laying the resident down or sitting upright and loosening tight clothing
  • Check medication chart for (and implement) anticipatory orders  
  • GTN or Anginine medication unless systolic BP < 90mmHg

PRN analgesia as indicated by symptoms / medication order

Confusion / Delirium

When to act
Resident's symptoms
Response
Act Now
Resident's symptoms

If the resident has new or worsening confusion AND one or more of the following:

  • Risk of harm to themselves, staff or other residents
  • Change in level of consciousness
  • Evidence of severe pain or distress
  • Temperature >38 deg or <35 deg
  • BGL <4mmol/L or ‘HI’ on BG monitor
  • Abnormal vital signs

Evidence of infection e.g. UTI, chest, skin 

Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • If resident for hospital-level treatment, phone ambulance, prepare ISBAR handover and notify ED of transfer
  • If resident for RACH-based level of care, prepare ISBAR handover and escalate to GP via video-telehealth (or GP telehealth service)
  • Contact family
  • DOCUMENT

If in last days of life – follow internal palliative pathways

Act Within 24 Hours
Resident's symptoms

The following symptoms may suggest a delirium:

  • Decreased ability to focus attention (cannot hold conversation or spell WORLD or NURSE backward)
  • Increased or fluctuating confusion; increase in night-time confusion
  • Behavioural changes e.g. anxiousness, wandering, calling out, aggression
  • Change in behaviour patterns / routines
  • Hallucinations (auditory or visual)
  • Positive delirium test (CAM score or 4AT score)
Response
  • Review and implement anticipatory orders
  • If this is a dementia-related behaviour change, contact Dementia Australia’s Severe Behaviour Response Team
  • Follow advice from Dementia Support Australia, or escalate through GP via video-telehealth (or GP telehealth service)
  • Contact family
  • DOCUMENT
Nursing Interventions

Assessments

  • Check and document all vital signs including urinalysis, BGL and pain assessment
  • Conduct thorough pain assessment (or use PAINAD) and provide PRN analgesia as appropriate
  • If an acute change – conduct delirium test (CAM score or 4AT score)
  • Check bowel chart for constipation, check fluid balance for dehydration / indicators of malnutrition
  • Check medication chart for recent medication changes
  • Perform dipstick urinalysis / blockages of catheters, chest auscultation, review wounds and check for other infections e.g. cellulitis

Interventions

  • Check medication chart for (and implement) anticipatory orders  
  • Ensure environment safe; avoid restraints and remove falls hazards, ensure resident has glasses and hearing aids. Re orient if in new environment
  • Provide frequent, calm reassurance and orientation / distraction techniques

Dehydration

When to act
Resident's symptoms
Response
Act Now
Resident's symptoms

If the resident has not been drinking water for 24 hours AND one or more of the following:

  • Persistent vomiting or diarrhoea and not tolerating fluids orally for more than 8 hours
  • Oliguria – little or no urine output for 12 hours*
  • Increasing agitation or confusion
  • Shortness of breath or tachycardia
  • Change in resident’s usual level of consciousness
  • Loss of balance, sunken eyes, cramps, dizzy, headache fainting
  • New swallowing difficulty (this could be a sign of stroke)
  • Abnormal vital signs

*oliguria is defined as urine output <0.5ml/kg/hr

Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • If resident for hospital-level treatment, phone ambulance, prepare ISBAR handover and notify ED of transfer
  • If resident for RACH-based level of care, prepare ISBAR handover and escalate to GP via video-telehealth (or GP telehealth service)
  • Contact family
  • DOCUMENT

If in last days of life – follow internal palliative pathways

Act Within 24 Hours
Resident's symptoms

If the resident has any of the following symptoms:

  • Reduced oral intake
  • Dark, concentrated urine (specific gravity >1.030 on dipstick UA)
  • Increasing confusion, agitation or drowsiness
  • Dry mouth and tongue
  • Listlessness
Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • Contact GP via video-telehealth (or GP telehealth service) if symptoms not resolving with anticipatory orders
  • Contact family
  • DOCUMENT
Nursing Interventions

Assessments

  • Check and document all vital signs including urinalysis, BGL, pain assessment and pulse oximetry (monitor BGL regularly)

Interventions

  • Check medication chart for (and implement) anticipatory orders  
  • If the resident is alert, sit upright and provide small sips of water (20-30ml) every 10-15 minutes. Thicken as appropriate for resident. Do not give oral fluids if there is evidence of aspirating (coughing, gagging, delayed swallow)
  • Consider requesting an order for sub cut fluids if resident is not palliative
  • If tolerating thin fluids, consider giving ice chips to suck
  • Consider electrolyte replacement drink such as Hydralyte
  • Provide regular mouth care with swabs dipped in water

In-dwelling Devices (IDC/SPC/PEG)

When to act
Resident's symptoms
Response
Act Now
Resident's symptoms

If there is an issue with a tube (blocked or dislodgement) AND one or more of the following:

  • Temperature >38 or <35
  • Increasing abdominal pain, bloating or vomiting
  • Increased agitation or distress
  • If tube has dislodged and unable to replace within 30 minutes (by appropriately trained staff)
  • n.b. acute distress may be the only sign of a blocked catheter in a resident with communication difficulties
  • Abnormal vital signs 
Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • If resident for hospital-level treatment, phone ambulance, prepare ISBAR handover and notify ED of transfer
  • If resident for RACH-based level of care, prepare ISBAR handover and escalate to GP via video-telehealth (or GP telehealth service)
  • Contact family
  • DOCUMENT

If in last days of life – follow internal palliative pathways

Act Within 24 Hours
Resident's symptoms

If the resident has any of the following symptoms:

  • Symptoms of UTI
  • Signs of local skin infection
  • Resident pulling at device causing trauma
  • New or increased haematuria which does not clear after 24 hours
  • Bypassing around catheter, or urethrally if SPC
  • Increasing resistance when flushing PEG, or decreased flow from IDC/SPC
Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • Contact GP via video-telehealth (or GP telehealth service) if symptoms not resolving with anticipatory orders
  • Contact family
  • DOCUMENT
Nursing Interventions

Assessments

  • Check all vital signs including urinalysis, BGL, pain assessment and document results
  • Ensure resident is not dehydrated

Interventions

  • Check medication chart for (and implement) anticipatory orders  
  • For blocked gastrostomy tube, try gentle flush and aspiration of warm water
  • If gastrostomy tube dislodged, replace tube within 2 hours (use a Foley catheter temporarily if unable to replace with dedicated tube)
  • Provide wound care to skin around insertion site
  • Check if tube is kinked, tangled of clamped, and support the resident to move / change position or move location of catheter bag to ensure it is below bladder level
  • Check that bowels have been opened and palpate the abdomen – constipation can result in obstruction to urinary flow
  • If oozing around site, check correct volume of water is inside balloon
  • If the resident is confused, place tube inside clothing out of reach (ensuring pressure injury prevention strategies maintained)

Falls (with or without headstrike)

When to act
Resident's symptoms
Response
Act Now
Resident's symptoms

If the resident has had a fall AND one or more of the following is present:

  • Increased confusion from resident’s normal, or fluctuating confusion / consciousness / increased agitation
  • Unable to get off the floor and
  • Leg or arm/wrist deformity
  • Leg shortening
  • Bruising or bleeding on head, or high degree of suspicion of head strike in absence of bruising or bleeding on head
  • Severe pain or weakness on movement
  • Able to get up however difficulty using a limb
  • On oral anticoagulants (warfarin/rivaroxaban/apixaban) and has hit head or is an unwitnessed fall
  • Abnormal vital signs
Response
  • Conduct A-G assessment, enact nursing interventions (blue section) and review ‘My Goals of Care Directive
  • If resident for hospital-level treatment, phone ambulance, prepare ISBAR handover and notify ED of transfer
  • If resident for RACH-based level of care, prepare ISBAR handover and escalate to GP via video-telehealth (or GP telehealth service)
  • Contact family
  • DOCUMENT

If in last days of life – follow internal palliative pathways

Act Within 24 Hours
Resident's symptoms

If the resident has had a fall AND has any of the following symptoms:

  • Persistent or increasing pain
  • Increased unsteadiness
  • Features that could lead to a further fall
  • Reduced movement of limb or inability to move in the resident’s usual manner
Response
  • Conduct A-G assessment, enact nursing interventions (blue section) and review ‘My Goals of Care Directive’
  • Contact GP via video-telehealth (or GP telehealth service) if symptoms not resolving with anticipatory orders
  • Contact family
  • DOCUMENT
Nursing Interventions

Assessments

  • Post fall assessment
  • If suspected head injury conduct neuro observations including Glasgow Coma Scale, and vital signs every 30 minutes for 4 hours, then 4th hourly for 24 hours and document results
  • Conduct pain assessment and provide analgesia as appropriate
  • Check medication chart for recent medication changes
  • Check all vital signs including lying and standing BP, urinalysis and BGL and document results

Interventions

  • If no obvious injury, monitor for any change in function or cognition
  • Review falls management plan

Mental Health / Suicidal Ideation

When to act
Resident's symptoms
Response
Act Now
Resident's symptoms
  • If there has been an attempt of suicide, or
  • Verbal threats to suicide, with a plan and lethal means available (dangerous drugs, accumulated medications, poison, weapons) 
Response
  • Conduct A-G assessment and enact supportive interventions (blue section)
  • Phone ambulance, prepare ISBAR handover and notify ED of transfer
  • Contact family
  • DOCUMENT
Act Within 24 Hours
Resident's symptoms

Signs of deteriorating mental health:

  • Emotional signs – drastic mood swings, hopelessness, rage, irritability, anxiety, withdrawn, vengeful thoughts, crying, yelling, arguing, fear, confusion
  • Behavioural signs – rocking/swaying, rapid breaths, pressured speech, body tenseness, loud or quiet, poor eye contact
  • Cognitive signs – defensiveness, blaming, obsessions/preoccupation, refusal to listen, cognitive biases such as overgeneralisation or black and white thinking
  • Statements like ‘it doesn’t matter anymore’
  • Unexplained change in behaviours
  • Putting affairs in order
  • Giving away belongings
Response
  • Review and implement anticipatory orders  
  • Check if resident has a mental health management plan and action the strategies
  • Enact supportive interventions (blue section)
  • Refer resident to psychological support worker and inform GP
  • NNSW – Change Futures ([email protected])
  • MNC – Each One Matters ([email protected])
  • If after hours and needing advice, contact the Mental Health Support line 1800 011 511
  • Contact family
  • DOCUMENT
Nursing Interventions
  • Environmental risk scan (stockpiled medications, sharp objects, plastic bags, cords etc.)
  • Respect personal space by standing slightly on the side, moving to a quiet space if possible
  • Use non-threatening body language using calm gestures and soft tone of voice
  • Allow for time by using silence and giving space for processing
  • Be empathetic and non-judgemental by actively listening, using communication strategies such as reflection and summarising
  • Supportive communication strategies include: listening (don’t fix, just listen), validate the person’s feelings, and ask about suicidal ideation if you are not sure e.g. “I am concerned about you, when you say you have had enough. Are you talking about suicide?”

Pain

When to act
Resident's symptoms
Response
Act Now
Resident's symptoms

If the resident reports or shows evidence of:

  • New moderate to severe pain unrelieved by prescribed regular and PRN analgesia (using approved verbal or non-verbal pain assessment tools)
  • Behavioural symptoms – aggression, resistance, rocking, guarding body part
  • Facial expression – grimacing, fear, tension, looking frightened
  • Verbalisations – self reporting, repeated requests analgesia, whimpering, groaning, crying
  • Physiological changes – sweating, flushing, tachycardia, hypertension, febrile

If the resident is reporting pain with any of these associated symptoms:

Distension of abdomen, swelling of limbs / joints

Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • If resident for hospital-level treatment, phone ambulance, prepare ISBAR handover and notify ED of transfer
  • If resident for RACH-based level of care, prepare ISBAR handover and escalate to GP via video-telehealth (or GP telehealth service)
  • Contact family
  • DOCUMENT

If in last days of life – follow internal palliative pathways

Act Within 24 Hours
Resident's symptoms

If the resident has any of the following:

  • Increasing reported pain
  • Increasing agitation or difficult behaviour
  • Changes to posture – standing, sitting reclining or guarding the pain

Changes to mobility, range, gait, endurance and fatigue etc

Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • Contact GP via video-telehealth (or GP telehealth service) if symptoms not resolving with anticipatory orders
  • Contact family
Nursing Interventions

Assessments

  • Check and document all vital signs Conduct comprehensive pain assessment – Brief Pain Inventory, ACI Pain Assessment, Abbey Pain Scale (useful for residents with dementia/non-verbal), PAINAD (useful for resident with dementia/non verbal)
  • Examine the area of pain – review tenderness, distension, infection, swelling, discharge

Interventions

  • Implement non-pharmacological methods such as ICE hot or cold packs, massage, relaxation techniques, TENS (Health Pathways)

Check medication chart for (and implement) anticipatory orders  

Skin Conditions

When to act
Resident's symptoms
Response
Act Now
Resident's symptoms

If the resident has developed a new skin problem AND one or more of the following:

  • Significant and increasing redness, heat, pain, rash or swelling of an area of skin
  • Blotching / hives consider allergic reaction
  • Temperature > 38 or < 35
  • Abnormal vital signs
  • Increasing agitation or confusion
  • Change in level of consciousness
Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • If resident for hospital-level treatment, phone ambulance, prepare ISBAR handover and notify ED of transfer
  • If resident for RACH-based level of care, prepare ISBAR handover and escalate to GP via video-telehealth (or GP telehealth service)
  • Contact family
  • DOCUMENT

If in last days of life – follow internal palliative pathways

Act Within 24 Hours
Resident's symptoms

If the resident has any of the following skin problems:

  • Redness, heat, pain, rash or swelling of an area of skin
  • A newly identified ulcer or large traumatic wound
  • New discharge from, or redness surrounding an ulcer
Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • Contact GP via video-telehealth (or GP telehealth service) if symptoms not resolving with anticipatory orders
  • Contact family
  • DOCUMENT
Nursing Interventions

Assessments

  • Check and document all vital signs
  • Conduct and document full skin assessment – blanching, tracking, itching, ooze, rash / blotches, hives, skin lesions, bruising, oedema, pressure points, blisters etc
  • Conduct and document pain assessment and provide analgesia as indicated

Interventions

  • Check medication chart for (and implement) anticipatory orders  
  • Check if resident has anticipatory orders in place for recurring skin issues, and enact
  • For burns, place under cold running water immediately for 20 minutes
  • For skin tears – replace skin flap over skin tear, cleanse and apply a silicon dressing
  • Mark the outline of the reddened area with a permanent marker and monitor for progression
  • Review HealthPathways Wound Care resources

Stroke

When to act
Resident's symptoms
Response
Act Now
Resident's symptoms

Symptoms of stroke:

  • Facial weakness – can the person smile? Has their mouth or eye drooped?
  • Arm weakness – can the person raise both arms?
  • Speech difficulty – can the person speak clearly and understand what you say?
  • Time – time of onset of symptoms and duration
  • Sudden confusion, dizziness, loss of balance
  • Loss of (or decreased) vison in one or both eyes, sudden blurring
  • Sudden, abrupt, severe headache
  • Sudden difficulty swallowing
Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • If resident for hospital-level treatment, phone ambulance, prepare ISBAR handover and notify ED of transfer
  • If resident for RACH-based level of care, prepare ISBAR handover and escalate to GP via video-telehealth (or GP telehealth service)
  • Contact family
  • DOCUMENT

If in last days of life – follow internal palliative pathways

Act Within 24 Hours
Resident's symptoms

If resident displays any symptoms of stroke but is not for transfer to hospital as per ‘My Goals of Care Directive’

Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • Contact GP via video-telehealth (or GP telehealth service) if symptoms not resolving with anticipatory orders
  • Contact family
  • DOCUMENT
Nursing Interventions

Assessments

  • Monitor and document vital signs

Interventions

  • Keep nil by mouth until medical review
  • Provide reassurance & keep resident comfortable whilst awaiting ambulance or commencing palliative pathway as per ACD

Urinary Symptoms

When to act
Resident's symptoms
Response
Act Now
Resident's symptoms

If you suspect a urinary tract infection AND one of the following is present:

  • Temperature > 38 or < 35
  • Abnormal vital signs
  • Increasing agitation or confusion
  • Moderate to severe pain

OR

  • Oliguria and resident is in moderate to severe pain

*oliguria is defined as urine output <0.5ml/kg/hr

Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • If resident for hospital-level treatment, phone ambulance, prepare ISBAR handover and notify ED of transfer
  • If resident for RACH-based level of care, prepare ISBAR handover and escalate to GP via video-telehealth (or GP telehealth service)
  • Contact family
  • DOCUMENT

If in last days of life – follow internal palliative pathways

Act Within 24 Hours
Resident's symptoms

If the resident has any of the following symptoms:

  • Burning, stinging or difficulty passing urine
  • Blood-stained urine
  • Offensive, thick or dark urine
  • More frequent urination
  • Reports or appears in pain, rubbing groin or abdomen
Response
  • Conduct A-G assessment, enact nursing interventions (blue section), review ‘My Goals of Care Directive’ and check for anticipatory orders
  • Contact GP via video-telehealth (or GP telehealth service) if symptoms not resolving with anticipatory orders
  • Contact family
  • DOCUMENT
Nursing Interventions

Assessments

  • Check and document all vital signs
  • Check bowel chart for constipation

Interventions

  • Check medication chart for (and implement) anticipatory orders  
  • Take a clean urine sample and perform a urinalysis and document results
  • Collect MSU where possible
  • Check IDC / SPC for blockages
  • Palpate abdomen to assess if resident has signs of urinary retention

End-of-life Symptom Management

When to act
Resident's symptoms
Response
Act Now
Resident's symptoms

If resident or staff report severe distress from symptoms that are not relieved by charted medications i.e.

(Symptoms may be – pain, breathing difficulty, bowel problems, nausea, vomiting, terminal agitation)

Response
  • Check medication chart for additional medications available
  • If no suitable / insufficient medications available:
  • Phone GP (if not available, call GP telehealth service)
  • Enact nursing interventions (blue section)
  • Phone ambulance – as a last resort if medical orders cannot be gained from any other source
Act Within 24 Hours
Resident's symptoms

If resident or staff report moderate distress from symptoms that are not relieved by charted medications i.e.

(Symptoms may be – pain, breathing difficulty, bowel problems, nausea, vomiting, terminal agitation) AND/OR

  • PRN medications are being used to their maximum amount allowed
Response
  • Check medication chart for additional medications available
  • If no suitable / insufficient medications available:
  • Phone GP via video-telehealth (if not available, call GP telehealth service)
  • Enact nursing interventions (blue section) 
Nursing Interventions

Assessments

  • Undertake comprehensive clinical examination including history of symptom/s

Interventions

Practice Tip

A-G Assessment

A – Airway – Is their chest moving? Is there noisy breathing? Is there mouth/neck swelling?

B – Breathing – Is there difficulty breathing? Can they talk in full sentences? Are they using accessory muscles to breathe?

C – Circulation – Is their BP lower than normal for them? Are they sweaty, cold or clammy? Do they feel dizzy? Are their lips pale or blue? Is their heart rate high, low or irregular?

D – Disability – Is there slurred speech or any limb weakness? Is their cognition at their baseline? Are they confused, agitated, aggressive or drowsy?

E – Exposure – Are there any concerning skin issues such as rash, wounds, bleeding? Are they febrile?

F – Fluids – Do they feel thirsty and have they been passing urine?

G – Glucose / Goals – If they are diabetic, is their BGL normal? Is there an Advance Care Directive?

Adapted from Sydney North PHN & North Sydney LHD, Deteriorating Resident Flipchart

Vital Sign Parameters

Vital sign Urgent review indicated (potentially life-threatening) Abnormal Normal vital signs
Response Unresponsive, responsive to pain only, or sudden change in mental state Responsive to voice Alert (or normal cognition for the resident)
Respiratory rate (breaths per minute) <6 or >30 6-9 or 25-30 10-24
Pulse oximetry
Ensure an accurate reading 		<88% despite oxygen 88-91 despite oxygen 92-100
Heart rate (beats per minute) <40 or >130 40-49 or 101-130 50-100
Systolic blood pressure (manual) <90 or >200 with symptoms 90-109 or 181-200 (and otherwise well) 110-180 (or range specified by GP)
Blood Glucose Level <4 or >15 and unresponsive to treatment and resident unwell Persistently 4.0-5.9 or >15 and resident well 6-15 (or range specified by GP)
Temperature (degrees Celsius) <35 or >39 35-35.5 or 37.8 to 39 35.6-37.7
Pain Clearly distressed despite analgesia Obvious discomfort despite analgesia Nil or tolerable pain

Always treat deterioration with suspicion. These parameters are a guide only and are not to replace clinical judgement. * Triage abnormal vital signs against the resident’s ‘normal’ parameters.

Adapted from Clinical Excellence Queensland ‘Management of acute care needs of RACF residents’ (2019)

End-of-Life Symptom Assessment Scale

Absent Mild Moderate Severe

0 1 2 3 4 5 6 7 8 9 10

Use the scale to choose a number between 0 and 10 that shows how distressed the resident is feeling, or what you are observing. Symptoms include:

  • Nausea
  • Bowel problems
  • Breathing problems
  • Pain
  • Agitation

Adapted from PCOC – Palliative Care Outcomes Collaboration assessment tools

ISBAR Communication Tool

I Introduction
  • Introduce yourself, designation and where you're calling from
  • Introduce resident; age and gender, resident length of stay in RACH
S Situation
  • What is the reason for calling?
  • Specify symptoms causing concern - ('red' symptoms or 'yellow' symptoms
  • Note ACD and Goals of Care Directive
B Background
  • Provide an overview of CURRENT health information
  • Previous illnesses of significance
  • Relevant problems and treatments to date
A Assessment
  • Clinical observations (BP, HR, oxygen saturations, respiratory rate and effort, pain, temperature, level of consciousness)
  • Findings of your A-G clinical assessment, combined with your clinical assessment of the situation AND consider Goals of Care Directive
R Recommendation
  • State nursing diagnosis, Goals of Care Directive and discuss next steps
  • Acute event requiring hospital intervention eg significant fall with #
  • Resident requires medical review, anticipatory orders do not cover needs
  • Resient requires treatment in place to palliate

Be sure to have ISBAR information and resident information / medication charts ready!

Adapted from ACSQHC ‘ISBAR Poster’ (2008)

Useful Contacts

Contact Service offering Information needed Hours of operation Contact Information
GP Telehealth Service HNC-funded telehealth service ISBAR, medication chart Relevant assessments 24 hrs per day
7 days per week 		1800 931 158
NSW Ambulance Transport to hospital
End of life protocol 		ISBAR 24 hrs per day 7 days per week Emergency – 000
Non-emergency – 131 233
Dementia advisory service – Severe behaviour response team Severe Behaviour Support team Dementia Behaviour Management Advisory service This service also offers a GP support line through the main number (for use by resident GP) ISBAR, med chart, pain assessment, delirium screen, strategies attempted, NOK consent (if unable, this can be ‘pending consent’) 24 hrs per day
7 days per week 		1800 699 799
Geriatric Care Australia Comprehensive Geriatrician Consultations Can also provide advice for behavioural and psychological symptoms in dementia ISBAR, medication chart Relevant assessments GP or NP referral (for bulk-billing) Mon – Fri 9.30am – 5pm (02) 9160 0079

[email protected]
ELDAC (End of Life Directions for Aged Care) Telephone advice service for end of life care ISBAR, medication chart Relevant assessments Mon – Fri 9am – 5pm (leave message outside of these times) 1800 870 155
Mental Health Line Support if concerned about a resident’s mental health ISBAR, medication chart, relevant history and assessments 24 hrs per day 7 days per week 1800 011 511
13YARN Aboriginal and Torres Strait Islander Crisis support ISBAR, medication chart, relevant history and assessments 24 hrs per day 7 days per week 13 92 76
Change Futures NNSW Psychology service for RACH residents – urgent support for suicidal ideations ISBAR, relevant history and assessments Mon – Fri 9am – 5pm (07) 3153 1093 or [email protected]
Each One Matters MNC Psychology service for RACH residents urgent support for suicidal ideations ISBAR, relevant history and assessments Mon – Fri 9am – 5pm 1300 003 224 or [email protected]
Public Health Unit
Phone is monitored 24/7, email is monitored only during business hours 1300 066 055
or [email protected]

References and Resources

Acknowledgements

HNC acknowledges the following for their guidance in helping to develop this triage tool:

  • Dr Desmond Graham, Geriatric Care Australia
  • Suicide / mental health information developed with thanks by ‘Change Futures’  www.changefutures.org.au
  • RACH managers throughout the HNC region, in particular Owen Lednor, Jodie Gavranov, Matthew Ashby, Alma O’Leary & Alan Pretty
  • Local Nurse Practitioners, including Alison Slinn, Lisa Garland, Anne-Maree Schweitzer & Debbie Deasey
  • The HNC HealthPathways team
  • This flipchart has been funded through the CWLTH-funded ‘Enhanced After Hours Support for RAC Homes’ project. 
  • Some information for this resource has been developed from the Sydney North PHN’s ‘Deteriorating Resident Flipchart’, with permission and thanks