Deteriorating Resident Triage Tool

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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance 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 Health Direct RACH Fast Track Service) Contact family
• DOCUMENT
• If in last days of life – follow internal palliative pathways

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’

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance Care Directive and check for anticipatory orders
• Contact GP via video-telehealth (or Health Direct RACH Fast Track Service)
• If symptoms not resolving with anticipatory orders
• Contact family
• DOCUMENT

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

• 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

• 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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance 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 Health Direct RACH Fast Track Service) Contact family
• DOCUMENT
• If in last days of life – follow internal palliative pathways

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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance Care Directive and check for anticipatory orders
• Contact GP via video-telehealth (or Health Direct RACH Fast Track Service)
• If symptoms not resolving with anticipatory orders
• Contact family
• DOCUMENT

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

• Check medication chart for (and implement) anticipatory orders
• Assist into upright position and provide O2, 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

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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance 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 Health Direct RACH Fast Track Service) Contact family
• DOCUMENT
• If in last days of life – follow internal palliative pathways

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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance Care Directive and check for anticipatory orders
• Contact GP via video-telehealth (or Health Direct RACH Fast Track Service)
• If symptoms not resolving with anticipatory orders
• Contact family
• DOCUMENT

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

• 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

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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance 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 Health Direct RACH Fast Track Service) Contact family
• DOCUMENT
• If in last days of life – follow internal palliative pathways

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)

• 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 Health Direct RACH Fast Track Service)
• Contact family
• DOCUMENT

• 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

• 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

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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance 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 Health Direct RACH Fast Track Service) Contact family
• DOCUMENT
• If in last days of life – follow internal palliative pathways

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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance Care Directive and check for anticipatory orders
• Contact GP via video-telehealth (or Health Direct RACH Fast Track Service)
• If symptoms not resolving with anticipatory orders
• Contact family
• DOCUMENT

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

• 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

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)
• Abnormal vital signs

n.b. acute distress may be the only sign of a blocked catheter in a resident with communication difficulties

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance 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 Health Direct RACH Fast Track Service) Contact family
• DOCUMENT
• If in last days of life – follow internal palliative pathways

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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance Care Directive and check for anticipatory orders
• Contact GP via video-telehealth (or Health Direct RACH Fast Track Service)
• If symptoms not resolving with anticipatory orders
• Contact family
• DOCUMENT

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

• 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 or 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)

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
• 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

• Conduct A-G assessment, enact nursing interventions (blue section) and review Advance 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 Health Direct RACH Fast Track Service)
• Contact family
• DOCUMENT
• If in last days of life – follow internal palliative pathways

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

• Conduct A-G assessment, enact nursing interventions (blue section) and review Advance Care Directive
• Contact GP via video-telehealth (or Health Direct RACH Fast Track Service)
• If symptoms not resolving with anticipatory orders
• Contact family
• DOCUMENT

• 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

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

• 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)
• Threatening staff or residents with a weapon

• Use de-escalation techniques
• Conduct A-G assessment and enact supportive interventions (blue section)
• Phone ambulance, prepare ISBAR handover and notify ED of transfer
• Contact family
• DOCUMENT

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

• 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 (intake@changefutures.org.au)
• MNC – Each One Matters (EACHOneMatters@each.com.au)
• If after hours and needing advice, contact the Mental Health Support line 1800 011 511
• Contact family
• DOCUMENT

• 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?”

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:

• Abnormal vital signs
• Change in skin colour or increased redness
• Discharges from orifices
• Distension of abdomen, swelling of limbs / joints

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance 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 Health Direct RACH Fast Track Service) Contact family
• DOCUMENT
• If in last days of life – follow internal palliative pathways

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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance Care Directive and check for anticipatory orders
• Contact GP via video-telehealth (or Health Direct RACH Fast Track Service)
• If symptoms not resolving with anticipatory orders
• Contact family
• DOCUMENT

• 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

• 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

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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance 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 Health Direct RACH Fast Track Service) Contact family
• DOCUMENT
• If in last days of life – follow internal palliative pathways

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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance Care Directive and check for anticipatory orders
• Contact GP via video-telehealth (or Health Direct RACH Fast Track Service)
• If symptoms not resolving with anticipatory orders
• Contact family
• DOCUMENT

• 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

• 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

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) vision in one or both eyes, sudden blurring
• Sudden, abrupt, severe headache
• Sudden difficulty swallowing

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance 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 Health Direct RACH Fast Track Service)
• Contact family
• DOCUMENT
• If in last days of life – follow internal palliative pathways

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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance Care Directive and check for anticipatory orders
• Contact GP via video-telehealth (or Health Direct RACH Fast Track Service)
• If symptoms not resolving with anticipatory orders
• Contact family
• DOCUMENT

• Monitor and document vital signs

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

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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance 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 Health Direct RACH Fast Track Service) Contact family
• DOCUMENT
• If in last days of life – follow internal palliative pathways

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

• Conduct A-G assessment, enact nursing interventions (blue section), review Advance Care Directive and check for anticipatory orders
• Contact GP via video-telehealth (or Health Direct RACH Fast Track Service)
• If symptoms not resolving with anticipatory orders
• Contact family
• DOCUMENT

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

• 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

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

• Symptom assessment score = 8 or above

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

• Check medication chart for additional medications available
• If no suitable / insufficient medications available: phone GP (if not available, call (Health Direct RACH Fast Track Service)
• Conduct A-G assessment, enact nursing interventions (blue section), review Advance Care Directive and check for anticipatory orders
• Phone ambulance – as a last resort if medical orders cannot be gained from any other source

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

• Symptom assessment score = 4 – 7

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

• PRN medications are being used to their maximum amount allowed

• Check medication chart for additional medications available
• If no suitable / insufficient medications available: phone GP via video-telehealth (if not available, call (Health Direct RACH Fast Track Service)
• Enact nursing interventions (blue section)

• Undertake comprehensive clinical examination including history of symptom/s

• Follow the PalliAged flowchart for pharmacological management of end-of-life symptoms or the PalliAged end of life symptom management advice
• Review the NSW CEC Anticipatory Prescribing Guide for recommended medications to request from GP
• Consider non-pharmacological interventions in the Hammond Care end of life flipchart
• Ensure the family are fully informed of the deterioration status
• Check if there are any spiritual needs that need to be addressed e.g. pastoral care visit
• Check if the resident has made any last requests or wishes that need to be addressed

Practice Tip

• NSWAS palliative care protocol allows a paramedic to provide a limited number of medications onsite for common symptoms
• Health Pathways – Management of the Terminal Phase provides suggested pharmacological and non-pharmacological interventions