Journal of Gerontological Nursing

Assessment 

Nursing Assessment of Ill Nursing Home Residents

Cathy R Barry, RN, MSN; Kathy Brown, RN, BSN; Debbie Esker, RN, GNP; Mary Dee Denning, RN, MSN; Robin L Kruse, PhD; Ellen F Binder, MD

Abstract

To provide quality care, nurses must be competent in assessment and documentation practices. This study reveals a need to update nursing skills related to early identification of acute changes in residents' conditions.

Abstract

To provide quality care, nurses must be competent in assessment and documentation practices. This study reveals a need to update nursing skills related to early identification of acute changes in residents' conditions.

Early identification of an acute change in the condition of residents in nursing homes and appropriate assessment by nurses could mean the difference between a mild illness and a serious decline in status, or a quick recovery with simple treatment and a prolonged course involving hospitalization. Nursing assessment and documentation is a basic nursing standard.

Nurses serve a key role in the nursing home setting by performing resident physical assessment, documentation, communication with the medical team, and evaluation of resident responses to treatment and medication (Potter & Perry, 1999). Expectations for clinical nursing practice stated by the American Nurses Association (ANA, 1991) define the nurse's role and responsibility for client care. These standards include:

* The priority of data collection is determined by the client's immediate condition of needs.

* Pertinent data are collected using appropriate assessment techniques.

* Data collection involves the client, significant others, and health care providers when appropriate.

* The data collection process is systematic and ongoing. Relevant data are documented in a retrievable form.

In the event of a resident's acute change in condition, it is the responsibility of the professional nurse to perform and document an assessment. Assessment includes, but is not limited to, measurement of vital signs and examination of body systems (Potter & Perry, 1999). Documentation is crucial to quality care of the client. Professional nursing standards require maintenance of a complete, accurate, and retrievable record of nursing care. Continuity of care, institutional policy, and legal necessity all compel the nurse to regard this role seriously. Despite the importance of nursing assessment and documentation, very little information is available about adherence to nursing standards, particularly for the nursing home setting.

Therefore, the purpose of this study was to answer the following research questions:

* How often do nurses in nursing homes perform vital sign assessment on residents at the time an acute change in condition is identified?

* How often do nurses perform any body systems physical assessment on residents at the time an acute change in condition is identified?

* Do nurses use standard lung sound terminology to describe their lung sound assessment findings?

METHODS

Data for this study were collected as part of a large prospective study of outcomes of lower respiratory infection (LRI) in the nursing home setting (Missouri LRI Project). Nursing home nurses were trained to report residents with an acute change in condition to research nurses, who would then evaluate the residents for eligibility for enrollment in the Project. Residents in nursing homes were considered to have an acute change in condition if they presented with any new symptoms categorized as either respiratory or non-respiratory. Respiratory symptoms were defined as cough, pleuritic chest pain, production of purulent sputum, shortness of breath, wheezing or respiratory difficulty, and cyanosis. Nonrespiratory symptoms were defined as decreased alertness, increased agitation, decreased oral intake, decreased activity and mobility, increased or new falls, new or increased confusion, and fever (greater than 37.8° C).

Table

TABLE 1PERCENT OF CASES WITH NH ASSESSMENT OF VITAL SIGNS (N = 4,959)

TABLE 1

PERCENT OF CASES WITH NH ASSESSMENT OF VITAL SIGNS (N = 4,959)

Potential cases of LRI in 36 nursing homes were identified for 4,959 residents during 38 months. Not all nursing homes were in the study for the entire 38 months; all but a few of facilities participated for at least 19 months. The evaluation by the research nurse included a physical assessment and an interview with the nursing home staff or a review of the resident's medical record for a description of the nature of symptoms, time of onset, and vital signs taken at illness onset.

This study is an evaluation of the prevalence of vital sign assessments (e.g., temperature, pulse, respiration) performed by nursing home nurses at the time a resident's acute change in condition was identified. Blood pressure was not included in the initial screening for the LRI project, and therefore, could not be included in this study.

Physical assessment data were collected during a 7-month period from a convenience sample of 289 residents at 12 of the 36 participating nursing homes in the LRI project. For any resident identified with an acute change in condition, the research nurse collected information related to any physical assessment performed, and documentation of that assessment by the nurse within the shift of illness onset. The information was obtained through nurse interviews and review of nursing home records.

For residents with non-respiratory symptoms, any body system assessment (e.g., cardiovascular, respiratory, abdominal, neurologic) was recorded. For residents with respiratory symptoms, any lung assessment was recorded. The terminology used to describe lung sound assessment was recorded verbatim. Lung examination terminology was then coded as "standard," "non-standard," or "mixed" by two independent research nurses. Lung sound terminology was defined as "standard" if any of the following words were used: crackles, wheezes, and rhonchi (Mikami et al., 1987). Lung examinations described as "clear" or "diminished breath sounds" were also coded as standard. Any other terminology was coded as non-standard or mixed.

Mixed terminology was defined as the use of both standard and non-standard terminology in one documentation of assessment findings. Examples of terminology considered nonstandard include: "moist respirations," "rubs," "congestion," "coarse," "rales," "raspy," "lungs filled," and "wet." Examples of mixed terminology include: "expiratory rubs bilaterally and wheezes," "wheezing, rubs, and crackles," "wheezing and congestion," and "rubbing with crackles."

Descriptive information about participating nursing homes was collected from Medicaid cost répons provided by the Missouri Department of Social Services, Division of Medical Services. If a cost report was not available, data were abstracted from Missouri Nursing Home and Residential Care Facility Profiles (Missouri Department of Health, 1996).

Table

TABLE 3RESIDENTS IN CONVENIENCE SAMPLE WITH BODY SYSTEM ASSESSMENT BY NURSING HOME NURSES (M = 289)

TABLE 3

RESIDENTS IN CONVENIENCE SAMPLE WITH BODY SYSTEM ASSESSMENT BY NURSING HOME NURSES (M = 289)

RESULTS

Nursing Home Facility Characteristics

The 36 nursing homes participating in the LRl project had a mean of 116 licensed beds (range 36 to 490 beds); 48% Medicaid residents (range 0% to 87%), and a mean annual occupancy rate of 84% (range 44% to 97%). Facility ownership was 64% for-profit; 31% not-for-profit, and 5% government. Thirty-one percent of the nursing homes were considered rural, while 69% were considered urban (urban location was defined as location within a Metropolitan Statistical Area). Facility characteristics for the 12 nursing homes from which body system assessment data were collected were slightly different, with a mean of 179 licensed beds (range 60 to 490 beds); a mean of 44% Medicaid residents (range 4% to 87%); and a mean annual occupancy of 88%. Facility ownership was 42% for-profit and 58% by not-forprofit. All 12 of these nursing homes were urban.

Vital Sign Assessment

To determine how effectively nursing home nurses meet the standard of assessment at the time of an identified resident's change in condition, the prevalence of vital signs performed on residents screened for the LRI project was calculated (Table 1). Thirty-one percent of the residents did not have any vital signs performed at the time of an acute change in condition, and only 36% had a complete set of vital signs taken (excluding blood pressure).

Body System Assessment and Documentation

Two hundred and eighty-nine nursing home residents were examined for evidence of prompt physical assessment and documentation by the nursing home nurse at the time of an acute change in condition (Table 2). Approximately half (52%) of the residents identified by the nursing home staff as acutely ill received some type of nursing physical assessment. Slightly more than half of the residents with respiratory symptoms received a lung assessment (54%), while less than half of residents with non-respiratory symptoms received an examination appropriate to their symptoms (43%). Most assessments were documented: 88% of lung assessments and 94% of body system assessments. Of those residents with a documented lung assessment (Table 3), only half (52%) of the assessments used standard terminology.

Table

TABLE 3TERMINOLOGY USED IN DOCUMENTED LUNG ASSESSMENTS (N= 135)

TABLE 3

TERMINOLOGY USED IN DOCUMENTED LUNG ASSESSMENTS (N= 135)

The relationship between facility characteristics and the frequency of vital sign and body system assessment and documentation were evaluated. There was not a significant association with any of the facility characteristics.

DISCUSSION

To the best of the authors' knowledge, this is the first study to evaluate the frequency of nursing home nurse assessment and documentation related to an acute change in condition. These findings suggest a significant problem with nursing assessment and documentation in the nursing home setting. These findings are also inconsistent with nursing standards of practice. To provide high quality care, nurses must be aware of the existence of these standards, have the appropriate skills for resident assessment, and accurately document findings using standard terminology.

One of the strengths of this study was that tt included a representative sample of nursing homes from both rural and urban areas. Information on a large sample of residents was collected with well-defined criteria for an acute change in condition. However, the study may have overestimated the prevalence of nursing assessment and documentation because some of the nurses may have altered their usual practice because of the presence of the research nurses.

After an exhaustive literature search, the authors were unable to find any research related to the prevalence of nurse assessment and documentation of vital signs and physical assessment.

Indeed, litde research is available regarding general documentation in the nursing home setting. One study performed in Sweden evaluated the effects of an educational intervention on the content and comprehensiveness of nursing care documentation. An audit of the nursing notes for all clients in nursing homes in six Swedish municipalities (n = 120) was performed before and after the intervention. A significant increase in nursing documentation was observed in the intervention group, but not in the control group. However, none of the records in either group met the requirements of Swedish national regulations (Ehrenberg & Ehnfors, 1999). The authors were unable to correlate their findings with resident outcomes, but this kind of information could be very useful for quality improvement.

Identification of the barriers to compliance with nursing standards was beyond the scope of the study. Further research should examine clinical competency standards for nursing home nurses and the effectiveness of continuing education at improving compliance with nursing standards. It would also be useful to evaluate the relationship between adherence to standards and clinical outcomes. Consumers and health care professionals are concerned about quality care, and this study has important implications for practicing nurses, nurse educators, managers, and administrators in the long-term care setting.

Nurses must be competent m their assessment and documentation practices. Nurse orientation programs should include physical assessment and documentation practices, with competency tests. Opportunities to update these skills should be provided through continuing education programs, and nursing home administrators should provide incentives for their staff to participate in such programs. Quality assurance programs should target timely nurse assessment and documentation as a process to monitor and, when deficiencies are identified, appropriate corrective plans need to be developed and implemented.

CONCLUSION

The findings of this study indicate that for a significant number of residents in nursing homes, nursing assessment and documentation is not performed at the time of an acute change in condition, and a basic nursing standard is not being consistently met. Future research will be necessary to elucidate successful strategies for improving nursing assessment and documentation in the nursing home setting.

REFERENCES

  • American Nurses Association. (1991). Standard of clinical nursing practice. Washington, DC: American Nurses Publishing.
  • Ehrenberg, A., & Ehnfors, M. (1999). Patient records in nursing homes: Effects of training on content and comprehensiveness. Scandinavian Journal of Caring Sciences, 13(2), 72-82.
  • Mikami, R., Murao, M-, Cugell, D.W., Chretien, J., Cole, P., Meier-Sydow, J., et al. (1987). International symposium on lung sounds: Synopsis of proceedings. Chest, 92(2), 342-345.
  • Missouri Department of Health, State Center of Health Statistics. (1996). Missouri nursing home and residential care facility profiles (Pub. No. 3.50). Jefferson City, MO: Author.
  • Potter, P.A., & Perry, A.G. (1999). Basic nursing: Theory and practice (4th edition). St. Louis: Mosby-Yearbook.

TABLE 1

PERCENT OF CASES WITH NH ASSESSMENT OF VITAL SIGNS (N = 4,959)

TABLE 3

RESIDENTS IN CONVENIENCE SAMPLE WITH BODY SYSTEM ASSESSMENT BY NURSING HOME NURSES (M = 289)

TABLE 3

TERMINOLOGY USED IN DOCUMENTED LUNG ASSESSMENTS (N= 135)

10.3928/0098-9134-20020501-04

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