October 2021

What would you do?

The following scenario demonstrates your accountabilities when performing nursing assessments.

Pedro, an RPN, is responsible for 45 residents at a long-term care home. At the beginning of Pedro’s shift, Mike, a personal support worker (PSW) reports that Mrs. Lee, slipped while she was in the shower. Mrs. Lee is an 89-year-old resident with early stages of Alzheimer’s disease.

Mike tells Pedro that there is no need to worry; he helped Mrs. Lee get into bed, and now she is resting comfortably.

Pedro asks Mike some questions about the fall: Was Mrs. Lee alone in the shower or did Mike witness the fall? Was she sitting or standing when she fell? Did she hit her head or lose consciousness?

Mike provides Pedro with additional information. Pedro has worked with Mike for several years and trusts his judgment and skill.

A full assessment

Pedro knows that, for an elderly patient, a fall is significant. It’s possible Mrs. Lee’s condition could have changed since Mike last saw her. She could have sustained injuries such as a subdural hematoma, concussion or bone fracture. Pedro knows that timely and consistent assessments are key to catching a change in condition before it worsens, which leads to overall improved patient outcomes. For these reasons, Pedro decides he should assess Mrs. Lee right away.

Pedro uses the long-term care home’s falls assessment tool to assess Mrs. Lee.

He also knows the importance of including residents in their care decisions, so he asks Mrs. Lee about what happened. He also asks her to describe areas of pain and discomfort. Since Mrs. Lee is in the early stages of Alzheimer’s, she has difficultly finding the right words to explain what occurred. Pedro takes the time to listen to Mrs. Lee express her thoughts and needs. During their conversation, he notices Mrs. Lee wincing while holding her left hip. Pedro documents this abnormal response.

Based on his initial assessment findings, Pedro completes a head-to-toe assessment on Mrs. Lee. He checks her vital signs and completes a physical examination. He notices redness and swelling developing on her left hip, and she cries out in pain when he palpates the area. He gathers and reviews information about her overall health by reviewing her patient records to verify which medications she is on or if she has had any previous falls. He also gathers other health care data such as medical history, nutritional status and functional status.

Pedro analyzes his findings and decides to consult with members of the health care team to determine the next steps for Mrs. Lee’s care plan.

The team collaborates

Pedro meets with members of the health care team and shares his findings. Pedro’s assessment identifies that Mrs. Lee’s care needs are beyond what the long-term care home can provide. Together, they decide to contact the physician. The physician reviews and discusses the assessment findings with Pedro. They decide Mrs. Lee should be sent to the hospital for further assessment. Pedro contacts Mrs. Lee’s family to tell them about the situation and that a transfer to the hospital aligns with Mrs. Lee’s care goals.

Pedro documents the information from the PSW and his assessment findings. He follows CNO’s Documentation practice standard, making sure to provide a complete record of the nursing care provided. This including the details of his assessment and his interactions with the PSW, the health care team and the physician. He also documents that Mrs. Lee’s family has been alerted. Pedro communicates this information to all members of the health care team and lets them know Mrs. Lee was sent to the hospital. Pedro also follows the long-term care home’s policy to complete a post-fall report.

Timely, consistent assessment is central to safe patient care

Pedro knew that re-assessing Mrs. Lee was critical to safe patient care because there was a risk of serious injury requiring medical intervention. Pedro met the Professional Standards in his assessment by describing Mrs. Lee’s situation and taking appropriate action when identifying her abnormal responses. He also met the accountabilities of the Code of Conduct by using appropriate knowledge, skill and judgment when assessing Mrs. Lee’s health care needs.

Pedro knew that collaborating with other members of the health care team would be essential for achieving a good outcome for Mrs. Lee. When he listened to and asked follow-up questions of the PSW at shift-change, and shared assessment findings with the RN and physician, he followed the Code of Conduct by collaborating and seeking advice to improve Mrs. Lee’s care. Asking questions to understand the situation also showed his commitment to improved quality practice. Finally, Pedro also met the Code by collaborating and communicating with his colleagues in a clear, effective, professional and timely way.

For more information about nursing assessments, check out our Nursing Assessments education page. If you have questions about assessments or your nursing accountabilities, contact our Practice Quality team.
Back to Top