Long-Term Care Survey Alert

Published on Fri May 28, 2010 PDF

Watch for this common initial sign of a perfusion change.

The clock is always ticking when a patient has signs of acute myocardial infarction. Below experts share four key tactics to help you detect and address this common acute care problem as effectively as possible.

1. Be on the lookout for typical and atypical signs of acute MI. "You want to keep your index of suspicion high," advises Carol Rutenberg, RNC-BC, MNSc, principal of Telephone Triage Consulting Inc. in Hot Springs, Ark. "Be alert to any complaints of chest, back, or neck pain, nausea,complaints of fatigue, shortness of breath, and/or change in mental status or other signs of impaired perfusion." A change in baseline is always concerning, she adds.

Don't miss: Consider a change in an elderly resident's energy level or mental status as a "red flag" that something is wrong with the person's perfusion, advises consultant Shelley Cohen, RN, MSN, CEN, in Howenwald, Tenn., who practices in the emergency department setting.

"When younger people have perfusion changes from a cardiac event, they get chest pain or shortness of breath, or both," Cohen says. "But when a geriatric patient experiences a perfusion change, they are more likely to show [initial] signs of lethargy or weakness or confusion." An example would be someone who usually gets up with his walker but today appears "all washed out." The person may have a skin color change depending on how severely affected she is by the perfusion change, Cohen adds. "But ... the key indicator is a change in mental status."

2. Always assess and document a resident's pain before administering pain meds. The resident may have a PRN ordered for arthritic pain, but when you ask him to describe his pain, he says his abdomen or chest hurts -- a definite trigger for further assessment. Keep a "careful eye" out for patients whose pain "is either different or associated with different symptoms than usual," advises Daniel Haimowitz, MD, CMD, a geriatric specialist and nursing home medical director in Levittown, Pa. The problem could be another acute-care issue. For example, says Cohen, "when elderly people have pneumonia, their most common chief complaint is belly pain."

3. Know what to do when you suspect acute MI. "The key is to catch it before it's bad," says Cohen. When you suspect someone may be having a cardiac event, the next step is to assess the person's airway, breathing, and pulse (the ABCs) and call for help, advises Cohen. "Look at the vital signs, skin color -- is the person breathing adequately? The person may be breathing but not well enough to ventilate, so you may have to put them on oxygen."

A facility could have standing orders for evaluating someone witha mental status change, which could signal a perfusion problem. But these aren't going to be effective if you don't have access to stat labs and have someone available who can evaluate the person, including interpreting an EKG, cautions Rutenberg.

Alternative: Contact the doctor and send the patient to the ED, advises Rutenberg. The nursing home nurse can call the ED triage nurse to give a report using the SBAR format (situation, background, assessment, recommendation), she advises (for a sample of an SBAR report, see the sidebar on page 43).

Major mistake: "What you don't want to do is wait and watch" if a patient undergoes an acute mental status/cognitive change, she warns. If it's due to MI, sepsis, or pulmonary embolism, etc., "the situation could turn lethal quickly," says Rutenberg.She reports seeing nursing home patients arrive by ambulance to the ED who had undergone a change in mental status. "And no-one had done anything" until the person had a cardiac arrest or deteriorated to the point of obviously needing emergent care.

4. Cover the bases with training.The facility should conduct training on how to recognize and assess a cardiac event in the geriatric patient, advises Cohen. "You can do this annually as part of the Basic LifeSupport training" by adding another half hour to review the red flags of acute MI in the geriatric population.

Also train the CNAs to know when to contact the nurse. The CNAs who know the resident best can detect subtle changes, Cohen observes. "You want them to observe a change, report the change" -- then the nurse makes the assessment.