Troponin (lab test) elevated

Also Consider:  Abnormal lab result, Chest pain, EKG abnormal

1. Take Vital Signs

• Temperature:

• Blood Pressure:

• Heart Rate: 

• Respiratory Rate:

• Oxygen Saturation:

2. Evaluate Symptoms and Signs

• If Pain:  exact locations, pain scale, description (sharp, dull, burning), persistent or intermittent

• Fainting, dizziness or lightheadedness when standing up

• Diaphoresis: Cold, clammy, pale skin

• Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress

• Cardiovascular:  Chest pain, new irregular pulse, cyanosis, mottling, edema

• GI: Nausea, vomiting, abdominal distention or tenderness, rebound tenderness, bowel sounds

• Response to any ordered PRN medications (nitroglycerin, oxygen)

3. Take Action using SBAR Report:

• Presence of other, significant symptoms or signs of illness 

  • Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.

• Immediately notify the medical staff & resident representative

  • All abnormal results

• Notify medical staff at the next regular rounds 

  • Normal results

4. Implement Management Plan

• Monitor vital signs every 4-8 hrs for 2-3 days

• Place on Intake & Output monitoring

• Place on 24-hour report for 2-3 days

• Obtain lab results (if ordered), and notify medical as needed of significantly abnormal values in lab tests (refer to appropriate Situation)

• Update care plan regarding  fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs

• Review status and plan of care with designated representative daily or with any changes

• Update advance directives if appropriate

2025-04-27