Weakness (one side, face, arm and/or leg)
Also Consider: General Weakness
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Causes
Common: Stroke, tumor, brain injury, spinal cord injury, bone fracture
Less common: acute illness in a patient who previously had a stroke or brain injury, infection, migraine, multiple sclerosis
1. Take Vital Signs
Temperature:
Blood Pressure:
Heart Rate:
Respiratory Rate:
Oxygen Saturation:
2. Evaluate Symptoms and Signs
Acute mental status change
If Pain: exact locations, pain scale, description (sharp, dull, burning), persistent or intermittent
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, diarrhea, abdominal distention or tenderness, rebound tenderness, bowel sounds
GU: New or worsened incontinence, pain with urination, blood in urine, urinary retention / bladder scan
Neurologic changes: consciousness/alertness, orientation, facial weakness, arm/leg weakness, decreased sensation in arm or leg, slurred speech, garbled speech
Skin: sweats (diaphoresis), cold/clammy/pale skin; any new skin condition, i.e., bruising (including potential head trauma), rash, infection/cellulitis
Fingerstick glucose (patients with diabetes)
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
Abrupt onset of noticeable change in strength or use of arm(s) and/or leg(s) or face not symmetric
Notify medical staff & resident representative within the next 16 hours.
Noticeable recent worsening of pre-existing weakness
Notify medical staff on the next business day
Gradual worsening of pre-existing weakness
SBAR Report
Situation: sudden onset of) "Weakness in” (Left) (Right) (Arm) (Leg) associated with:" (facial weakness) (slurred speech) (garbled speech) (mental status changes) (injury)
Background:
Reason the patient is in the nursing home (rehab for___, long term care for __).
When the weakness started, how severe it is, getting worse or staying the same.
Abnormal vital signs
History of previous stroke, TIA, brain tumor, brain injury
MOLST / Advance Directives
Recent illness, falls
General observation of patient condition
Blood glucose, if elevated
Abnormal findings on lung, cardiovascular, abdomen, genitourinary, neurologic or skin observations.
Signs or symptoms of dehydration, head trauma, injuries
Assessment: I am concerned about: __________
Recommendations/Requests:
Hospitalization for possible stroke in a patient in whom aggressive management is desired
Labs: CBC with diff, Lactic Acid, CMP/Chem14, Magnesium, Phosphorus, CK
INR if patient is on warfarin
“Hold” parameters for medicines that lower blood pressure
X-ray of affected body area
Dysphagia evaluation
Physical Therapy evaluation
Occupational Therapy evaluation
Speech Pathology evaluation for speech or swallowing issues
Other:
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
Monitor vital signs every 4-8 hrs for 2-3 days
Offer fluids frequently if able to tolerate po intake
Oral, IV, or subcutaneous fluids if needed for hydration
Place on Intake & Output monitoring
Monitor meal acceptance
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
Update advance directives if appropriate
2025-04-27
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