Assessments Required

Scenario 1

An 83 year old gentleman was admitted to an acute ward with leg oedema and increased shortness of breath, caused by end stage Congestive Cardiac Failure. Prior to admission he was living in a nursing home and receiving NHS Funded Nursing Care. It was felt by the medical staff that his condition was now such that it meant he could be discharged from an acute hospital setting.

At present he is being nursed in bed and is totally dependent on staff for his care needs, including positional changes. On some occasions he is able to feed himself, but normally requires assistance. He is currently receiving maximum medical treatment for CCF and takes oxygen therapy as he requires and this can vary on a day to day basis.

Assessments required:

• Physiotherapy
• Dietician
• Falls risk
• Social work
• UAP
• DPICP
• Blaylock
• Chronic conditions team

NNADR

Unpredictable: Yes due to instability of his medical condition

Complex: Yes due to his medical condition and his high level of care need

Stability: Medical condition is unstable and rapidly deteriorating. He is also likely to be readmitted in the future as a result of his medical condition.

Risk: Breathing problems

Skin integrity

All risks associated with immobility

OUTCOME: MDT was held to include the manager of the Nursing home in which he was living prior to admission. During this his care needs and condition were reviewed, it was felt at the MDT that due to the instability and deteriorating nature of his medical and the high level of care he now requires that he now meets Continuing Care under Criteria 1 and 3. The application was made accordingly and the patient discharged back to the Nursing Home.

Scenario 2

A 94 year old gentleman was admitted with a Urinary Tract Infection (UTI). Prior to admission he was living in a residential home. He has a long term supra pubic catheter which was being monitored on a weekly basis by the District Nurse. The UTI was treated and he is now ready for discharge.

At present he is mobilising independently with a walking stick, he is able to transfer from chair to chair independently but needs supervision when transferring from bed to chair. He has a good appetite. He needs only minimal help with hygiene. He is occasionally forgetful

Assessments required:

• Physiotherapy
• Occupational Therapy
• Falls risk
• Nutrition risk
• District nurse
• UAP
• DPICP
• Blaylock
• Social Work

NNADR

Unpredictable: Not unpredictable

Complex: Needs were not complex

Stability: His condition is stable

Risks: All risks associated with an indwelling catheter

OUTCOME: MDT was held which included the officer-in-charge of the care home, District Nurse, the family and patient. The patient’s previous needs were assessed against his current needs. It was felt at the MDT that there was no change in need, therefore, the patient returned to the residential home.

Scenario 3

An 81 year old lady was admitted to hospital with a chest infection. She has a history of recurrent chest infections and is an insulin dependent diabetic. Prior to admission she was living at home alone with no social services’ input but did have a private cleaner, her daughter would do the shopping. She was also known to the Chronic Conditions Team who was calling to monitor her at least once a week and used oxygen and nebulisers at home. Her chest infection was treated with antibiotics and she is now stable for discharge.

At present she requires only minimal help with hygiene needs, she is independently mobile with the aid of a Zimmer frame, and there is no history of falls. She is alert and orientated. She is able to manage her own insulin, her diabetes is well controlled and she is not being seen by the Diabetic Specialist Nurse. She uses both oxygen and nebulisers at home and is independent in her use of these. She uses the oxygen infrequently. However, she is unable to move the oxygen cylinder between rooms and will need help with this.

Assessments required:

• Physiotherapist
• Occupational Therapy
• Falls risk
• Chronic Conditions team
• UAP
• DPICP
• Social Work
• Blaylock
• Nutrition

NNADR

Unpredictable: The potential exists for recurring chest infections.

Complex: She is independent in managing her pre-existing conditions

Stability: At present her medical conditions are stable

Risk: There is a risk of recurrent chest infections

OUTCOME: MDT was held during which her condition and her care needs were discussed; this meeting included the Chronic Conditions Nurse and the patient. The patient stated that she wished to return home but would need some help. The Chronic Conditions Nurse stated that she would continue to monitor the patient on discharge. Home care was arranged to call twice a day, to help her wash and to move the oxygen cylinder. The patient was discharged home.

Scenario 4

A 95 year old lady had been living alone and receiving home care once a day. She was admitted following a fall. Her discharge was planned according to her wishes which were to return home with home care, all relevant assessments were completed at this time. She was discharged but returned to the same ward 24 hours later following yet another fall, however, on this occasion she stated to the ward staff that she now wanted to go into a care home. Her falls were investigated and no obvious cause was found.

At present she is mobile with a Zimmer frame and has had no further falls on the ward. She needs only minimal help with hygiene needs, has a good appetite and is orientated and has mental capacity.

Assessments required:

• Physiotherapy
• Occupational Therapy
• Falls risk assessment
• Nutrition risk
• Social worker
• DPICP
• UAP
• Blaylock

NNADR

Unpredictable: Potential exists for further falls

Complex: Her needs were not complex

Stability: She was currently stable

Risk: There is an ongoing risk of falls

OUTCOME: MDT which the patient attended. The patient stated that she did not want to go home and would like to go into placement. No nursing needs were identified by the MDT and it was felt that residential placement would be appropriate. The patient was happy with this outcome and was discharged to a residential placement.

Scenario 5

90 year old lady admitted from home to acute medical ward with a dense stroke. Previous stroke 8 years ago. This stroke has left her with aphasia, aphagia.

She is able to communicate appropriately with pen and paper and is orientated but gets frustrated at her limitations of communication.

She is being fed via a PEG tube and has all her medications this way. She is currently having trail teaspoons of thickened fluid but has not been very successful with this. She is nursed in bed and can sit out in the chair provided she is hoisted but regularly declines. She needs all care with other activities of daily living including positional changes, hygiene needs, and maintenance of safety. She often mouth breathes and needs efficient, frequent oral care to ensure her mouth is clean and moist. She sometimes requires suction when she cannot clear oral secretions. She is doubly incontinent.

Prior to admission was living in sheltered accommodation with support from home care twice a day and family support.

She realises she cannot return home and agrees to placement in a nursing home. The family is in agreement with this.

Assessments required:

• Physiotherapy
• Dietitian/nutrition
• Speech and Language Therapy – swallow and communication
• Occupational therapy
• Manual Handling
• Skin Integrity
• Falls risk assessment
• Stroke Team assessment
• Social Worker assessment
• UAP
• DPICP
• Blaylock
• NNADR
• Continuing Care Submission pack and Nursing Needs forms

NNADR

Unpredictability: Swallowing ability particularly with oral secretions and therefore breathing are both unpredictable.

Complexity: Complex – High level of dependency and limited communication.

Stability: Condition with regard to the stroke is stable at present but the issues with swallowing provide a degree of instability.

Risks: Those associated with immobility and incontinence including chest infection, skin breakdown. Infection around PEG site and other risks associated with PEG feeding. Swallowing and breathing in relation to oral secretions.

OUTCOME: Multi-disciplinary meeting with family – placement discussed and eligibility for continuing care addressed with the matrix and the criteria. All present felt she fulfilled the criteria for continuing care (Criteria 1 – volume and intensity of care: and partly Criteria 3 – instability in relation to swallow and breathing, also previous stroke). Application submitted to Local Health Board.

Scenario 6

This 80 year old lady was admitted to an acute hospital with a urinary tract infection. She has a long term catheter.

She is an insulin dependent diabetic and requires twice daily injections – normally done by the district nurse. Her blood sugars are stable and she has not required regular review by the diabetic nursing team. She also experiences recurrent urinary tract infections. She does have some mild confusion which does not give any management problems. Since admission, she has been reviewed by the old age psychiatry team who will follow up on discharge via community psychiatric nurse and out patients.

She has had occasional falls during the last few months (2 in three months). She is mobile with a Zimmer frame. She requires minimal help with hygiene. She is able to feed herself. She is capable of managing her oral medication but is unable to manage her insulin.

She lives alone and agrees she needs placement. Family agrees.

Assessments required:

• Diabetic specialist nurse
• Old Age Psychiatry
• Occupational Therapy
• Physiotherapy
• Falls risk
• Continence
• Social work
• UAP
• DPICP
• Blaylock

NNADR

Unpredictability: Needs to be monitored for urinary tract infections.

Complexity: Not complex

Stability: Stable at present but requires to be monitored for urinary tract infections.

Risks: Some risks of falls and those risks associated with long term catheter. Risk of unstable blood sugars.

OUTCOME: - The multi-disciplinary team met with family and discussed all care options. It was identified that she was eligible for funded nursing needs.

Application sent to the Local Health Board who agreed with the Multi-disciplinary team’s assessment. Funding agreed.

Scenario 7

89 year old lady admitted from residential bed in a dual-registered home to acute medial bed with aspirate pneumonia. Her general condition had been deteriorating for sometime in the home.

She is bed bound and has contractures of both lower limbs. She is doubly incontinent. She has swallowing problems and has only been tolerating occasional teaspoons of thickened fluid. She has a history of dementia but this has not been a management issue as her general condition is so poor and she is exceedingly frail. She gets frightened and does not understand what is happening and therefore tends to hit out and become agitated when being seen to. She is unable to communicate her needs adequately both due to her dementia and her frailty. There has been no recent input from psychiatry. She requires help with all activities of daily living including hygiene, skin care. At present requires two nurses to move and position her due to her reactions when being attended to. Her general condition appears to be deteriorating.

After discussion with the family regarding her nutritional status and her general condition – the doctors and the family agree that non-oral feeding is not appropriate.

She is in a dual-registered home and, prior to her admission was in a residential bed. Her care needs now far exceed that which can be provided in a residential bed. The family wishes her to return to the home and the home is happy to have her back in an appropriate bed.

Assessments required:

• Physiotherapy
• Speech and language therapy
• Dietician/nutrition
• Manual handling
• Social work
• Falls risk
• UAP
• DPICP
• Blaylock
• NNADR
• Continuing care submission and Nursing needs forms

NNADR

Unpredictability: Deteriorating condition. Reaction when being seen to.

Complexity: High dependency and mental status.

Stability: General condition deteriorating, no nutrition.

Risks: All risks associated with immobility including skin integrity, chest infection. Lack of nutrition and hydration. Swallowing compromised – risk of aspiration of oral secretions.

OUTCOME: Multi-disciplinary team met with family and nurse from the home. Continuing care eligibility addressed using the matrix and the criteria. All present felt she met the criteria for continuing care – criteria 4 (poor prognosis, terminally ill) and also aspects of criteria 1 (volume and intensity of need) and criteria 3 (instability). Application made to Local health board. They agreed with the Multi-disciplinary teams’ assessment and agreed funding. Arrangements made to discharge this lady back to the home into a nursing bed with continuing care funding.

Scenario 8

61 year old lady admitted from a nursing home with a chest infection. She has advanced multiple sclerosis and is only able to move her head. She is a temporary resident in the nursing home. She went there while her husband had planned cardiac surgery. He is her main carer and has been looking after her with just input from the district nurse. Unfortunately, he had an amputation of his lower right leg following his cardiac surgery. He has now been discharged as an inpatient but still attends for physiotherapy at the artificial limb and appliance centre. He has not yet had his prosthesis and is mobile in a wheelchair.

He is keen to have his wife home and she is keen to go home. They will not consider placement.. Also need to consider husbands needs as planning for home and he is disabled but unrealistic of his new limitations.

She can only move her head and is reliant on others for all activities of daily living. She is fully alert and orientated and has been fully involved in all the discussions regarding her discharge planning. Her swallow is slightly compromised and she is having a soft diet and normal fluids and requires physical assistance for all her oral intake. She has a well established colostomy and supra-pubic catheter – district nurse monitors these at home.

Assessments required:

• Physiotherapy
• Occupational therapy
• Speech and language therapy
• Multiple sclerosis specialist nurse
• Stoma nurse
• Manual handling
• Skin integrity
• Falls risk
• Social worker
• District Nurse
• Nutrition risk
• Dietician
• UAP
• DPICP
• Blaylock risk score
• NNADR
• Continuing Care submission and Nursing Needs Forms

NNADR

Unpredictability: Progressive disease process. Swallow urinary tract infection, blockage, entry site infection due to catheter, constipation due to altered bowel habit related to M.S.

Complexity: High dependency and risk factors

Stability: Progressive disease process – advanced stage but stable since admission to hospital in terms of directly related symptoms.

Risks: Infection – chest due to condition, challenged swallow and immobility; also supra-pubic catheter entry site and urinary.

All risks associated with immobility. Hydration and nutrition – reliant on others to ensure she has adequate.

OUTCOME: Multi-disciplinarymet with family and patient. Continuing care eligibility addressed using the matrix and criteria. All present felt she fulfilled the criteria for continuing care (criteria 1- volume and intensity of need; and parts of criteria 3). Risks discussed surrounding discharge home with care. Application submitted to local health board – agreed with the multi-disciplinary decision, however, further meetings required to include the district nurse.

Several meetings required to establish exactly what is required. The most recent meeting included representation from Local Health Board. The package of care required is large and therefore has to be agreed by the complex needs panel. This has now met and, as the package is costlier than they can approve, eventually this case had to go to the Welsh Assembly and was approved. The lady has now been discharged home.

Scenario 9

An 82 year old gentleman was admitted after tripping over a rug at home. He was living alone, receiving no home care but was having a private cleaner once a week. He had been mobile with a walking stick. His fall resulted in no bony injury but he did have extensive bruising to his left leg. As a result of this incident he lost his confidence and therefore his mobility suffered. At present he is beginning to regain his confidence, but is now mobilising with a Zimmer frame, he is fully alert and orientated, continent, has a good appetite but needs minimal help with hygiene needs.