What are District Nursing Summary Descriptors?
There are five levels of descriptors for Welsh Levels of Care:
Immediate/ Emergency Care - An exceptional, high risk, emergency/ crisis
situation requiring escalation and immediate intervention from professionals/
services.
Urgent Care - The patient is in a highly unstable and unpredictable condition
either related to their primary problem or an exacerbation of other related factors.
Can be managed in the community.
Complex Care - The patient may have a number of identified problems, some of
which interact, making it more difficult to predict the outcome of the visit.
Managed Care - The patient has a predictable and clearly defined problem but
there may be a small number of variations in care that are easily managed with
minimal impact.
Routine Care - The patient has a clearly identified problem, with minimal other
complicating factors.
What are District Nursing Lay Descriptors?
The Lay Descriptors provide information on the general characteristics of a patient at each level of
care:
• This is an emergency; the patient is in crisis and needs immediate action
• The patient is very unwell, and their condition is getting worse
• Continuous support will be given until the patient can be admitted to
hospital, moved to a place of safety or supported at home
• The patient is very unwell, their condition needs urgent review as it
has worsened or they have developed another serious problem
• A high level of support is needed
• This may be because the patient can no longer care for themselves,
their home has become unsafe, their illness has got worse
• Their usual treatment plan may need to change and be added to,
more professional help and care activities need to be put in place to
keep the patient safe
• Their condition needs to be checked very often to stop or find
deterioration
• The patients condition is complicated
• They have a number of known problems which may all need treating
• These conditions may interact making it difficult to know how the
treatment will effect the patient
• Their condition and the care given may vary
• Frequent checking of the patients condition is needed
• They may need care from other professionals
• The patient is usually stable on treatment
• The patient may have more than one problem but is not complicated
• Nursing care is planned but may need to change depending on the
patient's condition
• Their condition will need regular checking and care may vary
• Support may be needed from other professionals
• The patient is stable and settled on treatment
• Nursing care is routine
• They have a clearly identified problem, with few other issues
• The patients needs are not complicated and can be planned
• Reviews will be done to check the patients condition
What are District Nursing Clinical Descriptors?
The Clinical Descriptions provide an overview of the type of patient and the nursing interventions
that are required to meet the needs at each level of care.
• Crisis situation where there may be immediate risk to life or serious clinical
deterioration
• This is an emergency where the patient cannot be left without clinical
support
• The patient is acutely unwell, highly unstable, and highly unpredictable
• There may be immediate risk of harm to self and/or others by themselves
and/or others
• The patients care interventions and support networks do not meet their
current critical state
• The patient will be admitted to hospital or a place of safety unless the
situation is brought under control at home and/or extra support measures
are put in place
• The patient has urgent need of proactive intervention and close observation
• Rapidly changing unstable condition
• Action to be taken to stabilise and maintain the patient’s condition
• May need escalation of care needs through transfer to hospital or place of
safety
• May remain at home with a high level of support
• The work to deliver care is multifaceted, requiring frequent assessment and
review from multiple professionals
• The patient’s condition is complex with multiple health and/or care needs
• The patient may have a combination of treatments, either short term or
planning for longer term, for more than one health or care condition
• There may be difficulty predicting the outcome of interventions and care
needs may fluctuate
• Close monitoring is essential and regular multidisciplinary collaboration will
be required
• Urgent review may be necessary
• The patient is typically predictable and has a clearly defined problem but
there may be a small number of additional factors that affect how treatment
is provided such as chronic condition management
• There is a need for regular observation to detect any variations or
unplanned changes in the patient’s condition
• Care is delivered on a planned pathway designed to deliver a specific
treatment(s), for a common problem(s)
• The work to deliver care may include several routine activities planned
together
• Patient needs are predictable and routine
• The patient requires basic assessment and uncomplicated nursing care
• Care planning is straight forward, and the patient is stable, there is little
variance in delivered care
• The patient agrees with treatment and is cognisant
• The environment is safe
DN Nursing Theme 1 - Assessment, Observation and Risk
• Emergency /crisis posing an immediate risk to life, requires immediate
hospital admission or intensive observation and/or interventions to
remain at home
• Unresponsive requiring immediate intervention
• Situation is highly unstable and unpredictable, presenting significant risk
to patients and/or others requiring immediate intervention
• immediate risk of abuse, violence and/or aggression requiring immediate
intervention
• NEWS score ≥9 requiring immediate intervention
• Safeguarding concerns requiring urgent intervention due to significant
risk
• Acutely unwell requiring urgent care, medical assessment, close
monitoring, and increased nursing intervention which may result in
admission to hospital
• NEWS score between 6-8 patient highly unstable and unpredictable with
the potential to deteriorate rapidly
• Patient is highly complex and requires an intense level of intervention
• Advanced care co-ordination for a new patient or where there has been a
significant change in need to enable home care
• Patient unstable with fluctuating or deteriorating condition
• Frequent observation and/or intervention as patient needs are complex
• Frequent monitoring and review as needs are complex
• NEWS score between 3-5 frequent intervention as condition is unstable
and/or unpredictable
• May need planning for the long term or complex care planning
• Multiple agency involvement, Continuing Health Care and Fast Track
assessment
• Shared or joint visits required due to level of risk identified
• Symptoms difficult to manage, requiring monitoring and frequent
changes
• Monitoring and management of a usually stable and predictable patient
with/without chronic condition/s or multiple co-morbidities
• Patient has capacity but is at risk of self-neglect, requiring monitoring,
prompting and regular interventions
• Care can be managed through planned interventions and ongoing
support
• Routine holistic assessments and referrals to other agencies if required
• Routine observation of vital signs for a stable patient
• Patient is stable requires routine interventions delivered via an agreed
care plan.
• NEWS score 0-2, patient has a small number of clearly defined needs
Nursing Theme 2 - Social Support and Environment
• Crisis requiring immediate intervention to ensure safety and needs met
• Patient at significant risk of neglect and/or harm, and or unable to selfcare
• Immediate intervention and/or emergency respite care needed
• Environmental factors pose significant risk as patient requires
immediate intervention and no support available.
• High risk situation due to environmental and/or social factors
• Lack of social support/ poor relationship with family members posing
urgent risk to patient
• Environment highly unstable and unpredictable, needing rapid
resolution
• Supportive interventions not enough for patient needs so urgent
intervention required
• Complex family dynamics requiring social support to provide holistic
care for the family
• Patient with complex social needs lives alone/ is isolated.
• Environment not conducive to the patients’ needs so patient requires
additional support
• Support/ education/ training for patient and family/carers Providing
guidance and sign posting patient/family to services and means of
support/information
• Patient stable and able to live independently/ with family.
• No environmental &/or social issues identified
Nursing Theme 3 - Personal Care, Nutrition & Hydration
• Crisis situation, requiring immediate response/hospital admission for
extreme dehydration or malnutrition
• Severe damage to skin integrity requiring critical intervention
• Emergency situations requiring highly intensive interventions for the
patient to remain at home, totally dependent for all activities of daily
living
• Highly complex and unpredictable, requiring continuous nursing care
• Patient requires high level of enhanced patient support for most of the
activities of daily living
• Highly unstable, requires frequent review, observation and assessment
of wound/skin
• Requires urgent intervention from specialists and care may be provided
by other agencies
• Bladder and/or bowel problems requiring urgent action
• Complex wound care requiring, reassessment and frequent intervention
• Requires assistance with some activities of daily living, care package in
place, patients’ needs fluctuate requiring regular review
• At risk of dehydration, requires close observation of fluid management
and fluid balance
• At risk of malnutrition, requires close observation and monitoring of
dietary intake with intermittent intervention from specialist
• Complex bladder and bowel care needs, requiring ongoing monitoring
and regular interventions from range of healthcare professionals
• Requires planned observation and support of hydration and nutrition
needs
• Bladder and Bowel care for a stable patient where there are periods
requiring intervention
• Planned wound care with regular observation to detect variation in
condition
• Non-complex Patient who may require some support and assistance to
self-care
• Requires occasional assistance with some activities of daily living
• Routine assessment and management of simple wound
• Patient independent and self-caring, able to manage own elimination
and nutritional needs
DN Nursing Theme 4 - Cognition, Communication and Behaviour
• Behaviour is highly unstable and unpredictable requiring immediate
intervention and intensive support.
• Violence, aggression and/or confusion putting the patient/others at risk
of harm
• Significant risk of serious harm to self and/or others, requiring
immediate intervention
• Patient is in crisis, unable to communicate or express their needs due
to exacerbation of illness
• Behavioural problems/ mental health issues requiring urgent
intervention as poses risk to self or others.
• Inability to communicate own needs posing risk to self or others
requiring urgent intervention
• Lacks capacity & understanding so requires urgent intervention to
maintain safety
• Limited ability to communicate so difficult to predict needs
• Patient with cognition and/or communication difficulties experiencing
increased anxiety, requiring emotional support and / or, specialist
referral
• Requires Best Interest Meeting/Liberty Protection Standards (LPS)
application
• Patient lacks capacity &/or is non-concordant requiring
emotional/psychological support
• Patient has limited or fluctuating capacity. Requires ongoing review and
support to maintain safety.
• Patient has some difficulty communicating due to language barrier,
communication difficulties, learning difficulty/disability or limited
capacity, but able to make their needs known
• Periods when patient is non-concordant with some aspects of care
• Concordant with treatment but due learning difficulties or sensory
impairment requires enhanced support.
• Has capacity and is concordant with the treatment plan.
• Able to communicate & make their needs known.
DN Nursing Theme 5 - End of Life
• Crisis requiring immediate intervention, may require admission to
hospital/ hospice, or intense level of support & intervention to remain
at home
• Terminal symptoms posing risk to self or others, requires immediate
medication review or other intervention
• Patient is highly unstable and unpredictable, requiring frequent
assessment/ regular monitoring and intense intervention
• Requires intensive input from multiple members of the specialist end
of life team
• Terminally ill patient in last hours of life, establishing and receiving
planned palliative care input
• Patient and family require intense emotional support
• Palliative care/ end of life rapidly deteriorating, requiring fast track
Continuing Health Care assessment
•Advance Care Planning (ACP)/Do Not Attempt Cardiopulmonary
Resuscitation (DNACPR) complex and sensitive communication
• Support and guidance for patient and/or family as palliative/end of
life.
• Last days of life requiring symptom control management and/ or
holistic support
• Complex care needs, requiring close observation and regular review
of care plan.
• Fluctuating needs, requires varying levels of interventions by the
MDT
• Symptom management of complex condition &/or reversible
condition
• Supportive visit for newly diagnosed palliative/terminal care patient.
• Cultural/Psychological/spiritual support for patient at end of life.
• Stable palliative care patient with well controlled symptoms.
Healthcare needs are predictable with some variation
• Verification of expected death
• Routine care for stable palliative care patient
• Bereavement support visit for family
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