Acute alteration in physical health status

Part1: Continuum of Care

Part 2: Socio-economic and socio-cultural impacts

…including the Enrolled Nurse’s role

At the end of this session you
will be able to:
• describe the continuum of care for consumers
experiencing an acute alteration in physical
health status

• describe the implications of socio-economic and

socio-cultural realities on consumers and their
family/whanau due to acute physical health
alterations.
 Part 1
Continuum of care
…and the ENs role in the continuum of care
 What is a continuum?

older age
pre-birth birth childhood adulthood
80+

A sequence or progression of things.

What then is a continuum of care?
What is a continuum of care?
At home,
secondary
supported by tertiary care
care
primary care

Health services spanning all levels of intensity of care

Elements of the continuum of care
Primary Care- includes
promoting health and
prevention of illness,
GP care, community-based
health and support services

Secondary Care- in-patient acute hospital services, hospital-

based rehabilitation

Tertiary Care- specialised health services, rest home and private

hospital care
Scenario 2: Continuum of care for Pene
(See Scenario 2 in Canvas)

In Scenario 2 Pene has experienced an acute

alteration in his physical health status.

He will be admitted to Middlemore Hospital

(secondary care).
Acute Stroke Unit (ASU)-Middlemore Hospital

• Because Pene has a suspected stroke he is admitted to the

ASU- a specialised stroke facility which includes Stroke Nurse
Specialists as part of the multidisciplinary team

• Pene will be referred to allied health staff depending on his

needs e.g. left hemiplegia, speech difficulties etc

Note that patients with mild stroke are not usually admitted
to ASU, they may be discharged home with GP follow-up and
a referral to community based services.
 The Role of the EN in the secondary care setting**
for CVA may include:

• Monitoring the patient for the onset of signs and symptoms of a change in
consciousness or condition or extension of a stroke – alert RN
• Undertaking neurological assessments as directed by the RN
• Prioritising patient safety e.g. mediating or eliminating the risk of falls
• Assisting with ADL’s as per Nursing Care Plan e.g. undertaking pressure
area care if patient is unable to change position, or assisting with personal
care such as oral care
• Support the patients movement along the continuum of care (community
or tertiary care), for example:
o Assist in the Needs Assessment and discharge planning process if required
o Participate in a Multidisciplinary Team Meeting if required.

* Oral care is so important- but often neglected

**within your scope of practice
Pene starts here on the continuum, where to
from here?

Rest
home

Canadian Stroke Best Practices

https://www.strokebestpractices.ca/
Sione is ready for discharge from an acute
ward- he moves along the continuum of care…
1.Pene might
go here next
3. Pene, with a
serious decline in
his condition,
could move here.

Rest
home

2. Pene might then move back home

or he might need to go to a rest
home
 Where could Pene move to along the
continuum from the acute setting?
From the acute ward to in-hospital rehabilitation.

From rehabilitation to home or tertiary care (e.g. rest home or private

hospital)- the multidisciplinary team who have been involved in the
patients care, along with Pene and his family, make decisions about
where he will live on discharge. This is usually discussed and finalised
at a ‘Multidisciplinary Team Meeting.’

Needs Assessment Service (NASC) is involved once the decision is

made.

Placement in a rest home or private hospital (if this is the next step) is
facilitated by the Social Worker. The patient and family make the
ultimate decision- they choose the facility.
 The Multidisciplinary Team (MDT)
Who in the MDT apart from nursing staff (RN,EN,HCA) are most likely to provide expertise for the following issues a CVA patient might experience?

Issue post admission MDT member responsible

Swallowing difficulties
Reduced physical capability requiring therapy to
improve strength and function
Assessment and stabilisation of medical condition
Nutritional needs
Adjustments needed to home environment e.g.
ramps, hand holds
Finding a suitable placement in a rest home or private
hospital
Assessing the level of DHB care services needed by
patient in the community
Speech difficulties
 Did you get them all right?

Issue post admission MDT member responsible

Swallowing difficulties Speech Language Therapist

Reduced physical capability requiring therapy to Physiotherapist, Physiotherapy Assistant
improve strength and function
Assessment and stabilisation of medical condition Medical team
Nutritional needs Dietitian
Adjustments needed to home environment e.g. Occupational Therapist
ramps, hand holds
Finding a suitable placement in a rest home or private Social Worker
hospital
Assessing the level of DHB care services needed by Needs Assessor
patient in the community
Speech difficulties Speech Language Therapist
The Multidisciplinary Team (MDT) cont….

The members of the MDT could include others we have not listed, for
example:
• Pharmacist
• Specialists e.g. Eye Specialist, Geriatrician,
Diabetes Nurse Specialist
• Podiatrist.

A MDT will vary depending on the needs of the patient. Patients can
present with a CVA, but can also have other health issues (co-morbidities)
therefore other services are brought into the team.

An EN is an important member of the MDT with a vital role in the acute

care, rehabilitation and on-going support of a CVA patient.
 NASC
• The Needs Assessor has an important role after the acute care phase in
supporting movement along the continuum
• A description of services from NASC at Counties Manukau Health-

• When a person has a change in health or needs the Needs Assessor can
reassesses and change the services they receive.
MDT and a patient
and family-centred
approach

Finally, but most

importantly, when
decisions are being
made, the MDT
involves the patient and
their whānau/family; a
patient and family-
centred approach.

This Photo by Unknown Author is licensed under CC BY-NC-ND

 A patient and family-centred approach:
core elements
•Dignity and Respect. Health care practitioners listen to and honour patient and family perspectives and
choices. Patient and family knowledge, values, beliefs and cultural backgrounds are incorporated into the
planning and delivery of care.
•Information Sharing. Health care practitioners communicate and share complete and unbiased information
with patients and families in ways that are affirming and useful. Patients and families receive timely,
complete, and accurate information in order to effectively participate in care and decision-making.
•Participation. Patients and families are encouraged and supported in participating in care and decision-
making at the level they choose.
•Collaboration. Patients, families, health care practitioners, and hospital leaders collaborate in policy and
program development, implementation, and evaluation; in health care facility design; and in professional
education, as well as in the delivery of care.
https://www.hqsc.govt.nz/assets/Other-Topics/QS-challenge-reports/Excellence-through-family-and-patient-centred-care-Final-Report.pdf

For more information on people-centred care go to Health Navigator

https://www.healthnavigator.org.nz/clinicians/p/patient-centred-care/
 Summary

• The continuum of care for patients experiencing an acute alteration in

physical health status will differ from patient to patient
• The following diagrams represent a range of continuums-

Discharge home
Acute hospital
with community
stroke ward and Rest home Private hospital
based care
rehab.
services

Acute hospital
stroke ward and Discharge
rehab. Home

Acute hospital
Private
stroke ward Palliative care
hospital
and rehab.
Summary
continued…

• The Enrolled Nurse (EN) is part of the

multidisciplinary team in the acute setting,
and also involved in other areas along the
continuum of care such as rehabilitation
and tertiary care

• When decisions are being made,

particularly about a patients move along the
continuum of care, a patient and family-
centred approach is essential. The patient
and their whānau/family are involved in
decision-making and their preferences are
respected. It is important that the EN
supports a family-centred approach.

This Photo by Unknown Author is licensed under CC BY-SA-NC

 Part 2
The implications of socio-economic and socio-cultural
realities
 Scenario 2: Pene is discharged home

• Pene lives with his wife and their teenage son in a

two bedroom unit. He also has one daughter and son-
in-law who live in his local area but work full-time

• Pene is unsteady on his feet

• Pene gets tired very easily

• Pene has a business to run.

 Some common changes in people after a
CVA
How could this impact on Pene and his family?
•Rapid mood change

•Depression, and/or sadness, helplessness, hopelessness and

grief

•Changes in eating and sleeping

•Lack of energy

•Short attention span.

Source: Stroke Foundation of New Zealand

The implications
of an alteration What socio-economic (financial) realities might Pene and his
family face in the weeks, months and years ahead?
in health on the
patient and their
family *Enduring Power of Attorney
‘An enduring power of attorney (EPA) is a legal document which
sets out who can take care of your personal or financial matters if
you can’t.’
What socio-cultural realities might
Pene and his family face in the weeks,
months and years ahead?

(Socio-cultural refers to the things

Sione normally participates in
socially and culturally)
• Family, including extended family
• Church or similar
• Cultural activities
• Sports/creative/ volunteering?

This Photo by Unknown Author is licensed under CC BY-SA-NC

The impacts after a CVA are multi-faceted and life-changing

Financial

Social incl.
Employment
family

Pene and his

family

Transport Cultural

Housing
 Support in the community
• Non-Government Organisations (NGOs)- e.g. The Stroke Foundation

..and Age Concern- activity includes half price taxi’s and visiting
support for socially isolated older people
 Support in the community cont…

• MSD- benefits and financial assistance

• DHB-funded community health services via Needs Assessor
• General Practice- referrals e.g. District Nurse, Palliative Care Service
• and more…

This Photo by Unknown Author is licensed under CC BY-SA

How is this
information on the
socio-economic and
socio-cultural impacts
realities of an acute
health change
relevant to the EN?

This Photo by Unknown Author is licensed under CC BY

 Summary
• The socio-economic and socio-cultural realities of an acute physical health
alteration in health of a family member are often life-changing

• If the family member cannot return to work there is likely a worsening of

the socio-economic situation of the family, especially if another family
member stops work to take on caring responsibilities

• Participation in the community and in cultural and social activities need not
be affected and new opportunities for involvement may arise, but for many
this may become more difficult due to transport issues, reduced energy
levels and a lower level of physical capability

• Families can access support from the Government, DHBs and NGO’s. It is
important families know how to access services including financial
entitlements.