In practice, the diagnosis “Frail older person” is never an isolated diagnosis; an average of nine diagnoses is made for each client. Upon diagnosis, the PES structure, on which the Nanda is also based, is crucial:
A problem/diagnosis (P) can only be made if sufficient symptoms (S) are present and at least one causative factor (E) is identifiable. For example, E may be “cognitive decline”, “Single” or “malnutrition”. This causative factor determines the goals set as well as the interventions and organisation of care. To develop a care path for this group, E must be within view; for malnutrition another path is required than for cognitive decline. This is possible with the Nanda-Nic-Noc-system (N3).
The project focuses on two target groups. Besides the frail elderly, the target group “multiple problems” is also considered. This group is complex because there is no separate nursing diagnosis for it.
Data extraction is performed from the N3 database with the aim to gain insight into the causative factor (S) within the diagnosis “frail older person”.
- Frail older person. All the clients who are diagnosed as frail older persons are inventoried for the established causative factors (E), and the objectives, interventions and cooperation needed. The follow-up of these patients is three months, after which – based on the corresponding Noc indicators – assessment takes place in order to determine which objectives have or have not been achieved. The degree of objective attainment is then related to “the E”. On that basis, one or more care paths are developed. The aim is to involve at least 50 clients in the investigation. The emphasis will be on cooperation with general practitioners.
- Multiple problems. An overlap will partly exist with the Frail elderly group. Part of this group will also, in addition to health problems, have problems with social participation and daily life at home. This requires a multidisciplinary approach. The “key” can also be found in “E” here. First, the social problem is mapped to understand which factors are associated with the diagnosis. Then, a similar method compared to the frail elderly is followed. The emphasis will be on cooperation in the social societal domain.
The contractor “Co-operative district nursing care” wants to focus more on the outcomes of district nursing care.
Meetings will be organised to coach the district nurses. Two multidisciplinary meetings will also be organised during the project in order to discuss the current findings. District nurses, general practitioners as well as professionals from the social domain will participate. The extent to which the paths, which are to be described, can be complete depends on both the N3 input from the district nurses as well as the results of the two multidisciplinary meetings. These results also determine the number of paths that can be described.