The nurse's role in supporting the resident in an emergency situation is to be aware of patient records for DNR or similar documentation, and to communicate these wishes with respect and accuracy. The nurse will also be key in providing acute life support to the deteriorating patient.

Jane was on her way to bed in the evening: before retiring for the night, Jane always checks her blood sugar, although since joining the care home she sometimes needs prompting due to her cognitive impairment; the night staff always check it has been done and what the measurement is.

The RCN has provided education for staff about diabetes essentials which the team have used.

Sue was handing over to Danilo who was working on night duty, when the emergency alarm rang indicating an issue in Jane's room. On arrival, Jane was lying on the floor experiencing a seizure; there was damage to her arm, which was bleeding, and she had been incontinent of urine. Sue and Danilo immediately re-checked Jane's blood sugar as low blood sugars were previously thought to be the cause of her seizures. However, this was within the normal range.

Jane's seizure had been continuing for over 4 minutes and Sue called for emergency assistance via 999. During the time it took for the paramedics to arrive, Jane had experienced two further seizures and had not been fully conscious in-between. Danilo stayed with Jane whilst Sue attempted to contact Eileen but she was not at home.

The paramedics assessed Jane and in view of the continued seizures. Jane was taken to hospital.

Further resources

• NHS England. National Early Warning Score (NEWS)
• RCN. Diabetes Essentials
• Resuscitation Council UK. Respect

• preparation - of yourself, the environment and the person(s)
• planning
• communication
• support.

Preparation

• where ever possible speak face to face, in a private space with a do not disturb sign
• block time include time for support and questions
• consider any additional needs
• ethnicity
• language
• sensory loss
• cognitive impairment.

Planning

• know the back ground
• plan what you are going to say - rehearse if needed
• predict questions
• consider the options and what choice might be made.

Communication

• confirm who you are and who are speaking to
• ask them what they know so far
• break messages into smaller parts
• check back what has been heard and understood
• project time and privacy afterwards
• attend to physical needs, lavatory, drinks, tissues.

Support

• provide additional access to the key information e.g. a leaflet or web link
• arradocument the conversation
• make appropriate referrals or access to services
• ensure the team are aware of the conversation and the information shared (where appropriate).

In summary the role of the nurse in these circumstances is to:

• take responsibility
• organise
• co-ordinate
• record.

The staff were aware that Eileen is living with frailty but remains in her own home in the village visiting every day to see Jane. Rachel is keen to understand more about frailty and knows Danilo has completed some online learning. She asks Danilo if he is able to offer a brief teaching session in the afternoon and suggests that some of the residents' relatives might like to come. Danilo explains that;

People often have an image of someone who is "frail", perhaps a stooped thin shuffling older lady, but this is often inaccurate. Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves both physical and psychological. It is often described as not having the ability to "bounce back" from such things as infections or a physical trauma. However, frailty is not an inevitable part of ageing: it is a long-term condition, like diabetes or Alzheimer's disease.

Older people living with frailty are at risk of poor health and social outcomes such as dramatic changes in their physical and mental wellbeing after an apparently minor event which challenges their health. Frailty varies in its severity and individuals should not be labelled as being frail or not frail but simply that they have frailty. The degree of frailty of an individual changes, it naturally varies over time and can be made better and worse. Our role as nurses is to optimise the wellbeing of people who are living with frailty and to educate and support the person and their families so that they plan for the future.

How do we know if someone has frailty?

Sometimes we think we know someone has frailty by the way the look, speak or move, but more important indicators of frailty are frailty syndromes. Frailty syndromes include:

• falls (e.g. ‘collapse’, ‘legs gave way’, ‘found lying on floor)’
• immobility (e.g. sudden change in mobility, ‘gone off legs’ ‘stuck on toilet’)
• delirium (e.g. acute confusion, worsening of pre-existing confusion/short term memory loss)
• incontinence (e.g. new onset or worsening of urinary or faecal incontinence)
• susceptibility to side effects of medication (e.g. confusion with codeine, hypotension with antidepressants).

This example demonstrates how CPD can come in many different forms. Whilst open learning is often used, it is really useful to use colleagues' expertise and can be helpful and informative to provide education sessions that involve both residents and family members. Learning together cements a sense of community and can provide illuminating insights. 

Further resources

• British Geriatric Society (BGS) Managing frailty
• British Geriatric Society (BGS) Fit for frailty
• RCN. Frailty in older people
• RCN. Delirium in older people

Below you will find some further links to resources.

• NHS England. New care models programme
• NICE. Falls in older people: assessing risk and prevention
• NICE. Delirium: prevention, diagnosis and management
• NICE. Faecal incontinence in adults: management
• NICE. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes
• The Health Foundation. Emergency admissions to hospital from care homes: how often and what for?