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Several chronic diseases (>2) and/or unexplained symptoms
Chronic diseases
Long-lasting conditions which progress slowly.
Examples : cardiopathies, cerebral vascular accidents, cancer, chronic respiratory conditions, diabetes, etc. (World Health Organization, 2018).
Unexplained symptoms
Manifestations expressed and/or felt by clients which are linked to conditions that cannot be identified with certainty through a physical exam and/or other diagnostic tests (Park & Gilmour, 2017).
Examples : irritable colon, chronic fatigue, fibromyalgia, etc.
Chronic pain
An unpleasant [persistent or recurring] sensory and emotional
experience, due to actual or potential tissue damage, or described in
terms of such damage, lasting for more than three to six months,
and/or likely to affect the behavior or the well-being of the patient in
a negative manner. (Agence nationale d’accréditation et d’évaluation
en santé; ANAES, 1999).
It has an impact on the patient’s functional and relational capacities
in his/her daily activities.
Examples : arthrosis, neuropathological pain in diabetics, zona, residual pain from a stoke episode, etc.
Allergies and/or drug intolerances
An abnormal and specific reaction of the body when coming to
contact with a foreign substance (allergen) which does not cause
any issues in the majority of people (Larousse, S.d.).
Allergic reactions can be of the immediate type, with symptoms
appearing just a few minutes after taking the medication, or of
the delayed type. Symptoms related to a delayed allergic reaction
appear with a delay of several days, even several weeks (Centre
d’allergie Suisse, 2017).
Examples :
immediate type reactions : rashes, hives, swelling of the skin or mucus membranes (angioedema), flu-like symptoms (rhinitis), respiratory problems.
Delayed type reactions : cutaneous measles-like manifestations (maculopapular exanthema), with severe itching, and, in some cases, blistering (bullous form), rashes, sometimes painful with blood infiltration (petechiae), general feeling of illness with fever and
weakness.
Polymedication (>5)
The “concurrent use of multiple drugs” (Bjerrum, Rosholm, Hallas & Kragstrup, 1997) or the administration of an excessive number of drugs.
It is common among older persons, linked to polypathologies and
to chronic illness. It can also be inappropriate and can carry risks for
undesirable effects or drug interactions, increases the risk of falls,
or even the risk of mortality. Polymedication is the administration of
over five different substances over the course of seven days, by the
patient him/herself, and/or an informal caregiver, and/or a home care
professional (Frazier, 2005; Monegat, Sermet, Perroin & Rococo, 2014).
Cognitive deficits
Reduction of intellectual aptitudes, whether or not linked to cerebral lesions (Delaloye, 2010). Medical diagnostic already established and/or symptomatology.
Examples: problems with memory, attention/concentration, perception, judgment,
slowed thinking, difficulties in organizing, difficulties in problem-solving. Is there one
or more cognitive deficits present that impact ADLs and IADLs?
Financial difficulties and/or inability to afford the
services of assistance, care, treatments, auxiliary
devices, a means of transportation, and/or a food
supply
Difficulty and/or incapacity to manage daily administration, to make
payments for oneself, potentially for the family as well, without
a social/family network. Insufficient financial revenue, vulnerability.
Absence of a financial aid request. Examples : disability allowances.
Observations which may help in identifying financial
difficulties: delays in payments, empty fridge, limited variety and quantity of food,
deteriorating dental/oral condition, poor state of clothing, refusal of essential services
and/or ordering material, etc.
No informal care, an exhausted informal caregiver,
and/or family tensions
An informal caregiver is a person (family, friend, neighbor, acquaintance) who regularly offers care and/or assistance and support
on a non-professional basis, over a significant period of time and/or
in an intensive manner. Carrying out this role can lead to tensions,
misunderstandings, relationship conflicts, also among those in the
patient’s circle.
Caregiver exhaustion can be expressed, or not, in different ways,
such as health damage, fatigue, anxiety and/or significant chronic
stress, physical and/or mental distress, a need for respite, a worry/
fear of no longer being able to continue providing the assistance,
a feeling of social isolation, financial difficulties.
Low level of literacy (related to basic literacy issues, language, and/or cultural barriers)
« Ability to understand and employ printed information […] to achieve
one’s goals, and to develop one’s knowledge and potential. » (Organization for Economic Co-operation and Development, OECD; 2000).
Examples : recent immigrants, persons whose mother tongue is not the official language
of the country of care, low educational level.
Social isolation
Involuntary exclusion from social life and social ties (family, friends,
neighbors, social activities, etc.). A person who chooses to remove
him/herself from social life is not isolated.
Questions which could help identify social isolation: Does the person have contact with
friends, family, visits, phone contacts, emails, etc.?
What kind of social activities does the person like? Would he/she like to have more social
ties?
Inadequate housing and/or environmental barriers
All types of problems in the home and its immediate surroundings
which would make the client’s life difficult or dangerous.
Examples : cluttered kitchen, refrigerator out of order, presence of mice, cock roaches, bed bugs, slippery floors, doorsteps, difficulty accessibility, absence of
an elevator, ramp, violence in the neighborhood, etc.
Depression and/or suicidal ideation
Depression is a common mental disorder, characterized by sadness,
loss of interest or pleasure, feelings of guilt or low self-esteem, sleep
or appetite problems, a feeling of fatigue, and a lack of concentration.
Depression can be persistent or become recurrent, hindering significantly the ability of an individual to face his/her daily life. At its most
extreme, it can lead to suicide. (World Health Organization, 2018).
This item will be ticked as positive if the symptoms are objectifiable. A past depressive episode for which there is no current treatment is not taken into account.
Psychiatric diseases and/or mental disorders
(delusions, hallucinations, etc.)
Established medical diagnosis and/or objectifiable symptomatology.
Examples : disturbed perception of self or reality, mood disorders, disturbed interpersonal relationships, disturbed thought processes, reduced autonomy, and/or level
of independence in the management of daily life.
Addiction
A pathological relationship a person maintains with a substance
or a behavior; in the process of withdrawal or not, with or without
substitution treatment, with or without a decrease and control of
the consumption.
Examples : Addiction to sex, video games, licit or illicit substance, medication.
Anxiety or anguish that renders the clinical picture
unclear
Feelings of unease, apprehension, and worry, the cause of which
may or not be unconscious. Perceived danger, real or subjective.
Variations in mental function during the day
Behavioral manifestations and/or variable mood during the course
of the day. Emotional instability (rapid and significant mood
changes, variability, and instability).
Examples : outbursts of joy, calmness, and spectacular bursts of anger or tears.
Recurring solicitations of the primary and/or
secondary network
Frequent/repeated requests for assistance, support, presence,
information, relatively significant, expressed or not by the patient to
professionals, and non-professionals, to his/her informal caregiver,
or those in his/her circle.
Examples : frequent phone calls, need for reassurance
Ambivalent and/or conflictual communication with
a member of the primary and/or secondary network
Remarks and/or attitudes concerning one’s needs, health problems,
and/or health and life goals, made to the primary or secondary
care network, which are objectivized as contradictory, and/or varying, and/or conflictual. These may alter the relationship between
care-giver and care-receiver, and the relationship with the primary network.
Worries about symptoms, health conditions, and/or
medical information
Worry about the evolution of one’s disease and/or a relapse (cancer
or other) through questions to the care-giver regarding his/her
pathology, symptoms, health status. This concerns the physical and/
or mental health of the client.
Aggressiveness (verbal and/or physical) or mutism
Client’s means of communication and/or remarks, and/or gestures,
and/or behaviors (active or passive) which are threatening,
demeaning, dismissive, destabilizing towards the primary and/or
secondary network.
Resistance or opposition to care, whether active
or passive
Frequent negotiations for one or several care services, or categorical refusal, or repeated episodes of refusal, or avoidance strategies
put in place.
Examples : cancellation of services, absence, rejection/blocking of proposals and/or
assistance/care actions.
Recent degradation of health status perceived
by the patient
Client’s perception of his/her state of health, expressed as having worsened within the past month.
Overall change in the degree of independence
(ADL/IADL) in the last month
Examples : reduced participation in ADLs/IADLs, difficulty in following treatment advice,
deterioration in the degree of independence, etc
Transition period (ex. announcement of diagnosis,
hospital discharge, death of caregiver, divorce, work,
etc.)
A phase in life or a phase of disease during which a number of
changes occur. A transition indicates a change in health status, roles
and relationships, expectations or abilities. This means that there
is a change in the needs of the person in all systems and dimensions.
The transition requires that the person integrates :
- new acquaintances,
- other behaviors,
-
that he/she modifies the way in which he/she defines him/her self in the social context, in relation to his/her health or illness,
or his/her personal and environmental needs that affect his/her
health status (Meleis, Sawyer, Im, Messias & Schumacher, 2000).
Examples : diagnosis, return from hospitalization, hospitalization of informal
caregiver, death of informal caregiver, divorce, redundancy, etc.
Acute change in cognitive abilities
Rapid change in client’s usual behavior.
Examples : recent inversion of the nycthemeral rhythm (wake/sleep), memory and
thought disturbances, distractibility, disturbed language, disorientation, altered perception of the environment, agitation, irritability, impatience, wandering, euphoria, lack
of attention, reduced vigilance, lethargy, apathy, etc.
Unpredictability of health status (unusual symptoms,
decompensation of a chronic disease, wounds, pain,
etc.)
Uncertainty and/or impossibility to foresee the evolution in health
status and/or in the behaviors of the patient in the upcoming days, weeks.
Examples : frequent changes in treatment and/or dosage, physical and/or mental
instability, one or more urgent hospitalizations and/or a stay at a short-term acute care
(STAC) facility in the last three months. If one of the examples is affirmative, the notion
of unpredictability must be taken into account (HAS, 2014).
Multiple care providers in the secondary network
(primary care doctors, medical specialists, formal
caregivers, curators, etc.)
Over three professionals (medical, formal caregivers, social, etc.)
who regularly intervene and interact in the patient’s situation.
Absence or low degree of partnership between
the different actors of the primary and/or secondary
networks
Absence or weak connection due to a lack of communication or familiarity between the care providers
Therapeutic incoherence and/or loss of care plan
meaning from the professional’s point of view
Lack of logic, understanding, continuity, and coordination between
thought, expression, and action in the care provided to the patient.
Examples : disagreements, misunderstandings, differences in points of view
between the care providers and/or the patient, loss of direction in care, different
visions between the patient, informal caregivers, doctors, nurses, etc.
Health insurance problems (restrictions or limitations)
Health insurance problems which have an impact on the care.
Examples : limitation of reimbursement of care expenses, limitation of care due to the
patient’s insurance, non-reimbursement of medical expenses, etc.
Emotional and/or physical burden of care perceived by
the members of the secondary network (doctor, formal
caregivers, etc.)
Emotional burden : Feelings of powerlessness, loss of control, sadness, sorrow, anger,
anxiety, of an emotional invasion of one’s private sphere, feeling
attacked or persecuted.
Physical burden : A situation requiring the use of sustained and recurrent physical
strength, in addition to aids, multiple daily visits, absence of aids
or unsuitable aids, etc.
