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The Australian College of Nurse Practitioners is proud to showcase how Nurse Practitioners are changing the face of healthcare. Below is a vignette which demonstrates how we improve access to treatment:
My role as a Palliative Aged Care Nurse Practitioner is to see older people in the community or in residential aged care that have advanced chronic disease and are within the last year of life.
My role includes:
My work is varied and complements the care provided to my clients by their General Practitioner by providing specialised assessment, timely intervention, health literacy, clinical management and ongoing monitoring through an acute or unstable phase of end-stage chronic disease. I also augment specialist palliative care services by providing symptom management for older people at end of life.
Amelia [actual identity changed] was 82 years old and lived alone in a mobile home village. Amelia was referred to myself for Advance Care Directive discussions and future planning when it was felt she was likely within the last year of life. Her husband died four months previously, and had been Amelia’s primary carer. Amelia wanted to stay within her own home for as long as possible although she had chronic illnesses with frequent episodes where her illnesses worsened.
When I met Amelia, we had an extensive discussion where I discovered the following:
Over the following two weeks I visited Amelia twice a week and called her on alternate days. I liaised with her locum GP as her primary GP had been on leave. I ordered appropriate blood tests and collaborated with a diabetes nurse specialist to manage her diabetes. I ordered X-rays, conducted pain assessments and prescribed trials of additional pain medications to assess and ease her hip pain. I also provided education on pain management, blood sugar monitoring, and assisted with falls prevention in her home. I adjusted her warfarin and liaised with her GP to ensure ongoing monitoring.
I referred her to a team of aged care specialists who provided her with physiotherapy and nutrition services which enabled her to stay safely in her home. Finally, I coordinated and managed the Advanced Care Planning discussion with Amelia and her son and conveyed this plan to her GP. Once stable, I referred her back to her primary GP for ongoing management but left my contact number for future concerns if she was unable to get into her GP.