Caring for the Medically Fragile

• The term medically fragile refers to those patients who required more hands-on care. Typically, 24hr supervision by a skilled nurse. 
• Medical fragility can be measured by the Johns Hopkins Frailty Assessment calculator. This scale can be used to make decisions about the patient’s care plan. 
• A nurse who cares for medically fragile patients must be patient and well-versed in a variety of issues due to the underlying causes of what makes the patient frail. Families who have a loved one who falls into the “medically fragile” category may face many burdens, forcing them to admit their loved one to a facility that can provide the most optimal care and restore the patient’s quality of life. 

Medical fragility refers to a patient that has medical conditions or health concerns that require 24-hour supervision from a skilled nurse.  Often, these individuals are not able to care for themselves and need help with basic activities such as bathing, feeding, dressing, and other activities of daily living.   

Nurses have an important role when caring for those who are medically fragile, and many do not fully understand all that encompasses the care, time, skill, and empathy that nurses must possess in order to fully care for those that are medically fragile.   

The following are important to consider when dealing with the medically fragile population: the responsibilities of a medical fragility nurse, the five frailty indicators, difficulties families face caring for a patient with a medical fragility and assessing a patient with a medical fragility. 

Responsibilities of Medical Fragility Nurse

The fundamental roles and responsibilities of a medically fragile nurse involve managing patients with complex needs, undertaking comprehensive assessments, collaborating with healthcare professionals and developing nursing care plans.   

Patients with medical fragility require close supervision, attention, care, and therapeutic intervention during all or part of a 24-hour day.  The nurse must be mindful and knowledgeable of medical fragility needs with each patient and must be able to provide safe and effective care, coordinate well with others across the interdisciplinary team, and interact well with both the patient and family/caregivers. 

The stress level of a fragility nurse may be higher due to the increased care and demands that are needed in this unique and specialized position. 

Five Frailty Indicators for the Medically Fragile

When assessing the level of frailty among patients, it is important to have set criteria in place to determine the level of frailty and the care needed.  The five frailty indicators consist of: 

1. Unintentional weight loss 
2. Exhaustion 
3. Low energy expenditure 
4. Low grip strength 
5. Slow walking speed 

Once these five areas are assessed, an assessment calculator allows a clinician or researcher to enter five standardized measurements that equal a classification score.  The scoring is created by John Hopkins Frailty Assessment Calculator and is one of the most utilized and cited tools available for researchers and clinicians.   

A score of 3-5 = frail, 1-2 = pre-frail, and 0 = robust.  The outcomes of the calculator are used to reduce post-surgical/medical complications, reduce pain and suffering, and improve quality of life.

Difficulties with Medically Fragile Patients

Individuals with medical fragility have a wide range of complex medical conditions which require intensive, ongoing support from multiple providers and often times requires continuous skilled nursing care.   

Families of these individuals typically do a great job until the patient reaches a certain level of care that the family cannot continue to do alone, and the needs become more challenging or even impossible.   

Families caring for these individuals may also begin to have financial, marital, mental, and physical health difficulties, and difficulty maintaining outside work or a full-time work position due to the strain of providing care.  Many times, the caregiver begins experiencing strain and sometimes even a feeling of “burnout” as they often feel helpless and unsure of what the appropriate next steps may be for the patient.   

Once the level of care reaches this point, fragility nurses are often needed to step in to assist in these areas.   

Assessment of a Medically Fragile Patient

Patients with medical fragility can have various critical impairments such as weight loss, weakness, exhaustion, decreased gait and/or speed, decreased physical activity, more dependence with dressing, restricted walking, and incontinence.   

Declining health conditions, self-perceived physical limitations, and cognitive decline are all associated with negative outcomes related to frailty.  

 The nurse assesses the patient carefully in each of the above areas and gives a score based on the Frailty Indicators Scale.  The caregiver also has an important role in the assessment as they can typically offer a great amount of valid information regarding the patient’s deterioration in any of these areas as they may have noticed the regression.   

The detailed assessment offered by both the family/caregiver and the nurse is imperative in formulating a plan of care to assist both the family/caregiver and the patient.   

The Bottom Line

Fragility nurses have a huge role to fill in providing consistent, 24/7, effective, and quality care to patients who have developed more intense medical needs.  The fragility nurse also plays an important role in assessing changes among the patient that may indicate a different type of needed environment for the patient.   

The goal is for the patient to receive enhanced care, but if regression is noticed, the nurse is typically one of the first ones to notice any changes in assessments, the need for implementation of a team meeting, and the discussion of other possible treatment plans to allow the patient to reach his/her full potential as much as is safely possible.

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