Name of individual Date of completion C B A Breathing* Normal breathing, no issues with Shortness of breath or a condition, may Is able to breathe independently through shortness of breath. require the use of inhalers or a nebuliser and limit a tracheotomy that they can manage some daily living activities. themselves, or with the support of carers OR or care workers. OR Shortness of breath or a condition, which OR may require the use of inhalers or a Episodes of breathlessness that do not nebuliser and has no impact on daily consistently respond to management and limit Breathlessness due to a condition which living activities. some daily activities. is not responding to therapeutic treatment and limits all daily living activities. OR OR OR Episodes of breathlessness that readily Requires any of the following: respond to management and have no A condition that requires management by - low level oxygen therapy (24%); impact on daily living activities. a non-invasive device to both stimulate - room air ventilators via a facial or nasal mask; and maintain breathing (non-invasive positive airway pressure, or non-invasive other therapeutic appliances to maintain airflow ventilation) where individual can still spontaneously breathe e.g. CPAP (Continuous Positive Airways Pressure) to manage obstructive apnoea during sleep. Brief Write A, B or C description of below: need and source of evidence to support the chosen level
Name of individual Date of completion C B A Breathing* Normal breathing, no issues with shortness of breath. OR Shortness of breath or a condition, which may require the use of inhalers or a nebuliser and has no impact on daily living activities. OR Episodes of breathlessness that readily respond to management and have no impact on daily living activities. Shortness of breath or a condition, may require the use of inhalers or a nebuliser and limit some daily living activities. OR Episodes of breathlessness that do not consistently respond to management and limit some daily activities. OR Requires any of the following: - low level oxygen therapy (24%); - room air ventilators via a facial or nasal mask; other therapeutic appliances to maintain airflow where individual can still spontaneously breathe e.g. CPAP (Continuous Positive Airways Pressure) to manage obstructive apnoea during sleep. Is able to breathe independently through a tracheotomy that they can manage themselves, or with the support of carers or care workers. OR Breathlessness due to a condition which is not responding to therapeutic treatment and limits all daily living activities. OR A condition that requires management by a non-invasive device to both stimulate and maintain breathing (non-invasive positive airway pressure, or non-invasive ventilation) Brief description of need and source of evidence to support the chosen level Write A, B or C below: