Hannah C
14.2 Assignment
P5: Assess care needs of selected service user with physiological disorder
The care plan and care planning cycle
A care plan is document laid out to show and outline an individuals needs, the type of care they
need, who will provide the care and how the support will be given. It’s important as it can enable an
individual to understand what support they’re being provided, who will provide it and the desired
outcome. Additionally, (Berg, 2020) also emphasises the importance of care plans as they state that
it ensures an individual receives the right level of care that underpins their wishes and preferences
and that the care received is properly recorded to help benefit any future incidents.
The care planning cycle is a care plan that is recorded in different stages that arrange treatment or
care, covering the types of services for the service user.
Stakeholder consultation – Gathering all information regarding the service user as well as
agencies or professionals involved
Identifying health needs and priorities – Involves the consideration of the service users
needs in an holistic approach and prioritising desired outcomes
Plan and respond – Setting specific timeframes, locations and professional responsibilities
that aim to meet objectives and the desired outcome
Implement –The care plan will be properly enforced into action and the treatment stages
will officially start
Evaluate impact – Any care or treatment will be evaluated, if there are any difficulties, then
the cycle will be adapted in order to meet any of the new requirements
The care plan will continuously be monitored and after the evaluation, it will be reviewed if any
circumstances are changed. Furthermore, it’s important that the service user is at the centre of the
care plan as it would involve their needs and their wishes.
My case study
Richard (real name kept confidential) is a 55 year old male who was diagnosed with Coronary Heart
Disease when he was 49 years old after having a heart attack. Richard lives with his 20 year old son
in a second floor 2 bed flat and has two daughters who live a 20 minute drive away with his ex wife,
but he rarely sees them.
Richard used to be a full time lorry driver before his first heart attack but is now currently
unemployed after having his HGV license taken off him due to failing the medical assessment. While
Richard was a lorry driver, he had a poor diet due to having to eat from food vans that only provided
fatty foods such as burgers or kebabs. This frequent intake of unhealthy food caused him to become
overweight. It could be argued that the unhealthy diet and being a frequent smoker, influenced his
likelihood of developing coronary heart disease. Heart conditions have been common in Richards
family and his mother passed away of a heart attack at age 52.
Richard was diagnosed with CHD after his first heart attack 6 years ago. He woke up at night with
severe chest pain, pins and needles in his arm and felt slightly sick. As a result he went to A&E,
where he was later admitted to ICU in order to run tests. The next day they diagnosed him with CHD.
Later he received 4 stents and was referred for a cardiac rehabilitation programme. A few years later
1
, Hannah C
he had 2 more heart attacks where he had an extra 3 stents, meaning he now has 7 stents. He also
was diagnosed with high blood pressure, high cholesterol, type 2 diabetes, sleep apnoea and
depression. It could be argued that CHD influenced the development of these disorders.
Furthermore, any form of physical movement results in Richard becoming breathless and causes him
discomfort. These frequent symptoms often cause Richard to struggle to do simple day to day
activities.
Care needs assessment
The 12 activities of daily living by Roper, Logan and Tierney is frequently used when creating a care
plan. A study was done in order to determine whether their model of nursing care affected the
outcomes of patients with coronary obstructive pulmonary disease. The conclusion that was
recorded was that the ‘study demonstrated that there were improvements in patient’s outcomes in
the concept of holistic and individualised nursing care of patients with COPD according to the Roper,
Logan and Tierney model’ (Kara 2007,). As a result, they support the effectiveness of the model in
care needs assessments.
The 12 activities of daily living include; maintaining a safe environment, communicating, breathing,
eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature,
mobilising, working and playing, expressing sexuality, sleeping and lastly dying. I will be applying the
relevant ones to my case study.
Richard’s flat isn’t a safe environment for him due to his frequent breathlessness. He struggles to
climb the stairs especially if he needs to carry his food shopping. As a consequence, it would be
beneficial for him to move to a ground floor flat or to a bungalow. This is would positively impact his
social needs as it would enable him to leave his home safely and possibly more often without him
worrying about having to walk down the stairs.
A common symptom of CHD is difficulty breathing. This causes problems with doing any physical
action such as breathlessness or chest pain as there’s a strain on the heart. This makes Richard feel
deterred from attempting to undertake in daily tasks such as cleaning. Additionally, Richard
experienced difficulty breathing at night and was later diagnosed with sleep apnoea. Sleep apnoea is
when someone’s breathing stops and starts while they sleep and can lead to someone feeling very
tired during the day. Consequently, this impacts Richards’s physical and social needs as he is
constantly feeling tired. He was given a CPAP machine that pumps air into a mask while the
individual sleeps. It enables the person to be able to improve the quality of sleep and stops the
airways from getting too narrow.
Richards poor eating and drinking habits have resulted in him being overweight with a BMI of 35.
The desired outcome for Richard would be to lose weight and start eating healthier. In order to lose
weight, Richard could be referred to a dietician. A dietician would be beneficial for him physically as
they could create a diet plan that can educate him on what food could help him lose weight. Being
overweight causes Richard to feel self-conscious, but also makes it difficult for him to find motivation
to lose the weight. Consequently, Richard needs to become educated on what food would be
healthy for him and also encouraged to make adaptions to his diet.
Personal cleansing and dressing may prove difficult for individuals with coronary heart disease as it
can cause them to physically exert themselves. For example, when Richard tries to dress himself, he
usually becomes out of breath due to having to move. In addition, arthritis is common amongst
individuals with coronary heart disease, which can be painful when trying to clean or dress
themselves. This can negatively impact them emotionally and socially as they could be embarrassed
at not being able to complete a basic daily activity and they may limit the amount of changing or
washing they do, potentially resulting in them not wanting to leave their home.
2
