Assessment, Formulation & Management of Care - Care Plan for Stephen

Florence Nightingale Faculty
of Nursing, Midwifery & Palliative Care,
King’s College London
Assessment, Formulation & Management of Care
7KNIM730 2018/19
Practical Exam
Using the pro-forma overleaf you are required to write a care plan for ONE
identified or perceived need for either ‘Stephen’ or ‘Moyra’.
You may review the assessments on the KEATS site for this module.
The care plan must include a clear statement about the perceived or identified
need and possible goal(s). It is expected to be a client-focussed, practical,
working document with specific, measurable, achievable, realistic, and timely
goals and actions, with an indication of how these will be evaluated. You are not
required to reference the care plan but you are expected to choose an
appropriate, evidence-based intervention relevant to the client’s needs.
Your brief commentary should describe your rationale for focussing on the
particular need identified; outline the strengths and limitations of your care plan
in practice; and discuss how you might promote collaboration in practice.
Candidate number:.......................................................
Chosen client: Stephen  Moyra 
(Please tick the box to indicate which client your care plan is about)
Plagiarism Policy for Students undertaking programmes in the Florence Nightingale School of Nursing & Midwifery.
I have read and understand the statement concerning plagiarism. I confirm that the work attached is my own and that
I will follow the College and university Regulations in respect of plagiarism or any other examination offence.
Candidate’s initials............ Date..........................

Need identified:
The case study highlighted the mental illness of Stephan who was engaged in the face to face
communication with mental health nurse. In the current context, psychological need of the
patient is that he said he heard voices at night during sleep which disturbed his sleep and he
was in isolation since he thought it would be better for him to protect his mother. Considering
identified emotional need of Stephan, Stephen was scared to go to the hospital, because he
thought people will die in hospitals and Stephan wants to protect his mother since he was
scared about his mother. He had sleeping trouble when he had thought of protecting his
mother which made him awake at night. Moreover, he took cannabis to get rid of the
thoughts he was having night which disturb his sleeping pattern. He had false beliefs that his
friends want to harm him and they are always talking about him. He has no friends and barely
talk to other people because of his false beliefs that they would harm him.

Goal(s):
In next month, Stephan would stop hearing voices at night which disrupted his sleep; he
would be to be able to sleep 6 hours at night by releasing thoughts and beliefs.
Actions/Interventions:
The first,
Stephan would agree to involve himself in activity which would distract him
The second,
Stephan would agree to communication with mental health nurses about hallucinations.
The third,
Team agreed with Stephan that he would require pharmacological interventions such as
antipsychotic medications which would be given to him given to him for reduction of the
anxiety and help him to sleep at night for next 4 months. Moreover, his sleeping pattern
would be monitored for 6 months to evaluate the effectiveness of the interventions.
.
The fourth,
Stephan agreed that the team would offer support to his mother for next 6 months.
The fifth,
The team would refer Stephan to psychologist who will involve him in the psychological
session for next 5 months for coping with the voices he hears.
The sixth,
The team agreed that he would involve in the mindfulness therapy and other spiritual
activities that would release his false beliefs.
The seventh,