BUS4003: Care Plan Development and Implementation Case Study

This report presents a comprehensive analysis of a care plan designed for a 35-year-old woman, Ms. A, who has been recently admitted to a residential mental health care center due to a combination of physical and mental health challenges. The care plan addresses her complex needs, including past trauma, behavioral issues, and suicidal ideation, stemming from difficulties with housing and personal relationships. The report defines care plans, emphasizing their dynamic nature and the importance of continuous assessment, and explores the role of multi-disciplinary teams in providing holistic care. It delves into the principles and benefits of this approach, including patient involvement, specialized expertise, and effective communication, while also acknowledging potential drawbacks such as resistance from clinicians and financial discrepancies. Furthermore, the report discusses relevant theories and approaches to care, including the theory of self-care, self-care deficit, and nursing systems, providing a framework for understanding the patient's needs and the interventions required. The report also includes a reflection on the care plan, and provides references for further reading. The analysis aims to provide a thorough understanding of the care-based approach for mentally challenged patients.

Running head: CARE PLAN
CARE PLAN
Name of the Student:
Name of the University:
Author Note:

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Table of Contents
Introduction:...............................................................................................................................1
Discussion:.................................................................................................................................1
Case Summary:......................................................................................................................1
Definition:..............................................................................................................................3
Multi- Disciplinary Team:......................................................................................................4
Modules and Theories:...........................................................................................................7
Theory of Self- Care:.........................................................................................................7
Theory of Self- Care Deficit:.............................................................................................8
Theory of Nursing System:................................................................................................8
Reflection:..................................................................................................................................9
References:...............................................................................................................................11
Appendix:.................................................................................................................................13

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Introduction:
The health are plans are for the people are diagnosed with physical or mental
challenges. The primary aim of the health care professionals are to create and develop care
pans to address the illness or the health needs of the people. The situation is especially
challenging for the mentally challenged patients. They need constant attention and care as the
body of the patients go through a number of changes, and each of the patients with similar
type of mental challenges execute different types of symptoms and behaviours. Therefore, a
care plan and a care attitude is needed in order to response to the needs of the patients and to
appropriately address these need areas (Bristowe et al. 2015). Therefore, the aim of the
following essay is to provide a complete understanding of the care based approach that are
needed to include while incorporating a care plan of a particular patient. The essay will also
include different theories and approaches and analytical models in order to provide a
complete understanding of the topic.
The essay will discuss in the context of Ms A who is recently shifted to a residential mental
illness home as she is recently diagnosed with certain physical and mental illness. The essay
will therefore, provide a small understanding of the situations of Ms A and further will
provide an understanding of care planning considering the situations of Ms A.
Discussion:
Case Summary:
Ms A is a 35 year old woman who has recently been shifted to a residential mental
health care centre, as she has been diagnosed with certain severe and critical metal and
physical challenges. Ms A had initially been diagnosed with a physically challenging
situation, which was not sever at that point of time, though she was assigned with a social
worker who worked as her care giver. When she was assigned with the social worker, the

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later confirmed that Ms A could take her decisions and is capable of making individual
choices and can be viable for choosing an independent living condition. According to the
social worker Ms A represented to be a stable woman with good insights. However, at that
point of time Ms A had opted to move out of home and decided to live independently, and
she started applying for housing through the housing department. However, the process was a
long one, as thee housing department was snit choosing her application intentionally, rather
was nit prioritizing her paper because she had some physical challenges. This had frustrated
Ms a, and she was frustrated to a level that her mental health started deteriorating. Her
condition became much severe and critical within six months of her allocation of the social
worker. More importantly, since Ms A was denied of the permission of an independent
housing and since she did not choose to stay with her family, therefore, she had started giving
tantrums at home and her behavioural aspects had undergone some major changes, which
also resulted into her unstable personality disorder.
The whole situation had resulted into a breakdown in the family dynamics and she
had to be brought out of her home as she was in urgent need of care and attention and
therefore, she was transferred to a residential health care for mentally and physically
challenged patients. The challenging attributes to her mental health, resulted into and affected
her behavioural aspects as well, as she had been faced with police arrests, harassing the
professionals and the like. She also refused her medications and also executed a physical and
verbal altercations. The doctors identified that the denial or the rejection by the housing
department was associated with her past experiences of the death of her brother and her
inappropriate and traumatic experience with strange men, whom she came across via the
dating applications. She even started inflicting self- pain and was diagnosed with suicidal
inhibitions.

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Definition:
A care plan is a written assignment, applied for a particular individual viewing their
needs and requirements. The care plans are essentially included in the discourse of nursing,
and from the perspective of nursing, the care plan is referred to the outline of the care attitude
provided by the nursing approaches the care plan is essentially a guidance of the areas that
are needed to be provided with proper attention and care and along with this a care plan
includes the tools and the tasks that are to be implemented to address the need areas properly
(Bee et al. 2015). Care plan is a dynamic document that includes the areas that are to be
included in order to mitigate the need areas and includes a continuous reassessment of the
status and the changing behavioural attributes and the changing needs of the patients. It also
includes the diagnoses and the nursing interventions. The care plans vary as per the needs and
the requirements of varied diseases and in most cases the care plans are customised, basing
on the needs and the medicinal history of the patients (Mullick, Martin, and Sallnow. 2013).
Therefore, a care plan is a holistic understanding and approach of the that incudes, the
identified need areas, the approaches that are needed to be included in order to address the
need areas and the steps that are to be included to address the need areas of the patients and at
the same time it includes the medications that are suggested by the doctors and the dietary
plans that are suggested by the dieticians.
There is another form or type of care plan, known as the, Omaha Plan, which includes
the analytical systems and processes to establish a course of care. The Omaha plan also offers
alternative courses of action that can be addressable for a particular patients, as in many of
the cases it has been observed that given the current status or the situations of the patients, the
decisions regarding the care management of a particular patient often varies which requires
alternative options (Holley, and Davison. 2015).

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Multi- Disciplinary Team:
The multi- disciplinary care plan or team is a health care delivery model that are
created or formed to address the patients with varied needs. This particular model, as per the
academicians, has been created in order to address the shifts in the medicinal areas, for
example, the ageing population or the child welfare population. These model are also
developed in order to maintain a balance within the healthcare industry (Housley. 2017). The
multi- disciplinary approach within the health care industry, denies the traditional methods
and the traditional forms of health care plans and denies the predominantly institutionalised
methods and forms of heath care approaches and replaces them with new methods and
approaches.
The multi- disciplinary approach of healthcare, is a team approach to the health care system.
The evaluation of the diseases and the treatment planning are approached in a collaborative
manner, and the medical and the allied health care needs are approached in an integrated
manner with the involvement of the patients and the family of the patient, and therefore
includes an individual or patient specific treatment plan (Hui et al. 2013). The multi-
disciplinary approach towards the health care plans therefore includes shared responsibility
and since they have a team approach, therefore, different roles are assigned to different
individuals in order to address the varied needs of a patient.
The multi- disciplinary approach is characterised by the following five main principles.
 Firstly, the care plan includes and involves the patients in the decision making plan of
the health care plan. The management and the discussion involves the insights of the
patients as well. Also, the health care professionals ensure that timely and appropriate
information from the family of the patient and it is a vice- versa process (Powell, and
Baldwin. 2014).

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 Secondly, the multi- disciplinary approach is a team approach that involves the
specialised health care professionals, professional for the allied activities, a general
practitioner, and a care provider who is given the role of taking care and supervising
the patient all the time ad noting down the small changes that take place within the
behavioural or in any other aspects of the patient (Lash et al. 2014).
 Thirdly, the multi-n disciplinary approach includes an effective and appropriate
communication management and system within the group (Lash et al. 2014).
 Fourthly, the multi-disciplinary approach includes a decision based on the national
standards of the health and welfare of a particular state, and it also is abided by the
treatment decisions made by or promoted by the country and it also needs adequate
and proper information regarding the medicinal approaches and guidelines practiced
within a particular state (Powell, and Baldwin. 2014).
 Lastly, the multi- disciplinary approaches provide all the therapeutic options that are
available or can be accessible irrespective of the geographical barriers (Lash et al.
2014).
In order to gain a complete understanding regarding the multi- disciplinary approaches,
the barriers and the benefits of this approach must also be identified. The multi- disciplinary
approaches are included in most of the countries and in the developed nations the practice of
the multi- disciplinary approaches are very evident and very common. The multi- disciplinary
approaches suffice the expectations of the patients and fulfil the needs of the patients in a
rightful manner. The inclusion of the multi- disciplinary approaches have made it easier for
the doctors to identify all the need areas and all the changes that can be seen in a patient. This
particular approach has made it easier to address the needs and to understand the same (Lum,
Sudore, and Bekelman. 2015). More importantly, as it includes a patient oriented approach,
therefore, it becomes easier for them to address the need areas for the patients. Also,

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evidences has suggested that, since the inclusion of a multi- disciplinary approach, the
mortality rate of the patients have increased, and it has also improved the quality of life. The
multi- disciplinary approaches also impacted upon the financial aspects, as the cost of
hospitalization and the unplanned hospital remissions have been reduced because of the
inclusion of this approach (Clarke, and Forster. 2015). The approaches also use experimental
approaches into the care plan, using the documentation from the past cases. Thus, the multi-
disciplinary approach addresses the needs of the patients and provides the patients and their
families with a satisfied service. The multi-disciplinary approaches have also made the job of
the health care institutions easier.
Irrespective of the benefits of the multi- disciplinary approach, there are certain drawbacks of
the process.
 Firstly, there is a resistance observed among the clinicians. They do not want to
change or shift from their methods or understandings.
 Secondly, due to the lack of time of the clinicians, they often fail to attend the
meetings which negatively impacts upon the decision making processes.
 Thirdly, there is also an issue related to the management of the teams. There are also
issues with workforce pressures and disciplines (Rowlands, and Callen. 2013).
 Fourthly, there is observed a disparity among the public and private health care
professionals and multi- disciplinary approaches.
 Next, there is also an issue with the patient ownership.
 Also, there is an issue with the financial programs. It is often seen that there are
discrepancies in the remuneration of the multi- disciplinary services. The prices,
determined at the start varies form the cost shown in the end, and this is very
common, and the disparity in the financial structure is often quite high.

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 Lastly, the multi- disciplinary systems cannot always reach to remote rural areas, and
sometimes it is very difficult to reach the therapeutic needs in these remote sectors
which hinders the success of the multi- disciplinary approach (Rowlands, and Callen.
2013).
Modules and Theories:
The theories of the care planning are based on the models of care. The models of care
planning refer to the conceptual tool of care planning, which serves a standard example of the
combined concepts and the beliefs and thee intents that are related to the care planning. The
theory or the models of care planning are inspired and influenced by the nursing theories.
There are four basic theories of care planning, first, the theory of self- care, the theory of self-
deficit, and the theory of nursing system.
Theory of Self- Care:
The self- care approach refers to the activities that the individuals include by
themselves, in order to maintain their health and life, and their well- being. It refers to the
abilities of the individuals to care for themselves. The self- care requires to meet the self- care
requisites by meeting valid methods and related sets of operations and actions. It further
includes three approaches (Norman, and Ryrie. 2013). First, the universal self- care
requisites, which is, the requisites, that are common to all. For example, the balance between
the activities and rest and between socialising and solitaire. Secondly, it includes the
developmental self- care requisites, which refers to the aspects of adaptation. Lastly, the
health deviation of self- care, which includes the medical assistance, and being aware of the
pathological needs and requirements and the illness and injuries that are to be taken care of
by the people, themselves (Norman, and Ryrie. 2013).

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Theory of Self- Care Deficit:
The self- care deficit approach refers to the need areas where the nursing approaches
and helps are required. The self- care deficit aspect is required when a person is incapable of
self- care, then it is regarded as self- care deficit approach. The self- care deficit approach
refers to situation, when a person is incapable of taking care him or herself, and the nursing
help is eminent and absolute, it is regarded to be the self- care deficit approach where there is
a deficit in the self- care. Therefore, the self- care deficit approach includes five steps or
measures to address the need areas (Chang. 2013). First, contributing to the causes of others
and helping others out. Secondly, developing guidelines for the people in need. Thirdly,
creating a situation of support and developing an environment where the need for support can
easily be communicable, and also, providing support and guidance for the future needs.
Lastly, the approach also includes a teaching approach, whereby, the patients learn to address
their needs and at the same time, the care givers and the clinicians learn and understand from
each other (Bee et al. 2015).
Theory of Nursing System:
The theory of nursing system focus on the ways the nursing processes and systems
can justly and successfully approach the need areas of the patients. The theory of nursing
system includes all the clinical and the therapeutic approaches that are included in a care
approach to address the needs of the patients. The nursing system, includes the diagnosis
process, till the process of supervising and operating needs, and then further observed the
changes within the patients and it also includes the technological approaches related to the
nursing practices. The theory if nursing system includes all the tools and the materials that are
needed in appropriating the need areas of the patients (Kaakinen et al. 2018). The theory of
nursing system also includes the scopes and the opportunities and the potentials that are

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available in this industry, and further determines the kind of relationship that must be adhered
and practiced in the nursing system.
Therefore, these theories lay the background and the guidelines for the care plan
approach, and the theory of nursing is included in this approach, since the care planning is
essentially an aspect of nursing.
Reflection:
Considering the case study, that is presented here, I think it will be more appropriate
if the theory of nursing system is applied to approach the scenario of Ms A. Ms A is currently
suffering from a visual impairment, renal failure, a personality disorder and diabetes.
Therefore, the case of Ms A is very critical now, sand she needs constant care and attention.
As per the case study, Ms Ai s transported to a residential mental health placement, which is
a good decision. However, I believe that Ms A should have assigned with a Multi-
Disciplinary Team. The multi- disciplinary teams keep the patient under supervision, for 24
hours, and observe all the movement of the patient. Since Ms A is visually impaired and since
she is suffering from personality disorder which are making changes in her behavioural
approaches, therefore, I believe that she should be under observation all the time, and special
care planning should be developed in order to address her situation. The involvement of a
multi- disciplinary team, can develop the steps that will be appropriate and effective for her
situation and at the same time, the multi- disciplinary team can observed the changes, which
will be effective fir her further treatment. Involvement of a multi- disciplinary team will also
assure her sense of independence as she will be treated separately.
Further, the multi- disciplinary team must incorporate the theory of nursing system into the
care planning approach, as have already been discussed, the theory of nursing approach
includes a step by steps process and involves the equipment that are needed or can be

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applicable to address the need areas of teg patients. Since Ms A is suffering from acute
personality disorder and also renal failure, therefore, certain equipment are needed to address
her conditions. Also, the nursing theory approach includes the analytical and clinical
approach towards the conditions of the patients, therefore, the conditionings and the
situations of Ms A can be analytically approached and the continuous observations can help
in the process of assessing the gfir6ther need areas or behavioural changes that are likely to
take place.
Addressing the patients with mental challenges is one of the biggest and most crucial
approach, and I believe that they need constant attention and care, and the patients with both
mental and physical challenges are more critical to conduct and treat. Ms A is not only
mentally challenged but visually impaired as well, which is one of the biggest reasons for her
frustration, therefore, she not only needs constant care, but also needs support and help
through her daily works and that too in a very subtle way as she has a sense of independence
within her. Therefore, I think that Ms A should be approached with a multi- disciplinary
team that will provide her constant care and support and thus will help her through her times
of difficulty. Moreover, Ms A should be approached with analytical approach and there
should be involved equipment which can better her situation.

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References:
Bee, P., Brooks, H., Fraser, C. and Lovell, K., 2015. Professional perspectives on service user
and carer involvement in mental health care planning: a qualitative
study. International Journal of Nursing Studies, 52(12), pp.1834-1845.
Bee, P., Price, O., Baker, J., & Lovell, K. (2015). Systematic synthesis of barriers and
facilitators to service user-led care planning. The British Journal of
Psychiatry, 207(2), 104-114.
Bristowe, K., Horsley, H.L., Shepherd, K., Brown, H., Carey, I., Matthews, B., O’Donoghue,
D., Vinen, K. and Murtagh, F.E., 2015. Thinking ahead–the need for early advance
care planning for people on haemodialysis: a qualitative interview study. Palliative
medicine, 29(5), pp.443-450.
Chang, M.L., 2013. Toward a theoretical model to understand teacher emotions and teacher
burnout in the context of student misbehavior: Appraisal, regulation and
coping. Motivation and Emotion, 37(4), pp.799-817.
Clarke, D.J. and Forster, A., 2015. Improving post-stroke recovery: the role of the
multidisciplinary health care team. Journal of multidisciplinary healthcare, 8, p.433.

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Holley, J.L. and Davison, S.N., 2015. Advance care planning for patients with advanced
CKD: A need to move forward.
Housley, W., 2017. Interaction in multidisciplinary teams. Routledge.
Hui, D., De La Cruz, M., Mori, M., Parsons, H.A., Kwon, J.H., Torres-Vigil, I., Kim, S.H.,
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Mullick, A., Martin, J. and Sallnow, L., 2013. An introduction to advance care planning in
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Norman, I. and Ryrie, I., 2013. The art and science of mental health nursing: Principles and
practice: A textbook of principles and practice. McGraw-Hill Education (UK).

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Powell, H.A. and Baldwin, D.R., 2014. Multidisciplinary team management in thoracic
oncology: more than just a concept?.
Rowlands, S. and Callen, J., 2013. A qualitative analysis of communication between
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Appendix:

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