CHCCCS015: Individualised Care Plan for Signature Centre Patients

This assignment solution provides individualised care plans for three case studies: Mrs. Thompson (fall risk), Eleanor (stroke), and James (diabetes). The care plans address specific care issues, outline goals, propose interventions, and suggest evaluation methods. For Mrs. Thompson, interventions focus on fall prevention through environmental modifications. Eleanor's plan addresses post-stroke paralysis, speech difficulties, fatigue, and memory issues, with interventions including physical therapy, mobility aids, and cognitive rehabilitation. James's plan focuses on educating him about diabetes and providing support for insulin management. The assignment references relevant research to support the proposed interventions and emphasizes the importance of patient-centered care.

Running head: INDIVIDUALISED CARE PLAN
Individualised care plan
Name of the Student:
Name of the University:
Author Note:

1INDIVIDUALISED CARE PLAN
Case study A: Fall
Signature Centre Care Plan Residents Name:
Mrs Thompson
Care issue Goal Intervention Evaluation Signature
Fall To identify the
potential extrinsic
risk factors for
falls at home,
minimise the
chance of fall by
reducing the over-
clustered
environment of
the patient at
home and
improve the
overall task
performance,
independence and
accessibility of
the patient.
 Zero step entrance
 Glare-free floors
 Wheelchair and
walker facilities
 Remove shower
sills/hobs in
washrooms
 Install handles or
railing in
washrooms
 Modify the height of
kitchen benches
 Lighting at night to
show the way
 Non-slip strips on
stairs (Clemson et
al. 2019).
The interventions
can be evaluated
by observing the
patient and noting
the frequency of
falls or injuries
related to the
tripping of the
patient. Feedback
from the patient on
the utility and help
gained by each of
these interventions
can be useful to
evaluate the
efficacy of each of
these
interventions.
Case study B: Stroke
Signature Centre Care Plan Residents Name:
Eleanor
Care issue Goal Intervention Evaluation Signature
Post-stroke
partial
paralysis
To improve
muscle
movement and
control to retain
the
independence of
the patient in
performing
tasks.
 Physical therapy-
Exercise, heat and
massage to stimulate
the muscles and
nerves (Tanaka et al.
2019).
 Mobility aids and
supportive devices-
wheelchairs, braces,
walkers and canes.
 Assistive technology
and equipment-
The effectiveness
of the
intervention can
be evaluated by
monitoring the
changes in the
movement and
ease of
performing the
physical activity
of the patient.

2INDIVIDUALISED CARE PLAN
unique controls for
driving and eating
utensils.
Post-stroke
dysarthria
(Speech
difficulties
)
To overcome
difficulties in
speech and
communication
by strengthening
the muscles
responsible for
clear speech.
 Nurses must refer
the patient to a
speech and language
therapist (Miller and
Bloch 2017).
 Nurses can teach the
patient with various
physical exercises
that will strengthen
and the requisite
muscles for clear
speech.
 Communication aids,
such as electronic
communication
devices may also be
used.
Regular
communications
with the patient
and recording the
changes in
speech each time
may help in
evaluating the
success of the
interventions
suggested.
Post-
stroke
fatigue
To eliminate
post-stroke
fatigue by
enhancing the
overall strength
of the patient.
 Pharmacological
interventions can be
administered to the
patient depending on
the individual case.
 Non-
pharmacological
intervention includes
general fatigue
management
programs to educate
the patient and the
caregivers about the
effects of post-stroke
fatigue.
 Increasing step count
daily along with
regular exercise are
also useful nursing
interventions to
reduce fatigue (Choi-
Kwon, Mitchell and
Kim 2015).
An increase in
the daily step
count of the
patient is
indicative of a
positive outcome
of the
intervention.

3INDIVIDUALISED CARE PLAN
Post-stroke
memory
issues
To improve
cognitive issues
and recover
immediate and
long-term
memory
function of the
patient.
 Nursing
interventions include
cognitive
rehabilitation to
recover the memory
functions (De Luca,
Calabrò and
Bramanti 2018).
 Exercises of the
brain may also help
in increasing
concentration and
regaining the
memory function
(das Nair et al.
2016).
Regular short
memory tests can
indicate the
effect of
rehabilitation and
brain exercises.
Case study F: Unmet needs
Signature Centre Care Plan Residents Name:
James
Care issue Goal Intervention Evaluation Signature
Unmet
diabetic
needs
To educate
James and
increase his
awareness about
the different
dimensions of
diabetes and
provide access
to his insulin
requirements.
 As James is
unaware of the
clinical aspects of
diabetes, education
on the same is
essential (Griffey
et al. 2015).
 Training on
ordering insulin
injections to be
delivered to his
home is necessary
for James as he can
neither drive nor
lives near a
pharmacy.
 A new dose of
insulin might be
required for James
for a short period
James must
come for
routine check-
ups to keep his
condition of
diabetes under
control. A
quick routine
check-up is
needed to
update his
dose of insulin
according to
his current
clinical
condition.

4INDIVIDUALISED CARE PLAN
to recover from the
gap of three weeks
in dosage.

5INDIVIDUALISED CARE PLAN
References
Choi-Kwon, S., Mitchell, P.H. and Kim, J.S., 2015. Nursing interventions for poststroke
fatigue. Stroke, 46(10), pp.e224-e227.
Clemson, L., Stark, S., Pighills, A.C., Torgerson, D.J., Sherrington, C. and Lamb, S.E., 2019.
Environmental interventions for preventing falls in older people living in the
community. Cochrane Database of Systematic Reviews, (2).
das Nair, R., Cogger, H., Worthington, E. and Lincoln, N.B., 2016. Cognitive rehabilitation
for memory deficits after stroke. Cochrane database of systematic reviews, (9).
De Luca, R., Calabrò, R.S. and Bramanti, P., 2018. Cognitive rehabilitation after severe
acquired brain injury: current evidence and future directions. Neuropsychological
rehabilitation, 28(6), pp.879-898.
Griffey, S., Piccinino, L., Gallivan, J., Lotenberg, L.D. and Tuncer, D., 2015. Applying
national survey results for strategic planning and program improvement: the National
Diabetes Education Program. Evaluation and program planning, 48, pp.83-89.
Miller, N. and Bloch, S., 2017. A survey of speech–language therapy provision for people
with post‐stroke dysarthria in the UK. International journal of language & communication
disorders, 52(6), pp.800-815.
Tanaka, N., Matsushita, S., Sonoda, Y., Maruta, Y., Fujitaka, Y., Sato, M., Simomori, M.,
Onaka, R., Harada, K., Hirata, T. and Kinoshita, S., 2019. Effect of stride management assist
gait training for poststroke hemiplegia: A single center, open-label, randomized controlled
trial. Journal of Stroke and Cerebrovascular Diseases, 28(2), pp.477-486.