University Nursing Care Plan Report: Rehabilitation and Community Care

This report presents a comprehensive analysis of a rehabilitation and community care plan, focusing on a case study of a patient with metastatic ovarian cancer. The report delves into the client's problems, needs, strengths, and weaknesses, and outlines relevant nursing diagnoses, goals, and interventions. It emphasizes the application of the advance care planning model and discusses the justification for each diagnosis, the client's progress, and the facilitators and barriers to the healthcare plan's implementation. The analysis includes a detailed examination of nursing interventions, such as direct questioning, providing a non-judgmental environment, and involving the patient in future planning. The report concludes by highlighting the importance of advance care planning in improving the mental and physical health of patients and provides a comprehensive overview of the elements involved in the plan, including nursing diagnoses, justifications, interventions, and relational aspects. The report also acknowledges the challenges in applying a healthcare plan in serious cases, such as cancer, and emphasizes the positive impact that effective implementation can have on patient confidence and well-being.

Rehabilitation and
community care

Table of Contents
INTRODUCTION...........................................................................................................................1
MAIN BODY...................................................................................................................................1
(a ) Client's problem, need and strength, weakness- ...................................................................1
(b) Nursing diagnosis and goals..................................................................................................2
(c) Nursing intervention and relational........................................................................................2
(d) Justification of each diagnosis................................................................................................3
(e) Client's progress towards progress.........................................................................................3
(f) Facilitators and barriers of the health care plan......................................................................4
CONCLUSION................................................................................................................................4
.........................................................................................................................................................5
REFRENCES...................................................................................................................................6

INTRODUCTION
Rehabilitation and community care offers kind of health services which helps in the
providing better health outcomes and easy treatment(Fairweather, Sanders, Cressler and
Maynard, 2017). This is very important for patient in providing health care equipments at the
home so that patient can be treated at the home and by self care alternatives. This project report
contains detailed information about the health care plan which includes client's needs, strength
weaknesses on the basis of mentioned case study of Carla 's story. In addition, on the basis of
case scenario, advance care planning model has been selected.
MAIN BODY
Advance care plan is a kind of plan which gives direction for the care of patient
individually in future. This plan is applicable for adults on all life stages. It is necessary for a
care plan that it should be designed as per the need and requirement of the client or
patient(Tholin and Forsberg, 2014). In this report, an advanced care plan is discussed which is
based on the diseases Metastatic Ovarian Cancer. This care plan is described as follows:
(a ) Client's problem, need and strength, weakness-
Problem- Patient suffers many disease and for them health issues is a big problem. As
per the case study, the client Mrs. Carla is suffering from the Metastatic Ovarian Cancer. Due to
this she is about near to death.
Need- Basically, patient needs treatment at the hospital but apart from it, they requires a
health care plan at home. On the basis of analysis of case study, the patient requires a stable
family situation where she can live freely because in their family there are disputes regarding to
the treatment of Carla. Additionally, as per the advance care model, they need to develop a plan
for future which can help to the Carla if she gets unable to speak or move.
Strength- For a patient or client biggest strength is support from the family. In the
situation of Metastatic Ovarian Cancer, patient 's strength can be family support and good
treatment. In this case study, Carla 's strength is support of their family. Her family do not wants
that Carla dies before born of new child to her daughter.
Weakness- In the disease like metastatic ovarian cancer, the weakness can be mentally
instability due to various reasons. In the case of Carla, weakness is mismatch in thinking of
family members.
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(b) Nursing diagnosis and goals.
Nursing diagnosis is a kind of nursing process that is related to provide clinical
judgement to solve the health regarding issues for families, communities and individuals(Rose,
Ferguson, Power, Togher and Worrall, 2014). This is very important in the treatment of the
patients because in the absence of this it can be difficult to manage the health issues at the home.
As well as it is an elementary part of advance care plan because it emphasis on the future. There
are some nursing diagnosis which can be applied in the case of Carla for better health:
1.Health promotion- This type of diagnosis is related to the creating awareness about
the health in the mind of patients. These type of diagnosis includes patient's readiness for
particular health issues. Basically, health promotion diagnosis's main objective is to promoting
the health outside of the hospital. On the other hand it helps to the patient's family to be aware
for health of patient in future. Herein, the case study of Carla, their family is need to be aware
about the health of Carla at their home. Some example of health promotion diagnosis are
sedentary lifestyle etc.
2.Risk Nursing Diagnosis- This diagnosis is related to identification of issues regarding
to the health. In other words it finds the factors that are risk for the health of patient. For example
analyse of risk factors like smoking, obesity etc. In the case of Carla, disease is serious so it is
not necessary to identify the issues but family members can find the issues at home which impact
the health of Carla negativity. Additionally, this diagnosis can help in making health care plan
more comprehensive for future of Carla.
3.Syndrome Diagnosis- It is a kind of diagnosis which is combination of two or more
nursing diagnosis. Example of syndrome diagnosis is the ineffective tissue perfusion.
(c) Nursing intervention and relational.
1.Intervention - First interventions is that try to ask direct questions with the patient to
keep away from mentally depression. This is important because if a patient gets busy in
answering the questions of different people then it will remove negative thought from customer's
mind. As per the case study, Carla needs to be interacted with family members and as per the
need of advance care plan she is needed to be aware about future positiveness.
Rational- According to studies, it is analysed that many cancer patients adopt option of
suicide after the leave from the hospital(.Moore, Hogg and White, 2012). The reason behind this
is that they suffers from the negativity and do not wants to become burden on family. Herein, the
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case of Carla, she wants to leave herself from life due to difficulties in surviving. In this
situation, Carla can be motivated by advance care plan. This is why because if her family
members will tell about positive things of future and promise her that she will recover soon in
further time.
2. Intervention- Basically metastatic cancer patient requires an open non judgemental
environment. That patient should be provided therapeutic communication. In the case of Carla,
she is needed a communication methodology for expressing feelings freely. Carla's family
members can make chat about the future planning of her health.
Rational- Try to promote and encourage the patient's thoughts and feeling. This can
enhance the mental situation of the patients. On the other hand, in the absence of this
intervention it can be tough for the cancer patient to remain positive.
3.Intervention- Involvement of the patient in making planning about the future goals and
objectives as per the advance care plan model. This will enhance the confidence of the patient as
well as increase the willingness to live. In the case study, Carla can change her thought of suicide
if family members involve her in the future planning.
Rational- Due to active participation in problem solving and future planning can control
over the patient from negative thinkings. As well as it will feel special to the patient.
(d) Justification of each diagnosis.
Justification is important in the context of the nursing diagnosis because without
justification it is hard to implement the the diagnosis for the patients as well as it is required for
advance care plan to make it more promising. (Chung, Niewczyk, DiVita, Markello and
Granger, 2012). Herein justification of each diagnosis is described below in the aspect of the
selected case study.
1. Health promotion is required for the physically and mentally development of the
patient at the home. In the case of Carla, she is suffering from the cancer so it is important to
promote the health of patient. This type of health promotion requires support from the Carla 's
family who are aware for her health.
2. Identification of risk factor is necessary for better health of the patient. This is why
because in the absence of proper identification it can be difficult from solving the health issue.
Same as in the case of Carla, family members requires to identify the issues which makes Carla
more weak and less confident.
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3. Third diagnosis is the combination of two or more diagnosis which is required in the
wherein disease is serious like Metastatic Ovarian Cancer in the case of Carla.
(e) Client's progress towards progress.
Eventually, advance health care plan helps the patients in overcoming from the disease in
future in typical situations. Additionally, it impacts on the mental health of patient in compare to
physical health. In the case study of Carla. She is suffering from the Metastatic cancer and their
family member's goal is to keep Carla positive and happy. Though there are many disputes in
thoughts of family members. Due to effective implementation of the nursing diagnosis and
advance care plan Carla can change her negativity towards the life and can become more
confident. As well as their family members goal can be achieve because of the nursing diagnosis
and health care plan.
(f) Facilitators and barriers of the health care plan.
Reflection- In the case, they use the health care plan which is mentioned. In the context
of the physical condition of Carla, it is not easy to apply the health care plan. In addition she is
suffering from the Metastatic Ovarian Cancer so it is not guaranteed that health care plan will
help. Though they are using advance care plan which has some facilities and barriers as follows:
Facilities-
1. It recognise the environmental issues which can effect the health of the patient. Like in
the case of Carla, they applies the “risk nursing diagnosis” that recognise the issues.
2. Helps in identify the ways to improve the atmosphere outside the hospital for better
health of the patient. Same as in the case of Carla, their family members can apply the health
care plan's diagnosis for better health of Carla.
3. Encourage family members to apply precautionary measures for protection of the
patient.
4. It helps in ensuring about safe future of patient like in the case of Carla, they make
advance care plan for making secure health of Carla.
Barriers-
1. Lack of coordination among the family members of Carla can arise the issue for
implementation of health care plan.
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2. There are dispute in the thinkings among the family members of Carla so that it is
hard to apply the health care plan. This requires equality in the members of
family.
3. It is not guaranteed that this plan will success surely because future is uncertain.
CONCLUSION
From above project report it has been concluded that an advance health care plan is very
important for the health of patients. It protects the patients at the home in future. Eventually, it is
important in improvement of mental situation more then physical health. Apart from it, health
care plan consists various information in it. Like nursing diagnosis , its justification, intervention
and relational etc. All these elements are important in the context of the advance health care plan.
Additionally, disease like cancer it is hard to apply a health care plan because patient does not
want to live. Though effective implementation of the health care plan can help the cancer patient
in becoming confident.
REFRENCES
Books and journals:
Fairweather, G. W., Sanders, D. H., Cressler, D. L. and Maynard, H., 2017.Community life for
the mentally ill: An alternative to institutional care. Routledge.
Tholin, H. and Forsberg, A., 2014. Satisfaction with care and rehabilitation among people with
stroke, from hospital to community care.Scandinavian journal of caring sciences. 28(4).
pp.822-829.
Rose, M., Ferguson, A., Power, E., Togher, L. and Worrall, L., 2014. Aphasia rehabilitation in
Australia: Current practices, challenges and future directions.International Journal of
Speech-Language Pathology. 16(2). pp.169-180.
Moore, L., Hogg, L. and White, P., 2012. Acceptability and feasibility of pulmonary
rehabilitation for COPD: a community qualitative study.Primary Care Respiratory
Journal. 21(4). p.419.
Chung, D .M., Niewczyk, P., DiVita, M., Markello, S. and Granger, C., 2012. Predictors of
discharge to acute care after inpatient rehabilitation in severely affected stroke
patients.American journal of physical medicine & rehabilitation. 91(5). pp.387-392.
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