Rehabilitation and Community Care Plan: A Comprehensive Analysis

This assignment analyzes a rehabilitation and community care plan using a case study of a patient with metastatic ovarian cancer. The report begins with an introduction to community-based rehabilitation and its goals. The main body details the chosen model of care, advance care planning, and its relevance to the case study. It then discusses the client's needs, problems, strengths, and weaknesses, along with a client-centred care plan, including nursing assessments, diagnoses, goals, interventions, and rationales. The assignment also covers plans for referrals, a review of the client's progress, and the facilitators and barriers to providing effective care. The client, Carla, faces challenges due to her condition and conflicting desires regarding treatment. The care plan emphasizes the importance of patient autonomy and comprehensive support from healthcare professionals and family members. The goal is to improve the patient's quality of life while navigating the complexities of her illness.

Rehabilitation and
Community Care

Table of Contents
INTRODUCTION...........................................................................................................................3
MAIN BODY...................................................................................................................................3
Description of the model of care............................................................................................3
Model of care and its relevance to case study........................................................................3
Facilitators and barriers to providing effective client-centred care........................................3
Client centred care plan..........................................................................................................3
Client’s needs, problems, strengths and weaknesses..............................................................4
Plan for referrals and justification..........................................................................................6
Review of client’s progress toward goals...............................................................................7
Facilitators and barriers..........................................................................................................7
CONCLUSION................................................................................................................................8
..........................................................................................................................................................8
REFERENCES................................................................................................................................9

INTRODUCTION
The main aim of community based rehabilitation is help individuals with disabilities by
providing them physical therapy, equalization of opportunities and medical integration
rehabilitation programs for disable or the people who are suffering with certain diseases
(Scobbie & et. al., 2015). These type of programs are not restricted to professionals in the
healthcare, physiotherapy, social services and educational. Rather these programs involve the
individuals who are with disabilities or disease, community, their family and also appropriate
professionals. The given project will be explained through the advance care planning by using
Carla's case study who is suffering from metastatic ovarian cancer.
MAIN BODY
Description of the model of care
(Covered in PPT)
Model of care and its relevance to case study
(Covered in PPT)
Facilitators and barriers to providing effective client-centred care
(Covered in PPT)
Client centred care plan
Client-centred care are also known as patient- centred care. Under this plan, patients as
individuals who are accessing health system for treatment and care as an example a hospital.
When it is about health system in resources, it applies to integrated social care and health
system (Asher & et. al., 2016). Advance care planning focuses on care and needs of individual
rather than needs of service as well as the type of treatment individuals want to take, they
have full right to choose the treatment they want. Some people do not get satisfaction with the
care of nurse because they have their own views about care and their priorities of life. Health
care worker should be flexible because they have to treat different people with different
diseases. This plan will help to provide a better care to overcome patients with their disease.
Advance care planning is to improve their health condition as they are they are in last stage of
ovarian cancer which is difficult to cure and also giving patients freedom that they can choose
which type of care they want and speak for themselves. These type of plan helps to provide a

better care to those who need it. These plans focus on the patient as well as the treatment . All
individuals want to be happy in the last days of their life. And these plan assure that their
clients are happy with their care of services.
Client’s needs, problems, strengths and weaknesses
Carla is an old women and suffering from metastatic ovarian cancer. She undergone
multiple therapies like chemotherapy and surgery. Metastatic ovarian cancer progressing as
time is passing and because of that the person depending upon family for every need
(Marshall, Bauer & Isenring, 2014). Husband of patient wants that she lives for more days in
order to see the grand child. As per individual's every need a nurse is appointed, who helps to
get every care required by patient. Carla's husband and children are so caring which motivates
Carla to live more but person does not want to be dependent on others so she wants to stop
active treatment and this problem results in argument between Carla and William. Family of
Carla was making her emotional and special because patient knows about the disease and its
severity. Family of individual wanted that person should see the upcoming grandchild, so they
were insisting to take an active treatment.
Nursing
assessment
Nursing
diagnosis
Goals Interventions Rationale Evaluation
Carla does not
want to feel
pain and stop
treatment,
William does
want to let
Carla go so
William wants
to continue
with the
treatment.
Metastatic
ovarian cancer
is complex
and difficult
to diagnosis.
Early
symptoms can
not been seen
for few weeks
and the
diagnosis is
also lengthy.
Diagnosis is
Goals of
nurses are to
provide a
better care to
every
suffering
patient
(Langstaff &
et. al., 2014).
Carla was
suffering from
metastatic
ovarian cancer
Nursing
interventions
are those
which
facilitate their
achievements
which are
implemented
and planned
(Maddocks &
et. al., 2016).
Using and
planning
Family
support is
very
important for
the patient to
get motivation
to live more.
The nurse was
trying to assist
with the
Carla's
condition so it
can be easy to
It is very
important to
evaluate the
Carla's
condition and
family could
interact with
the nurse to
know about
the condition
so that it will
be easy to
know how

important
before giving
any kind of
treatment. It
gives a clear
picture of the
disease and
which helps to
decide for the
carers to give
proper
treatment.
Pelvic exam:
During this
exam, doctor
inserts gloved
finger into the
vagina and
simultaneousl
y presses hand
on abdomen
to feel the
pelvic organs.
And external
vagina, cervix
and genitalia
also
examined.
Imaging
tests: Tests
like CT scans
which was
crucial, in this
case nurse
wanted to
provide
person
everything
accordingly
the need.
And also good
care so it can
impact on
Carla's
liveliness so it
can be easy to
give active
treatment as
individual's
husband was
ready to give
any treatment
for Carla's
better
condition.
nursing
interventions
based on the
good quality
information of
effectiveness
is very
important to
ensure which
is desired
outcomes of
the care are
achieved.
Carla's
husband is
supportive,
William helps
to Carla to
fulfil needs.
Person had a
son whose
name was
Lyn. Lyn used
to take care of
Carla by
staying at
home. And
Lyn used to
assist the
Carla's
condition.
treat person's
disease.
Usually
patients with
metastatic
ovarian cancer
suffer with the
severe pain so
nursing
interventions
are important
to overcome
from that pain
(Wade, 2015).
Carla can
progress.
Family should
help the nurse
in decision
making about
the Carla's
treatment so it
will easy for
nurse to
provide care.

or ultrasound
of pelvis and
abdomen, can
help to
determine
shape, size
and structure
of ovaries.
Blood tests:
Blood test
include organ
function tests
which can
help to
estimate
overall health.
Testing blood
for tumour
markers
which indicate
ovarian
cancer.
Surgery:
Sometime
without any
surgery
doctors can
not be sure
about
diagnosis.
Surgery is to
Josey, who
was a
palliative care
nurse, started
visiting home
to assist with
Carla's
treatment.
As the whole
family was
concerned
about Carla's
treatment
because Carla
wanted to stop
as individual
knows about
the condition.
The family
were so
supportive,
they used to
motivate
person for
active
treatment.

remove ovary
and have
tested for the
signs of
cancer.
After these
diagnosis
surgical
management
is important to
start further
treatment
(Khan & et.
al., 2014). To
determining
extent of
disease and
which surgery
is suitable this
diagnosis is
important.
Plan for referrals and justification
Carla was dealing with the crucial stage of metastatic ovarian cancer. Patient has been
undertaken multiple chemotherapy and surgeries but condition was not progressing. It was
difficult for both individual and their family. As individual undergone chemotherapy and
surgery the condition of Carla was not able to cure because of the severity of disease. So does
not wanted to continue with the treatment even if person's family wanted to given an active
treatment for betterment. Individual's son used to stay at home to check on the condition of
her mother. And a care nurse also appointed to look after person. Individual's family used to
do everything which was making person happy.

As family wanted to continue with treatment because it will improve or stable the
condition but sick patient does not wanted to continue with the treatment. So family decided
to appoint a nurse for the needs and treatment which can help Carla to live happily until death.
Review of client’s progress toward goals
Carla was suffering from metastatic ovarian cancer which can not be cure at the last
stage of it. Nurse who is take care of person used to visit home to see individual and used to
gain more knowledge about patient. As Josey interacted to Harry and tried to know more
about the patient. Josey contacted with Carla's general practitioner to discuss conflicting
views and expectation of family. Family of the concerned individual wanted to see her happily
and hoping that patient can see the upcoming grandchild. And Carla wanted to be free from
pain as she was undergoing the treatment. To progress in condition, nurse was appointed
which was taking care of every need as patient’s family wanted to reduce illness so that
condition can be improved further.
Facilitators and barriers
Advance care have many approaches to get over from these type of diseases. Every
strategy has its own challenges and barriers to face (Cleaver & Nixon, 2014). The sever
conditions like cancer are very complex and difficult to treat. The advanced care planning
explains about several surgeries and chemotherapy and that also do not assure to completely
overcome from such conditions (Wakabayashi & Sakuma, 2014). For Carla the major barrier
to take treatment was it was a severe condition and everybody knows about the results. And
secondary Carla does not wanted to continue treatment, Carla wanted to be free from pain
means Carla wanted to die. Barriers affect any approach which is used to solve problem or
treat any disease. These can be reduced by using advanced care planning of care as it helps to
make decisions about treatment and care which patient wants to receive . Nurse was kept to
care Carla and with the required needs. For nurse it was difficult because there were different
views of family about the treatment so it was a major barrier. Advanced care planning include
symptoms, treatment, physiological and physical to cure or reduce any diseases so it can
provide good lifestyle to patient.

CONCLUSION
From above case study it has been concluded that advanced care planning include
particular disease and setting which helps to overcome from the chronic disease and also the
treatment which patient wants to take treatment and care. This model helps to reduce the illness
and also prevent the disease in initial stages. Carla who was 58 years old and suffering from
metastatic ovarian cancer. There were few barriers for treatment, so it was difficult to continue
the treatment. Client-centred plan is constructed which will help to study the case in proper
manner. Needs and problems of client were explained which helped to provide care. Diagnosis
which helps to know about disease and the therapy which should be given. Nursing interventions
are important in case of Carla's health condition. With the help of advanced care planning, it will
become easy to treat any disease.

REFERENCES
Book and Journals
Fairweather, G. W. & et. al., (2017). Community life for the mentally ill: An alternative to
institutional care. Routledge.
Marshall, S., Bauer, J. & Isenring, E. (2014). The consequences of malnutrition following
discharge from rehabilitation to the community: a systematic review of current evidence
in older adults. Journal of Human Nutrition and Dietetics. 27(2). 133-141.
Maart, S. & Jelsma, J. (2014). Disability and access to health care–a community based
descriptive study. Disability and rehabilitation. 36(18), 1489-1493.
Langstaff, C. & et. al., (2014). Enhancing community-based rehabilitation for stroke survivors:
creating a discharge link. Topics in stroke rehabilitation. 21(6). 510-519.
Maddocks, M. & et. al., (2016). Physical frailty and pulmonary rehabilitation in COPD: a
prospective cohort study. Thorax. 71(11). 988-995.
Cleaver, S., & Nixon, S. (2014). A scoping review of 10 years of published literature on
community-based rehabilitation. Disability and Rehabilitation. 36(17). 1385-1394.
Wakabayashi, H., & Sakuma, K. (2014). Rehabilitation nutrition for sarcopenia with disability: a
combination of both rehabilitation and nutrition care management. Journal of cachexia,
sarcopenia and muscle. 5(4). 269-277.
Asher, L., & et. al., (2016). Community-based rehabilitation intervention for people with
schizophrenia in Ethiopia (RISE): study protocol for a cluster randomised controlled
trial. Trials. 17(1). 299.
Challis, D. & et. al., (2018). Care management in social and primary health care: the Gateshead
Community Care Scheme. Routledge.
Wade, D. (2015). Rehabilitation–a new approach. Overview and part one: the problems.
Scobbie, L. & et. al., (2015). Goal setting practice in services delivering community-based stroke
rehabilitation: a United Kingdom (UK) wide survey. Disability and rehabilitation.
37(14). 1291-1298.
Sánchez-Rodríguez, D. & et. al., (2016). Sarcopenia in post-acute care and rehabilitation of older
adults: A review. European Geriatric Medicine. 7(3). 224-231.
Clark, R. A. & et. al., (2015). Alternative models of cardiac rehabilitation: a systematic review.
European Journal of Preventive Cardiology. 22(1). 35-74.
Iemmi, V. & et. al., (2015). Community-based rehabilitation for people with disabilities in low-
and middle-income countries: a systematic review. Campbell Systematic Reviews. 15.
Stott, D. J. & Quinn, T. J. (2017). Principles of rehabilitation of older people. Medicine. 45(1). 1-
5.
Khan, F. & et. al., (2014). Effectiveness of integrated multidisciplinary rehabilitation in primary
brain cancer survivors in an Australian community cohort: a controlled clinical trial.
Journal of rehabilitation medicine. 46(8). 754-760.