Monash University NUR2007: iSAP Patient Care Action Plan for William

This report presents a patient care action plan for William Main, a 60-year-old man with stage IV colorectal cancer, residing in Dandenong, Australia. The assignment, part of the NUR2007 course, involves a detailed needs assessment, identifying both met and unmet needs, including physical, emotional, and psychological challenges. It also includes a scan of local resources and services available to William and his family, such as Estia Health, St John of God Pinelodge Clinic, and Prestige Inhome Care, providing contact details, opening hours, and the types of needs each service can address. The report culminates in a bullet-point action plan outlining immediate and potential future healthcare needs, assigning responsibilities to healthcare team members for interventions such as nutritional support, symptom management, mobility assistance, and psychological well-being. This plan aims to improve William's quality of life and address his palliative care requirements, referencing relevant research to support the recommendations. The plan addresses various issues that can be faced by the patient and provides a detailed plan of action to be taken by the care team.

[Monash ID]-NUR2007-AT2
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information. You can remove the highlighting when you have entered the relevant
text.
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[Monash ID]-NUR2007-AT2
iSAP case template – NUR2007
Patient Care Action Plan for: William
Main Contact: Glady
Main Contact’s Relation to client: William’s wife
Council area where client lives: Dandenong
Client address: Dandenong
Background:
Briefly describe the patient/client, their carer(s), access to family and social
support, living setting, their condition and recent healthcare trajectory, current
resources being used and any other key background information. (~250 words)
William is 60 year old man living in the city council of Dandenong in Australia. He grew
up in large family. He had witnessed his father and mother to live till nineties, however he
finds the same difficult for him because he found certain changes in his bowel habits. He
had discovered blood on the paper and toilet bowl. He is worried because the GP has
advised for a colonoscopy and he was diagnosed with stage III colorectal cancer indicating
regional lymph node involvement. This condition has made the patient very distressed.
After the diagnosis, he had a colon resection and six months of chemotherapy. This has
affected his health significantly and he visited the GP every two months and the outpatient
colorectal clinic every six months. However, 12 months later another blow for William was
that his colorectal cancer progressed to stage IV. Due to the worsening liver function,
tolerating chemotherapy has become very difficult for him. Due to the poor prognosis of
William, he and his wife are considering about surgery option. The ultimate reference from
the GP is that William should be shifted to a specialist palliative care service (SPCS) as
they will closely look after him and contact with GP and community nurse too. On
admission to the service, the community nurse has found that he is less mobile and
increasingly fatigued. Therefore, the current consideration for the community nurse and his
wife is to identify the current needs of Williams and plan future options for care. This is
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necessary as he is slowly becoming more frail with the progression of disease.
Needs assessment
Provide a brief summary of findings from the PCC4U Needs assessment:
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Progressive disease form, including identifying which of your patient/client’s needs
are currently met, and prioritising unmet needs. Indicate any immediate needs, and
any potential needs that might arise within William’s illness trajectory. You can use
headings and/or bullet points. You should include references where appropriate,
especially when identifying potential needs. (~250 words)
According to the PCC4U needs assessment, the needs of client that is currently met are as
follows:
Priority referral- The patient has been referred to the SPCS and extra assistance in care is
also needed
Patient well-being- The patient has no financial or legal concern and problem in sexual
functioning and relationship. The patient also requires information about support services
as he prefers getting care at home.
Ability of caregiver to care for patient- The patient has no legal concerns or inter-personal
relationship problem
Caregiver well-being- There is no problem with the caregiver in terms of overall well-
being and functioning.
The main unmet needs of William includes:
Appetite problem, pain, nausea and vomiting
Physical and emotional health problems due to colorectal cancer
Management of activities of daily living
Psychological symptoms like fear, anxiety depression and mood disorder (Solano et al.,
2016).
Due the progression of William’s cancer to stage IV, the following potential care needs
might arise in the future:
 Management of fatigue, constipation and gastrointestinal mobility in patient
 Need to manage appetite of patient and provide proper diet, adequate fluid and
electrolyte balance
 Need to provide comfort and emotional support to patient due to psychological
issues
 Attending to mobility needs of William by providing support in ADLs, giving
therapeutic exercise like breathing and mobilization exercise
 Increased need for assistive support and physical therapy
 Need for psychological and behavioral intervention to help cope with disease
and depression (Costi et al., 2014)
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Local resources and services scan
Use the table below to provide details of local services which are available to the patient/client and their family.
~500 words equivalent*. (Add additional rows to this table as necessary).
* Note that word equivalence indicates an approximate amount of information. Depending on the specific needs or services you
identify, additional words might be required (e.g services with complex opening hours might need more explanation than those
open all the time, or some services might offer a wider range of resources than others – you should provide a similar quality of
description for each). Focus on providing RELEVANT and NECESSARY information. Aim to identify ~10 services.
Service name and
brief description
Address/ contact
details and website
URL
(if available)
Opening
hours/contact
hours
How to
access (e.g.
is a referral
required?)
What needs
can this
service help
to meet?
Healthcare
team member
responsible for
referral/action
Additionalcommen
ts
EXAMPLE
Robincreek Clinic,
local health centre
123 Sesame St,
Robincreek
03 1234 4321
www.rcc.org.au
Mon-Fri 9am-5pm
Sat 9am-12pm
Sun closed
Emergency number
for out-of-hours
No referral
needed
Doctor Tanga
specializes in
palliative care
and respiratory
conditions
Patient can
make own
appointments.
Nurse can
support/follow
up.
A useful back-up if
the client’s usual GP
is not available.
Estia Health 151 David Street
Dandenong 3175
Telephone
[phone]
http://
www.estiahealth.com.a
u
All days
Sunday-Saturday
(9 am to 6pm)
No referral
needed
It is fully
residential
aged care
facility
committed to
provide
individualized
care to older
adults. It can
help William
Qualified
coordinators and
health
professionals
like
physiotherapist
and nurse
available round
the clock
It is a useful service
if clients wants care
within a home like
environment
(Dandenong. Estia
Health, 2017).
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fulfill health
care needs
within a
St John of God
Pinelodge Clinic
1480 Heatherton
road,
Dandenong vic 3175
03) 8793 9444
INFO.PINELODGEC
[e-mail].A
U
MONDAY TO
FRIDAY - 4.30PM
TO 8.30PM
WEEKENDS
AND PUBLIC
HOLIDAYS -
2.30PM TO
8.30PM
No referral
required and
direct contact
option
available
It can help to
meet
psychological
and emotional
health needs of
William. It is a
private mental
health hospital
providing
supportive care
to patient
The
multidisciplinart
team of
psychiatric care
staffs can help
address
depressions,
anxiety and
other problems
in patient.
Psychological needs
of William can be
addressed here. In
patient and day
programs are also
available (St John of
God Pinelodge
Clinic, 2017)
Prestige inhome care 1480 Heatherton Rd,
Dandenong VIC 3175
1300 10 30 10
24 Hours service
avaialble
No referral
needed
It can help to
meet physical
health and
palliative cate
needs in the
home of client.
In home care
palliative
specialist like
nurses and
professional
carers can
provide high
standard of care
to patient from
the comfort of
home
As home care is a
preferred by
William, this local
health care centre
can help to support
care and ADLs of
client from home.
The best private 24
hour nursing care is
available here from
the comfort of own
home (In Home
Private 24 hour
Nurse Care -
Prestige Inhome
Care, 2017).
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Make the Change-
Diet and Exercise
108-110 Centre
Dandenong rd,
Dingley village, VIC
3172
0449 910 601
Monday- Saturday-
9 am – 6pm
Sunday -Close
No referral
required
Dietician will
help to meet
adequate diet
and nutrient
requirement of
William
Dietician It will help address
symptoms of
constipation,
appetite loss and
diarrhea in patient
Pride Mobilty
Products
Dandenong VIC 3175
1800 800 990
www.pridemobility.co
m
Monday-Saturday No referral
required
It will help
address
mobility and
support in
ADLs of
patients. It is
the world’s
leading
designer of
mobility
products.
Nurses and
Mobility support
team
It provides high
quality mobility
device to help
clients achieves the
highest quality of
life and mobility
goals (Corp et al.,
2017).
Step Forward
Psychology
173 Como Parade East,
Parkdale VIC 3195
0432 662447
All days Book an
appointment
by calling at
0432 662447
It will help to
address
psychological
needs of client.
Psychologist It is important for
William to promote
mental health and
overcome anxiety
and depression (Step
Forward
Psychology, 2017).
Live Strong
Physiotherapy and
Health services
Shop 7,489 Nepean
Hwy, Chelsea VIC
3196
[phone]
8am-8pm No referral It will to
address aching
muscles related
problem and
improve
Physiotherapist Promote relief from
pain due to bed rest
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circulation
(LifeStrong
Physiotherapy
Chelsea, 2017)
Hallam residential
care
47-49 Belgrave Hallam
Road, Hallam VIC
3803
[phone]
All days No referral It will help to
address
palliative and
respite care
needs of
patient
Palliative care
nurse
It is an exceptional
aged care and
palliative care
service in Australia
(Aged Care
Services Australia
Group | ACSAG.
(2017)
Chelsea Central South
Pattinson Pharmacy
425 Nepean Hwy,
Chelsea, VIC 3196
Monday -
Thursday:
7am - 8pm
Friday:
7am-5.45pm
Saturday:
8am - 1pm
No referral It will meet
pharmacy
related needs
of client (For
Every Body
and Soul - Soul
Pattinson
Chemist,
2017).
Pharmacist and
chemist
On time delivery of
pharmaceutical
product (For Every
Body and Soul -
Soul Pattinson
Chemist, 2017).
Hartley Glena
Catherine
517, St. Kilda Rd,
Melbourne VIC 3000
Monday- Saturday By
appointment
It can address
all
complications
related to
colorectal
cancer
Oncologist It provides
Gastroenterology
and colonoscopy
services
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Action plan
Develop a bullet-point action plan for how William’s healthcare team should address
any immediate healthcare needs, as well as setting in place support for any potential
needs that are likely to arise in the course of his illness trajectory. For each point,
briefly identify the need, the action, who is responsible, and when it should be done.
Aim to identify at least five to ten specific actions. (~200 words)
EXAMPLE:
 Nutrition: nurse to arrange visit by dietician to develop eating plan for William
and his wife based on their food preferences. Arrange before next weekly
meeting.
1.
Need: Since William has appetite problem like appetite loss and poor lung
function, making eating plan and dietary needs of William is important
Action:
 Contact the oncologist for nutritional requirement and food intake
 Maintaining fluid and electrolyte balance all the time
 Allow the client to eat as per dietician plan (Balstad et al., 2014)
Person required: Dietician and community nurse
2.
Need: Management of adverse physical symptoms related colorectal cancer in
William
Action:
 Regular assessment of patient for adverse symptoms like abdominal pain,
constipation, diarrhea and fatigueness
 Addressing medication need of patients (Papamichael et al., 2014)
Person required: Oncologist and palliative care nurse
3.
Need: Attending to lower mobility related issue of William
Action:
 Checking for functional level of mobility
 Providing assistive device to support ambulation (Van Blarigan & Meyerhardt,
2015).
Person required: Nurse and physiotherapist
4.
Need: Promoting psychological and spiritual well being of patient
Action:
 Promoting spiritual well-being of patient by means of curative treatment
 Engaging client in meaningful activities
 Promoting closer proximity with family member
Person required: Palliative care nurse:
5.
Need: Preventing risk of infection in patient
Action:
 Maintain personal hygiene of patient
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 Monitor environment and maintain cleanliness of environment surrounding the
patient
Person required: Community nurse
6.
Need: Need to manage pain from metastasis in patient
Action:
 Identify pharmacological interventions to address pain
 Administer analgesic and chemotherapy agents as prescribes
Person required: Nurse
References
Aged Care Services Australia Group | ACSAG. (2017). Acsagroup.com.au.
Retrieved 14 August 2017, from http://www.acsagroup.com.au/
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[Monash ID]-NUR2007-AT2
Balstad, T. R., Solheim, T. S., Strasser, F., Kaasa, S., & Bye, A. (2014). Dietary
treatment of weight loss in patients with advanced cancer and cachexia: a
systematic literature review. Critical reviews in oncology/hematology, 91(2),
210-221.
Corp., P. (2017). Pride Mobility Products. Pride Mobility. Retrieved 13 August 2017,
from https://www.pridemobility.com/about-us
Costi, R., Leonardi, F., Zanoni, D., Violi, V., & Roncoroni, L. (2014). Palliative care
and end-stage colorectal cancer management: the surgeon meets the
oncologist. World Journal of Gastroenterology: WJG, 20(24), 7602.
Dandenong. Estia Health. (2017). Retrieved 13 August 2017, from
http://www.estiahealth.com.au/locations/dandenong
For Every Body and Soul - Soul Pattinson Chemist. (2017). Soulpattinson.com.au.
Retrieved 14 August 2017, from http://www.soulpattinson.com.au/
In Home Private 24 hour Nurse Care - Prestige Inhome
Care. (2017). Prestigeinhomecare.com.au. Retrieved 13 August 2017, from
https://www.prestigeinhomecare.com.au/services/24-hour-care-and-nursing
LifeStrong Physiotherapy Chelsea. (2017). LifeStrong Physiotherapy Chelsea.
Retrieved 14 August 2017, from http://www.lifestrong.com.au/
Papamichael, D., Audisio, R. A., Glimelius, B., de Gramont, A., Glynne-Jones, R.,
Haller, D., ... & Rutten, H. (2014). Treatment of colorectal cancer in older
patients: International Society of Geriatric Oncology (SIOG) consensus
recommendations 2013. Annals of oncology, 26(3), 463-476.
Solano, J. P. C., da Silva, A. G., Soares, I. A., Ashmawi, H. A., & Vieira, J. E. (2016).
Resilience and hope during advanced disease: a pilot study with metastatic
colorectal cancer patients. BMC palliative care, 15(1), 70.
St John of God Pinelodge Clinic. (2017). Sjog.org.au. Retrieved 13 August 2017,
from https://www.sjog.org.au/pinelodge
Step Forward Psychology. (2017). Sforward.com.au. Retrieved 14 August 2017,
from http://www.sforward.com.au/
Van Blarigan, E. L., & Meyerhardt, J. A. (2015). Role of physical activity and diet
after colorectal cancer diagnosis. Journal of Clinical Oncology, 33(16), 1825-
1834.
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