Care Plan Scenario
Stephen is 45 and has had a diagnosis Schizo-Affective disorder (ICD-10-CM Diagnosis Code F25.9, 2021) for the past 25 years. His recent period of recovery has been interrupted by a deterioration in his physical and mental health that required admission to your acute inpatient admission ward.
He has been detained under a Section 2 of the Mental Health Act after making threats of violence to neighbours and Police officers who responded to complaints of a bad smell coming from Stephen’s flat.
Stephen is very ‘overweight’, not physically active and has been suffering from chronic constipation that, in the past, has required in-patient stays on a surgical unit for manual evacuation. He receives a regular depot injection of Flupenthixol and tolerates antidepressants but will not take Fybogel or Lactulose. He drinks 6 litres of Pepsi a day and lives on ‘takeaways’; he cannot recall when he last opened his bowels and his fingernails have faeces under them.
He has a severe fungal infection in his groin that has inflamed his skin, which has broken in places. This painful, burning sensation makes it difficult for him to settle and rest following a fraught admission process.
On admission to the unit past medical history was provided as :
Schizo-Affective Disorder
Chronic Constipation
Hypertension
Recurring fungal infections in groin
Family Medical history provided as:
Maternal grandfather suffered from ‘Nerves’, possibly depression
Bowel cancer in Stephen’s mother, survives with Ileostomy and one older sibling also has regular bowel polyp removal
Father died with COPD 5 years ago
Prescribed medication includes:
Flupenthixol depot, 250mg every 2/52
Procyclidine 30mg a day.
Clinical observations:
Weight: 16 st 4lb.
Height: 5.4”
Risk assessments have not been completed prior to admission.
Apprentice requirements
You have been allocated as Named Nurse on the ward and you have been allocated to co-ordinate and lead on her health promotion planning needs in a holistic manner.
You will be required to identify a relevant care need / needs which could be supported by health promotion and create a care plan specific to that. The care plan should reflect patient collaboration and have SMART goals at its centre.
You should also provide a realistic review and support schedule and all parts should be underpinned with rationale and relevant supporting evidence.
See the guidance for the structure for the whole assignment of which this is only one part.
Word limit 2,500 words
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