Health Dept Magazine Health Dept Magazine

31Aug/102

how would I make a care plan? For the following?



John Smith is a 74-year-old male who lives with his wife in a trailer on a private parcel of land. John has severe arthritis and uses a walker around his home. For longer distances, he requires a wheelchair. He has a manual wheelchair, but it is uncomfortable and is taped in several areas. In addition to the arthritis, John has poorly–controlled, insulin-dependent diabetes, hypertension, and a history of panic attacks. Other than his wife, John has no family in the area. John has been resistant to services in the past, but his wife has convinced him to see what he may be eligible to receive. John and his wife are unable to get by on the Social Security checks they receive monthly. They have received a final shut-off notice on their electric bill and they are in need of a roof repair to keep the water from leaking in the entryway of the trailer.



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  1. Any Care Plan follows four steps

    Assess = what is the problem

    Plan = How can it be solved

    Implement = action the plan

    Evaluate = Has it solved it

    this means that it is a cycle and REMEMBER to regularly update i.e. renew plan at regular intervals or when something changes.

    your Client has the following problems and you need a care plan for each problem

    Mobility = first get a referral for a new wheelchair from OT or equivalent for your country

    Pain = review of analgesia by doctor or referral to pain management team for his area

    IDDM= Introduction of Diabetic Liaison Nurse and Dietic Liaison plus a possible review of insulin

    Hypertension = review of medication by doctor

    Anxiety = review of methods used to reduce levels of stress plus a general review from family doctor

    Financial= referral to social services

    Housing = Referral to Social Services

    In short your Client requires what is known as a Multi Disciplinary Approach. No one professional group could tackle all of his needs.

  2. Ask John if he’s a veteran, if so call 1-800-827-1000


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