Read the assignment brief and complete the instructions.
This assessment counts towards 50% of your final grade.
Total marks available for this assessment: 20 marks.
Pass Mark: 50% (10 marks).
Assessment Brief:
As a new care giver in the community, you were asked to take responsibility for caring for a sixty seven (67) year old male patient, Mr. John Snow, who was recently discharged from Georgetown Public Hospital Co-operation.
He was suffering from Diabetes and Hyperlipidaemia for the past seven years but was unable to control same.
He recently developed a diabetic foot ulcer and was admitted for management with intravenous medications and insulin to control his condition.
After five (5) days of being an impatient he was discharged with medications for seven days as follows :
1. Clindamycin 300mg po QID
2. Flagyl 500mg po BD
3. Metformin 500mg po TID
4. Daonil 5mg po OD
5. Asprin 81mg po OD
6. Ramipril 5mg po OD
7. Atrovastation 10mg po Nocte
8. Vitamin C 1gm po OD
9. BCO 1 tab po OD
10. Diclofenac 50mg PO PRN pain
11. Omeprazole 20mg po OD
The patient also requires daily cleaning and dressing of the wound with normal saline and iodine.
Mr Snow is often non-compliant with his treatment regime and normally eats whatever he desires. He is usually a late sleeper and lacks physical activity and exercise. Mr Snow was warned of his carefree behaviour and if he continues he can actually lose the affected limb.
Mr Snow is living alone with his son visiting twice a month and usually buys his meals as he doesn’t know how to cook. Mr Snow’s son can afford to employ a home care provider is willing to adjust his father’s lifestyle to achieve better health.
As the care provider, kindly evaluate the client’s condition and with the support of his family and the instructions of the health care provider, develop a care plan to suit Mr Snow’s condition and his needs for the seven days.
Note the following:
His Glucose and blood pressure level reading for the last five days are as follows:
· Day 1: 365 mg/dl, 130/85 mm/hg
· Day 2: 395 mg/dl, 128/79 mm/hg
· Day 3: 289 mg/dl, 139/89 mm/hg
· Day 4: 343 mg/dl, 145/92 mm/hg
· Day 5: 271 mg/dl, 140/90 mm/hg
· Cholesterol : 367mg/dl
Assessment Criteria:
Your Care Plan must include but not limited to the following:
A) Background Information and General Overview of the Patient (4 marks)
B) The Patient’s Diagnosis (4 marks)
C) Goals and Outcomes (4 marks)
D) Intervention Strategies (4 marks)
E) Evaluation (Short Term & Long Term) (4 marks)
End of Assessment
Care Plan for Mr. John Snow
A) Background Information and General Overview of the Patient:
Mr. John Snow is a sixty-seven (67) year old male patient who was recently discharged from Georgetown Public Hospital Co-operation. He has been suffering from Diabetes and Hyperlipidaemia for the past seven years, which he has been unable to control effectively. Recently, he developed a diabetic foot ulcer, leading to his admission for management with intravenous medications and insulin. Mr. Snow’s non-compliance with his treatment regimen, sedentary lifestyle, and poor dietary habits pose significant risks to his health, including the potential loss of his affected limb. He lives alone, with his son visiting twice a month and providing support. Mr. Snow’s son is willing to adjust his father’s lifestyle to improve his health.
B) The Patient’s Diagnosis:
Mr. John Snow has been diagnosed with the following conditions:
- Diabetes Mellitus (uncontrolled)
- Hyperlipidaemia
- Diabetic Foot Ulcer
- Hypertension
C) Goals and Outcomes:
Short-term Goals (within 7 days):
- Stabilize blood glucose levels within the target range (100-180 mg/dl).
- Promote wound healing and prevent infection in the diabetic foot ulcer.
- Improve blood pressure control within the target range (less than 130/80 mmHg).
- Educate Mr. Snow about the importance of medication compliance, diet, and exercise.
- Establish a daily routine that includes wound cleaning and dressing.
Long-term Goals:
- Achieve and maintain optimal blood glucose levels.
- Manage hyperlipidaemia and achieve healthier cholesterol levels.
- Achieve and maintain optimal blood pressure levels.
- Promote weight loss through a balanced diet and regular physical activity.
- Ensure Mr. Snow’s overall well-being and prevent further complications.
D) Intervention Strategies:
- Medication Management:
- Ensure Mr. Snow takes medications as prescribed.
- Monitor blood glucose and blood pressure levels daily.
- Adjust insulin and oral medications based on glucose levels.
- Wound Care:
- Clean and dress the diabetic foot ulcer daily with normal saline and iodine.
- Monitor the wound for signs of infection or poor healing.
- Dietary Changes:
- Develop a personalized meal plan focusing on balanced nutrition and controlled carbohydrates.
- Educate Mr. Snow on portion control and the importance of avoiding sugary and high-fat foods.
- Physical Activity:
- Encourage light exercises like walking and stretching daily.
- Gradually increase physical activity based on Mr. Snow’s abilities.
- Education and Support:
- Provide regular counseling and education about diabetes management, foot care, and medication adherence.
- Involve Mr. Snow’s son in the care plan and educate him about his father’s needs.
E) Evaluation (Short Term & Long Term):
Short-term Evaluation (within 7 days):
- Monitor blood glucose and blood pressure levels daily and compare with target ranges.
- Assess the progress of wound healing and any signs of infection.
- Review Mr. Snow’s compliance with medication regimen and dietary changes.
- Evaluate Mr. Snow’s engagement in physical activity and his understanding of self-care.
Long-term Evaluation:
- Regularly monitor and adjust the care plan based on long-term progress.
- Periodic blood tests to assess cholesterol levels and overall health.
- Measure weight and body mass index (BMI) to track weight loss progress.
- Assess Mr. Snow’s knowledge and ability to manage his conditions independently.
Conclusion:
By implementing this comprehensive care plan, involving medication management, wound care, dietary changes, physical activity, education, and support, Mr. John Snow’s health can be improved and his risk of complications reduced. It is important to work closely with Mr. Snow, his son, and the healthcare provider to ensure successful implementation and long-term management of his conditions.