Society is full of different people of different ages, races, languages, jobs and backgrounds and each of these people have different personalities, do things differently and react to things differently. These differences do not change when we get ill or are injured and it is therefore very important that each different person get health care which is suited to these differences. Anna is just one of these people who requires such health care. She has cancer which she has been told by her Consultant is more advanced than they had thought. She has already had one course of chemotherapy and radiotherapy which was followed by a phase of remission.

She has recently been staying in a Marie Curie hospice but has decided that she would rather go home as her children didn't like to visit her there and she misses her home and the things there. Anna is a music teacher, though she hasn't been able to work for a few months, she is married to Mike, a self-employed builder, and she has two children, twin boys of nine. In this assignment I will take on the role of the District Nurse who is drawing up a care plan for Anna prior to her decision to leave the hospice and return home. 'A Care Plan is a statement of the service being provided and it's goals' (Oxford Concise Medical Dictionary, 1998) CARE PLAN CYCLE In order to produce a good care plan which explores every area of care and covers every need of each individual patient there are several stages to go through. This is called the care plan cycle and it consists of nine stages shown below.

I will now go through each of these nine stages explaining what they are and how this will relate to Anna in her care planning. PROVIDE INFORMATION This is the first stage of the cycle and it refers to the initial investigation into what services are available. During this stage options are discussed with the client and more information on these options is collected. It is then decided which options are suitable for the specific client and which of these options the client has access to and is eligible for. In Anna's case she will need to find out about community services which are available to her in her home and whether she will need to pay for these services. She will need to find out what services are provided by her local GP practice and whether she can receive help from her local district nurse and whether she can receive help from an outside organisation such as the Marie Curie Foundation.

REFER FOR ASSESSMENT Once it has been established which available services are suitable for the client it will be necessary to get assessment from these services. Unfortunately service providers have limited staff and resources and therefore not everyone can get an assessment. Service providers must consider, amongst many things, the urgency of the client's need. They must also address the practicalities i. e. where the client is and whether they have any additional difficulties not covered by their particular service, such as communication difficulties.

Many service providers also like to know if the client has used any of their other services or has been in contact with them before. Anna's situation is of some urgency and it is very important to both her and her family that her future care is arranged so that she can concentrate on her husband and children. The hospice which Anna stayed in was run by Marie Curie and therefore she has had contact with the organisation before though not their community services. The hospice she stayed in was near to her home and she has no other difficulties not related to the cancer so practically their help would not be difficult. ASSESS NEED Assessment by the different service providers will have highlighted the particular needs of the client and it is now necessary to relate these needs to the particular organisations. The relevant organisations will talk to the client in order to understand his or her needs and provide the best care possible.

The needs are then prioritised into the ones which need to be addressed urgently as soon as possible and the ones which can wait until the urgent needs are dealt with. Anna's needs are quite basic and relate to the fourteen activities of daily living which are Maintaining a safe environment, Communicating, Breathing, Eating and drinking, Body functions, Personal cleansing and dressing, Maintaining normal body temperature, Mobility, Working and playing, Sexuality, Resting and sleeping, Learning, Religion and Dying. Anna understands and accepts that she cannot care for herself and that her husband cannot fulfil all her needs by himself but she does not want to continue her hospice care. She misses her home and her family and friends are not comfortable visiting her there especially not her children. Anna needs someone to come in the mornings to help her wash and dress so that her husband can go to work and she needs someone to come and sit with her during the night so that her husband and children can sleep.

She is currently on morphine pain relief and this will need monitoring and updating as will her care. IDENTIFY SERVICES ALREADY PROVIDED By establishing what services are already being provided for the client some care can be implemented quicker. This is because the professionals from this service are already involved in the clients case and therefore have knowledge of the clients situation making it easier for them to modify or update the care. This also means that the professionals needed are probably already involved. Anna has recently been cared for in a Marie Curie Hospice and therefore it is going to be a lot easier for her to gain access to their community services. She will also have had prior contact with her GP due to her cancer and he will be aware of her decision to return home from the hospice.

PLAN CARE With all the information collected and arrangements made in the previous four steps of the care planning cycle the actual care plan can now be drawn up. A care plan should contain the overall objectives the specific objectives of the user, the carer and the service providers the criteria for measuring the achievement of the objectives the services to be provided by whom the cost to the user and the contributing agencies the other options considered any point of difference between the user, care planning practitioner or other agency details of any unmet needs with reasons the named personnel responsible for implementing, monitoring and reviewing the care plan the date of the first review Department of Health: Care management and assessment- practitioners' guide A care plan for Anna is included within this assignment. The main points of this care plan are: that a care assistant from a private company which Anna will have to pay for comes every morning at approximately 8 am to help her wash and dress that a Marie Curie nurse will come every night at 10 p. m. and sit with Anna through the night.

that the District nurse will visit regularly after the care assistant has been and GP will be in regular contact with her to address any issues she may have and to monitor her care. that she is to be given morphine pain relief in a syringe driver which she can boost if she feels the need to. This will be monitored so that Anna can be allowed to administer higher levels as the cancer progresses. IMPLEMENT CARE Once the care has been planned in detail focus must be put on putting this planning into action in the client's care. The care planner must ensure that the care plan is being followed by both the care professionals and the client him or herself. Anna's care professionals must be committed to following her care plan so that she is able to live her life as normal as possible.

If Anna has friends coming to visit and the care assistant does not turn up until say 11 am meaning that she is not dressed when her friends come this means that she will miss out on valuable time with them. It is also important to Anna that she is able to spend time with her husband and children which she likes to do by listening to music or watching television in the evenings after school / work. If the District nurse decides to come at 8 p. m.

one night instead of the morning and there is something Anna needs to discuss with her then she misses time with her family. MONITOR PROGRESS To ensure that the care plan is being followed and that the care plan is working it's progress is monitored closely this is done by talking to both the client and the care professionals to make sure they are satisfied with the care received / given . All aspects of the care plan are monitored from whether the aims of the care plan are being met to whether the client can afford to continue the current care. It will be important to monitor Anna's care to prevent the situations mentioned in the previous section on implementing care. Also, due to the nature of Anna's illness, her condition could deteriorate or change quite quickly and it is important that her care mirror this. REVIEW AND EVALUATE MODIFY CARE PLAN All care plans are reviewed on a regular basis whether there have been problems or not.

Reviews involve talking to all the people who are involved in all aspects of the care plan. Clients are asked if they are satisfied with their care or if there is anything they would like to change. Care professionals are asked to assess whether or not they feel that the care is adequate and whether or not they feel it is working and if not what they feel could be done to improve it or make it work. These views are brought together and discussed in review meetings where the care plan is scrutinised in great deal and any issues which have arisen are addressed and the modifications to the care plan contemplated. A review of Anna's care plan may find that her morphine dosage is no longer dealing with the pain and therefore the care planners will discuss increasing her dosage and how much she can boost using her syringe driver.

The review could find that she needs more round-the-clock care perhaps while her husband and children are away at work / school and if she doesn't have any friends visiting on that day. They may find that her condition has deteriorated and that she is having trouble eating, for instance, in which case they would need to arrange some alternatives. Problems may not be related to her medical condition and may be financial perhaps Anna and her family can no longer afford to pay for the care assistant to help her wash and dress in the morning in which case they may need to look into outside funding. Once it has been decided whether there are any issues which need to be addressed and these issues have been discussed in detail it then has to be decided how to introduce these into care plan. To do this we go back to the fifth stage of the cycle PLAN CARE where the changes are put into a new revised care plan which then needs to go through the same stages of IMPLEMENT CARE, MONITOR PROGRESS, REVIEW AND EVALUATE, MODIFY CARE PLAN, PLAN CARE and so on which is why they call the stages a care planning a cycle.

On the following pages is the care plan which I have prepared on behalf of the district nurse for Anna. THE PRACTITIONERS INVOLVED IN ANNA'S CARE As you have seen from the care plan cycle and the care plan many practitioners are involved in Anna's care from people who deal with her emotional needs such as her family and friends to people who deal with her medical needs such as her GP, there are also people who deal with her personal routine needs such as the Care Assistant. Along with all these people there are also many other people who could have been involved such as Counsellors. The next page is a chart showing all the involved practitioners and all those who could have been involved and what area of care they were related to. I will discuss the contribution each person had in terms of Anna's care and explain how the people who I suggested could have been potentially involved fit in. As you can see from the chart on the previous page I have split Anna's care into two branches cancer care and additional care.

The branch entitled cancer care leads to the medical area of Anna's care such as the chemotherapy and radiotherapy whereas the branch entitled additional care leads to the more personal areas of Anna's care such as her family and friends. CANCER CARE MARIE CURIE FOUNDATION The Marie Curie Foundation provide two branches of care their hospice care, which provides residential 24 hour care and their community care which provides care in the home. Anna has used both these services spending time in her local hospice and also using the community services in which a Marie Curie Nurse who visits her in her home, sitting with her and caring for her during the night allowing Anna's husband to sleep. The input of the Marie Curie Foundation on Anna's care has been quite substantial. Without the foundation's services Anna might not be as comfortable and happy with her care as she is. Their community services with Marie Curie Nurses means that Anna is able to get care in her home without putting pressure on her family and friends, being at home also encourages visits from friends or family who perhaps were not comfortable visiting her in the care settings especially her two children.

The hospice care means that, if Anna or her family feel the need, Anna can receive respite care giving her family a break and taking the strain off her personal relationships. LOCAL HEALTH CENTRE Anna's local heath centre has provided and has the potential to provide many services through many practitioners. Her GP provides her with all the palliative care that is not possible for nurses to give her. For example the GP has the power to increase Anna's pain relief which is a big part of how good or bad she feels and is therefore a huge part of her overall care and how well she can cope with each day. The local health centre will also be responsible for the services of the District Nurse who is a key practitioner in Anna's care not least because the District Nurse is in charge of drawing up Anna's care plan.

The District Nurse visits Anna every day to discuss the care plan and any changes that need to be made to it and also to talk about any other issues that Anna wishes to bring up. He / she is therefore an essential part of the care in terms of support and advice. However as the illness progresses Anna's needs in terms of support and advice may go beyond the District Nurse's scope and there is then potential for a Counsellor to become involved in her care. The Counsellor will have more time to talk to Anna without having to worry about Anna's medical needs and may therefore allow her to talk more deeply about her feelings and what she wants. HOSPITAL The hospital is very much part of Anna's cancer care though their input is decreasing as Anna's illness progresses and there is less and less they can do to help her. However in the initial stages of Anna's cancer they would have had a huge input on her care.

It would have been her Consultant at the hospital who confirmed the diagnosis of cancer and decided what course of action / treatment would be their next step. The Consultant would have then followed her care through this course of action / treatment which at some point involved the expertise of the Therapeutic Radiographer who would have been in charge of the administration of both the chemotherapy and the radiotherapy. PHYSIOTHERAPIST There is potential for a Physiotherapist to become a part of Anna's care plan in the future. As her illness progresses she may become weaker and unable to maintain her mobility then she may develop problems with her muscles as they are not being used and therefore become stiff. A Physiotherapist could come maybe two or three times a week to stretch these muscles and therefore these muscles would not be as stiff and Anna would not have to cope with muscle cramps on top of everything else. ADDITIONAL CARE FAMILY AND FRIENDS Anna's family and friends have been an integral part of her care from day one and will continue to be throughout her illness their input is the largest of all the practitioners and people involved.

In particular her husband and children have been of paramount importance to her. It is very important that her home / family life remain as normal as possible if not for Anna but for her children who at nine years old will find this whole situation very difficult to deal with. Anna enjoys sitting down with her husband and children at night and watching TV, listening to music and generally spending time together. As Anna is no longer able to do the house work her husband and children need to do it this cuts the time that they can spend with their mother / wife here there may an opportunity to introduce another person in to the care plan. Some kind of Domestic help who would do all the cleaning around the house and perhaps the washing up would allow the family more time together. As you can see from my flow chart Anna's Friends are a very important part of her care.

It is important for Anna to be healthy on the inside as well as on the outside and this will be accomplished by keeping her life as normal as possible and helping her to feel good about herself. Anna's friends are a big part of normality for her and also play a big part in making her feel good about herself. Things such as clothes shopping which she would usually do with her friends should not be abandoned and in fact should be encouraged as it combats both these areas. By shopping with her friends Anna can feel as normal as possible and she can buy clothes to help her feel good. Anna can also feel good by visiting the hairdresser and / or beautician, or having these people come to her house. Anna really enjoys the music that herself and her family sometimes listen to at night and before she got ill she was, in fact, a music teacher.

She finds that the music helps her to think of other things and this need brings in potential for yet another practitioner. Music Therapists, who often work with people with brain damage, use music as a sort of therapy and their services would be ideal for Anna in order for her to relax and sort things out in her head. CARE ASSISTANT Every morning a Care Assistant comes to help Anna get washed and dressed this is very important to Anna and her family. Just because Anna is ill and is not going out does not mean that being clean and presentable is not as important to her as it is to anyone else.

However she is now unable to do this completely by herself and needs help. Although her husband or friends could do this it is very uncomfortable for them and embarrassing for Anna and could cause problems in her relationships with them. The Care Assistant coming means that Anna does not have to go through this, it also means that she can be ready if any of her friends or family drop round. As we talked about in the section on physiotherapists as her illness progresses Anna may loose some mobility and this may cause problems when bathing or showering.

This suggests a need for another health professional, an Occupational Therapist, this professional can arrange for bath or shower aids among many other things which will allow Anna to carry on having a wash every day. The Care Assistant will also help Anna with her breakfast however he / she would leave after that and unless a friend drops round Anna would be left alone for lunch. This is a problem as Anna is unable to get downstairs without help and will not be able to get herself lunch. To solve this problem it may be an idea to include the services of Meals on Wheels who can deliver the food to Anna.

As you can see the main emphasis of Anna's care at this point has been put on making her as comfortable as possible by ensuring that she is not in pain either physically or mentally and also ensuring that she spends as much time as possible with her family and friends. This is opposite to putting the main emphasis on her medical treatment by putting her through more tests and trials and therefore wasting the time she has left with the people close to her. As you have seen from this breakdown of Anna's care Anna and her family have been consulted throughout and their views and family situation (i. e. two young children) has definitely been incorporated. However in many cases these things are not considered and the practitioners take over.

In order to stop this from happening and to encourage the client and his / her family to be involved there are many activities which could be introduced to the care planning process. It may be a good idea for the client and her family to make a care plan of their own which they can then present to whoever is drawing up the care plan who can then discuss this care plan with them. In discussion they would decide the viability of some of the ideas, how they could be implemented or perhaps modified. This activity would produce a viable care plan with all the client's and their family's ideas down in writing which could then be consulted by the person drawing up the care plan.

This assignment demonstrates the importance of care plans in relation to health care. They provide a complete outline of the whole multidisciplinary care which is especially important in cases such as Anna's where there is a number of different professionals involved. The care plan allows each of these professions to see what the others are doing in order to provide a better quality of care.