Care planning

This is a process where a health and social care professional

and a service user share ideas of how one should be supported
to improve their health and well-being. This information is
recorded and later referred to by different professionals
supporting the individual and it included how one can be
supported emotionally, physically, and intellectually if they
need accommodation, transportation, education needs and
others.
An example of care planning;

A treatment plan for Mrs. Smith Johns

Treatment plan processes and care methods
Cycle of planning
This is a procedure carried out by health and social care
professionals to ensure that an individual is supported
holistically and focused on (personal-centered care) by
assessing, planning, implementing and evaluating the required
health and social care needs.
A cycle of planning involves different steps, and these include;
 Assessing needs. This is the first step carried out when
making a cycle plan for a service user and it involves
professionals learning about the individual’s preferences,
needs and dislikes, this step is carried out by having one
on ones with individuals, going through their medical
records and speaking to their close family and friends.
 Planning suitable care. In this step, professionals use the
documented record obtained from the assessment and
create a plan. This plan includes things such as procedures
required to meet the service user’s needs, making sure
that the individual is supported following the
measurements put in place for person-centered care, their
strength and weakness, and how they will be supported
physically, emotionally, intellectually and socially.
  Implementing plan. At this stage, health and social care
professionals put the plan to use by applying the required
procedures to support the individual’s health and well-
being. For this stage to take place, a multidisciplinary team
is required. This is when different health and social care
professionals work together to meet specific goals needed
to improve a service user’s health and well-being, this
includes doctors, therapists, nurses, social workers and
others.
 Monitoring effectiveness. At this stage, the care plan has
already been put to use and health and social care
professionals are keeping an observation regularly. This is
important as it helps professionals to identify any changes
occurring during the provision of the required support and
they will later use this to conclude if the support and
treatment provided is effective on the service user’s health
and well-being.
 Reviewing and amending adjustments. This is the last step,
and it is usually carried out after 12 months, but it may
change depending on the individual’s improvement or no
changes. Reviewing a care plan helps health and social
care professionals to make any adjustments if the support
and treatment provided are not effective for the
individuals.
Potential care methods and Strategies
There are three main potential care methods and strategies,
and these include primary, secondary and tertiary care.
Primary care
This is the first support and treatment an individual receives
from health and social care professionals. During primary care,
one can be supported by professionals such as GPs, opticians,
pharmacists and the A &E department. The roles and
responsibilities of these professionals include;
 Creating care coordination such as ensuring that service
users can easily have access to community resources and
receive the required support and treatment.
 Looking at any social determinates that are affecting the
service user’s health such as employment, housing and
education.
 Assessing to be able to focus on a specific illness, condition
or issues one has and make a referral to the required
specialists for example, an assessment may show that an
individual has dementia, and the GP will make a referral to
neurologists, therapists and other professionals that work
with people that have been diagnosed with dementia.
 Help to prevent and control illnesses by advising service
users to wash their hands regularly, take their medications
on time and promote a healthy lifestyle by eating a
balanced diet.
Secondary care
This is a type of care that requires specialists to make a
diagnosis, treat and manage a specific illness or condition.
Secondary care includes specialists such as cardiologists,
gynecologists, rheumatologists, physiotherapists, pediatric
consultants and dermatologists. All these specialists are
qualified in specific areas and only provide treatment to those
areas. For example, cardiologists only deal with patients that
have been diagnosed with heart diseases and do not work with
females that have issues with their reproductive system. The
roles and responsibilities of professionals carrying out
secondary care services include;
 Cardiologists diagnose and carry out assessments to treat
and support service users with heart diseases such as
heart attack, high blood pressure, heart failure and others.
 Gynecologists are responsible for supporting female
service users with reproductive problems, expecting
mothers and their unborn babies.
 Rheumatologists are responsible for diagnosing, treating
and managing service users with musculoskeletal disorders
such as broken bones, tissues and muscles.
 Physiotherapists who are specialized in providing. support
to service users with disabilities, injuries or have been
involved in accidents through exercises, and therapy.
 Pediatric consultants who are responsible for treating and
supporting children with illnesses, disabilities and injuries.
  Dermatologists who are specialized in providing support to
service users who have been diagnosed with skin
conditions such as skin cancer.
Tertiary care
This type of care is provided to service users that require higher
specialized professionals that use advanced technology and
resources to make a diagnosis, treat and manage the rare
condition. Tertiary care includes end-of-life care where service
users are supported in pain management in their last days,
rehabilitation where a service user needs extra support after
being involved in incidents such as accidents and encourages
them to live independently and hospice care.
Case study
Mrs Smith Johns is a 68-year-old university lecturer that has
been diagnosed with Alzheimer’s disease, a psychotic
disorder. In her early 50s, she experienced symptoms such as
forgetfulness, taking longer to complete daily tasks, repeating
questions and struggling to engage with her students as she
used before. However, she did not receive any medical
support as she claimed that she was just too tired from her
work and needed to just sleep it off. Mrs. Smith leaves alone
as her husband passed and her only child Sarah lives in a
different state but visits her regularly. In her mid 50’s, Mrs.
Smith was admitted to a hospital following an incident where
her workmates claimed that she wandered off after seeing her
late Husband who was holding her hand and taking her home.
At the hospital, professionals carried out an assessment and
realized that her Alzheimer's had been undetected for over
some good years which resulted in increasing memory loss,
less flexibility, difficulty communicating, changes in moods,
depression, sleep difficulties, poor control of bowels,
delusions and hallucinations.
Based on her assessment, a care plan was created and was
aimed at;
 Treating Mrs. Smith’s mental health condition through a
prescription of anti-depressing pills.
 Enhance her safety measures at home by making sure
there is someone to supervise her in case she wanders
and make sure she is taking her medication correctly and
on time.
 Educating her child and close friend about Alzheimer’s
and how they can help to promote her well-being.
 Encouraging her to be more outgoing and professionals
recommended joining an adult day care program which
she can attend at least once a week.
 And this plan was to be reviewed after 12 months to
follow up on her progress and how it has positively
impacted on her health and well-being.

Assessing the care needs of Mrs. Smith Johns.

The table below shows the different needs of Mrs. Smith, the
care she needs and how health and social care professionals
should work in a multidisciplinary team to support her
accordingly.
Needs Care needs
Physical The assessment showed
that due to not receiving
the required support from
health and social care
professionals, Mrs. Smith
was at risk of being
immobile. This means that
Mrs. Smith will lack the
ability to move her body
on her own and it will
affect her in a way that
she will not be able to not
to carry out day-day
activities such as dressing,
eating, showering and
going to work. And she
will need another person
to help her carry out these
activities. Failure to do so
will be at a higher risk of
having accidents such as
falls.
Outcomes to be
achieved
This can be
addressed by
putting safety
measures in place
for Mrs. Smith such
as an alarm that she
can use to call her
caregiver in case she
requires any help.
Safety devices such
as handrails and
stairlifts prevent
accidents when
accessing higher
buildings.
During
physiotherapy, To
assist activate and
build muscles,
physiotherapists
employ a variety of
techniques,
including resistance
training and passive
 range of motion
exercises. This can
stop muscular
atrophy and
preserve muscle
tone, both of which
are crucial for
general physical
function.
Intellectual Mrs. Smith experiences This can be achieved
symptoms such as by providing
forgetfulness, which is an medical dispensers
indicator of memory loss, that contain dates
one of the major signs and and times as to
symptoms of Alzheimer’s when she needs to
disease. This will affect take her
her in a way that she will medications to
forget what she needs to avoid confusion.
do throughout the day, Professionals can
which will impact her way also advise her
of living and her health. daughter to install a
For example, when having reminder app on
her medications and she Mrs. Smith's phone
forgets when to take them that goes off every
or which one to take, she time she must take
will end up not taking any her medications.
or taking the wrong one
which can lead to
poisoning, taking of over
 and under dose.
Emotional Alzheimer's disease
progresses over time and
limits individuals on
certain things such as lack
of independence. This
means that Mrs. Smith is
likely to go through
depression as she will not
be able to go back to her
job and will need another
person to help her carry
out things she used to
easily do on her own.
Social As stated in the case
study, Mrs. Smith
struggles to find the
correct words to use when
communicating with
others. This will affect her
social life in such a way
that people will not
understand what she is
saying and will fail to
respond correctly.
A treatment plan for Mrs. Smith Johns.
This can be
overcome by
encouraging Mrs.
Smith's daughter to
spend more time
with her so that she
does not feel lonely.
Mrs. Smith can be
referred to support
groups where she
will be able to
interact with others
and feel included.
This can be
overcome by
referring Mrs. Smith
to a speech and
language therapist
who will suggest
things such sign
language to make
her communication
easier.
A treatment plan is a document that requires a
multidisciplinary team to decide on the best ways to support a
service user after looking at their symptoms, medical history,
and other factors that are contributing to their well-being. For
Mrs. Smith, professionals involved in her treatment plan will
include occupational therapists, speech and language
therapists, physiotherapists and audiologists. This treatment
plan aims to manage her symptoms such as mood swings and
forgetfulness to stimulate her cognitive functioning, prescribe
medication where necessary for example anti depression pills
to health with her depression and other mental conditions she
may be experiencing and educate her family and friends on
how to support her as well as themselves as supporting people
with Alzheimer’s can be physically demanding and emotionally
draining.
Considering Mrs. Smith John's individual needs.
Mrs. Smith's individual needs may vary as her condition
progresses throughout the years. For example, she struggles to
find the right words to use when communicating with others
indicating that she needs communication assistance which can
be obtained by the use of brail or teaching her how to use sign
language making it easy for her to communicate as well as easy
for people that are communicating with her to be able to
understand her and support her accordingly. Safety, as
mentioned in the case study, Mrs. Smith wandered off as she
was having a delusional episode, this can put her life at risk as
she may end up on a busy road which will result in an accident
or even be kidnapped. Therefore, this must be challenged by
providing a care assistant who will keep notice of where she is
at all times.
Mrs. Smith will also have personal care needs as her condition
progresses Alzheimer's damages weakness in one's muscles
leading to paralysis meaning that she will need support with
dressing, eating, movements, cooking and other day-to-day
activities. And lastly, she will need emotional support as the
disease will require her to stop doing things, she used to do
such as going to work, which can result in frequent depressive
episodes.
Gender being a female, Mrs. Smith may prefer female doctors,
because she feels more at easy sharing which brings comfort
and perceived understanding between her and the caregiver
Age;
Being an Alzheimer's caregiver may be emotionally and
physically draining. Older caretakers might not be as energetic
or as strong as younger caregivers. Elderly people may find it
particularly difficult to meet the demands of caring, including
the need for regular monitoring and support, which may limit
their capacity to offer intensive or round-the-clock care.
Cultural beliefs;
It's possible that mental health issues are stigmatized in some
societies. This stigma may discourage people and families from
seeking care and addressing the illness openly. In the cultural
community, spreading knowledge and educating people about
Alzheimer's can help reduce stigma and promote early
detection and intervention.
Action to be taken
Some of the actions to be taken when making a treatment plan
for Mrs. Smith Johns will include making a medical assessment
which will help to rule out any other illnesses or conditions
associated with Alzheimer's, diabetes, stroke and other heart
diseases. To make decisions on which medications she should
take, although Alzheimer's has no cure, professionals can
prescribe anti depressing pills to reduce the severity of her
depression and memantine to help with her memory loss. And
encouragement such as motivating her to take part in activities
that will keep her occupied such as playing puzzles and bingo.
1. Neurologist - specialized in the identification and
treatment of disorders affecting the brain and neurological
system. This is done by doing thorough neurological
examinations and scanning of the brain.
2. Psychiatrists- These are mental health doctors who
specialize in management of behavioral and psychological
symptoms of Alzheimer's disease. They give therapy
treatment, medicine prescriptions, and support to their
patients.
Validity and reliability of sources of information.
Since Mrs. Smith lives on her own and has memory loss, it may
be hard for her to explain to professionals the severity of the
signs and symptoms she is experiencing, therefore,
professionals must make sure that the information they are
recording is accurate to avoid putting Mrs. Smith on the wrong
medication.
 Behavioral Interventions - A variety of tactics are used to
control behavioral symptoms include agitation,
aggressiveness, and sleep difficulties. Reduce problematic
behaviors and improve wellbeing with the use of
strategies including environmental adjustments,
regimented routines, and validation treatment.
 Cognitive Stimulation - Numerous exercises and other
therapies can boost cognitive function and support people
in retaining their cognitive talents longer. Puzzles, memory
exercises, reminiscence therapy, and computer-based
cognitive training programs are a few examples of these.
 Medications - In the short term, Alzheimer's disease
symptoms related to cognition and behavior can both be
managed with the use of drugs. Cholinesterase inhibitors,
such as donepezil, rivastigmine, and galantamine, as well
as memantine, may be part of this group of drugs.
Professional responsibilities.
After Mrs. Smith's diagnosis, she will either be admitted to a
hospital so that professionals can keep a close look at her and
carryout observations, or she will be taken to a care home
where she will be looked after by her parents or if be supported
at her home depending on the decision made by close friends
and family. However, in all situations, she will be cared for and
supported by carers who will be responsible for monitoring her
well-being by making records of what she has done throughout
the day which is later reviewed by other professionals involved
in making a treatment plan, maintaining her hygiene by making
sure she is dressed and showered and assisted with brushing
her teeth.
Primary;
 Geriatrician- focuses on the identification, management,
and treatment of illnesses and ailments that afflict senior
citizens, such as Alzheimer's. They organize treatment
regimens, deliver comprehensive medical care, and keep
an eye on disease development.
 Primary Care Physician - offers general medical treatment,
such as diagnosis, monitoring, and care coordination, and
serves as the first point of contact for patients with
Alzheimer's disease.
Secondary;
 Psychiatrist - manages behavioral and psychological signs
of Alzheimer's disease and has expertise in mental health
concerns
 Neurologist - In addition to giving the proper drugs and
carrying out other examinations, neurologists diagnose
 Alzheimer's disease and offer specific therapy and
management.
Allied;
 Social Worker - Assists people and families in locating
resources, offering emotional support, and organizing
care. They assist with long-term care planning, provide
counseling and link people with neighborhood resources
and support networks.
 Registered Nurse (RN) - offers direct care, medication
administration, and healthcare service coordination. They
help keep track of symptoms, inform patients and their
families about the illness, and provide support and
direction.
Reviewing care needs.
Reviewing care needs for Mrs. Smith is important for health
and social care professionals as it will help to identify any
growing needs or needs as her condition progresses which will
later be taken into consideration, hence improving her well-
being, safety and health. Reviewing her care needs will enable
health and social care professionals to provide effective
treatment as they will know if the treatment put in place is
working for her or if it requires updating. It allows the
professionals to put any safety measures in place, this can be
done by ensuring that she has locks on her doors and her keys
are only accessed by people who support her.
Reviewing care needs helps professionals to identify any
potential barriers in the treatment plan which will enable them
to overcome them. For example, being unable to adhere to
treatment. This can easily be experienced by Mrs. Smith since
she has the symptoms of memory loss making her forget about
when to take her medications, however, it can be overcome by
providing clear instructions on how and when she should take
her medication. This can also be written on a note that her
carers will be able to take note of it. Another barrier is being
financially unstable. Since Mrs. Smith will not be able to go to
work anymore, she is likely to struggle to pay off any external
treatments recommended by professionals such as
physiotherapy sessions, however, this can be overcome by
advising her close family and friends to get insurance or
financial assistance that will help cover her bills.
 Communication Challenges - Gaining correct information
during the evaluation of the treatment plan may be
difficult for people with Alzheimer's because they may
have trouble comprehending and articulating their
requirements and this can be overcome through use of
clear and simple language, visual aids, and non-verbal
communication techniques to enhance understanding.
 Financial Constraints - The cost of different medical
procedures, prescription drugs, and other support services
may be included in Alzheimer's disease treatment
programs. Financial constraints may make it difficult to
 adhere to and obtain the suggested treatment plan. This
can be overcome by Together with social workers or
financial advisors look into community resources,
insurance policies, and financial aid programs that can
help people with their financial difficulties.
 Lack of Awareness and Stigma - Lack of knowledge and
stigma around Alzheimer's disease may result in a lack of
acceptance of the suggested course of therapy. This can be
overcome by Conducting community outreach and
educational programs to raise awareness about
Alzheimer's disease.
The outcomes of the plan on the overall health and well-being
of Mrs. Smith
The table below shows how the plan would improve the health
and well-being of Mrs. Smith
Needs How the plan would improve
health and wellbeing overall
Physical The plan would improve this
Safety. One of Mrs. Smith's by encouraging her carer to
physical needs is safety since put familiar things she can
she is forgetful, hence easily recognize in place such
confusing her surroundings. as a blanket which will her
This will impact on her feel more comfortable
wellbeing as she is likely to
get distressed if she feels like
she does not know where she
is.
Intellectual
For example, her decline in
cognitive abilities such as
speech delays and difficulty
solving day-to-day problems
makes her independent of
other individuals.
Emotional
Since Mrs. Smith is going
through all these changes, she
is likely to experience anxiety,
depression, confusion and
loss of identity. This will affect
her in such a way that she will
end up withdrawing from
society and increase the
chances of her committing
suicide or having suicidal
thoughts.
Social
For example, Mrs. Smith
struggles with forming
relationships and engaging
with others which also leads
to withdrawal from the
society
The plan will help boost her
cognitive functioning by
encouraging activities such as
memory games and puzzles
that will help to keep her
active.
With a plan put in place, it will
help to establish a supportive
environment where she will
be able to have access to
things that give her a sense of
security such as furniture.
A plan will address this and
come up with ways of
stopping it from happening,
for example by encouraging
Mrs. Smith's family and
friends to pay her regular
visits, which will help her to
families with faces she
recognizes. Regular visits will
also help her feel loved and
 cared for.

Justifying the treatment plan

Why is providing safety to people with Alzheimer's appropriate
Advantage;
 Prevention of Injuries and Accidents - By putting safety
measures in place, the chance of mishaps and injuries is
considerably decreased, which improves the physical
wellbeing of people with Alzheimer's by lowering the
possibility of fractures, brain injuries, and other harm that
might arise from mishaps.
Disadvantage;
 Restriction of Freedom and Autonomy - The independence
and autonomy of people with Alzheimer's may be
restricted by the use of safety measures like locked doors
or monitoring devices. Frustration, loss of freedom, or
decreased participation in favorite activities may come
from this.
Why is promoting independency for people with Alzheimer's
important
 Preserving Dignity and Self-Esteem - Maintaining
independence enables people with Alzheimer's to feel
respectable and deserving of success. Their ability to
actively engage in daily life, make decisions, and maintain
 a sense of control over their lives has a good effect on
their emotional wellbeing.
Disadvantage;
 For those with Alzheimer's, especially at later stages of the
illness, independence may come with safety hazards. They
could struggle to appropriately assess risks or make the
right choices, which might result in mishaps or damage.
Why is provision of a supportive environment important for
people with Alzheimer's
Advantage;
 A supportive environment helps lessen the anxiety and
agitation that are frequently experienced by people with
Alzheimer's. A relaxed, orderly setting with recognizable
items, signals, and rituals can promote a sense of security
and familiarity, which reduces stress and enhances
emotional well-being.
Disadvantage;
 It may be necessary to have access to specialist technology
or make structural changes in order to provide a
supportive atmosphere for people with Alzheimer's.
Families or caregivers may experience difficulties due to
the cost of making environmental modifications or
acquiring essential supplies, especially if they are
underfunded or have little support.
Forming relationships is important for people with Alzheimer's.
Advantage;
 People with Alzheimer's can have a feeling of social
connection and emotional support by forming and
sustaining connections. It might be beneficial to interact
with loved ones, close friends, carers, and peers to fight
feelings of loneliness and boost general emotional well-
being.
Disadvantage;
 People with Alzheimer's may encounter communication
difficulties as the disease worsens, including issues with
language, understanding, and memory. Relationships may
be hard to start and keep up because people may find it
difficult to communicate, follow discussions, or recall
specifics about others.