Introduction
This essay outlines a comprehensive individual care plan for Ms. Yasmin Rahman, a 34-year-old woman admitted to Accident & Emergency with severe epigastric and lower abdominal pain. As part of an NVQ Level 4 in Health and Social Care, this analysis applies theoretical and practical knowledge to develop a person-centred care (PCC) approach tailored to Ms. Rahman’s medical, emotional, and social needs. The essay begins with an assessment of Ms. Rahman’s condition and identified needs, followed by specific goals and interventions to address her acute health crisis and underlying stressors. It critically evaluates the care delivery process, considering her cultural preferences and holistic well-being. By drawing on evidence-based practices and relevant literature, this care plan aims to stabilise her clinical condition, support her mental health, and promote long-term recovery. The discussion will highlight the importance of multidisciplinary collaboration and the application of clinical tools to ensure effective care delivery.
Assessment of Needs and Identified Problems
Upon admission, Ms. Rahman presented with acute symptoms indicative of a serious underlying condition. Her vital signs revealed a blood pressure of 102/66 mmHg, heart rate of 112 beats per minute, respiratory rate of 22 breaths per minute, oxygen saturation of 97% on room air, and a temperature of 38.2°C. These observations suggest a potential acute abdominal issue compounded by systemic stress, possibly infection or inflammation. Using the National Early Warning Score 2 (NEWS2), her parameters indicate a medium risk, necessitating urgent clinical review (Royal College of Physicians, 2017). Her pain, rated 9/10 and described as stabbing and radiating to her back, alongside nausea and vomiting after a high-fat meal, raises concerns of conditions such as pancreatitis or a gynaecological issue, given her irregular menstrual cycle and last period being five weeks prior.
Beyond her physical symptoms, Ms. Rahman exhibits signs of emotional distress. She has reported low mood and poor nutritional habits linked to occupational stress as a charity fundraising coordinator. Her recent increase in mild alcohol intake and grief over her mother’s death further compound her mental health challenges. Additionally, living alone, while maintaining close ties with her sister and friends, may limit immediate support during recovery. Her cultural identity as a Muslim woman, with a preference for gender-specific care, must also be respected in the care delivery process (Sheikh, 2007). Lastly, her concern about workplace reliability highlights a need for social and occupational support. These multifaceted issues necessitate a holistic care plan addressing both acute medical needs and underlying psychosocial factors.
Goals and Outcomes
The care plan for Ms. Rahman is structured around four primary goals with specific timelines for review. Firstly, the aim is to stabilise her clinical condition within 24 hours to prevent deterioration, ensuring timely intervention for any changes in her health status while alleviating distress. Secondly, reducing her elevated temperature to below 38°C within 24 hours and to a normal range (36.5°C-37.5°C) within 48 hours is critical to manage discomfort and prevent complications such as dehydration. Thirdly, addressing the underlying cause of her abdominal pain and associated symptoms within 72 hours is essential to prevent further deterioration and reduce pain and nausea by at least 50%. Finally, over a longer term of three months, the goal is to improve Ms. Rahman’s emotional well-being and coping strategies for occupational stress and grief, enhancing her quality of life through mental health support and social integration.
Interventions and Care Delivery
1. Immediate Clinical Stabilisation
To address Ms. Rahman’s medium-risk NEWS2 score, an urgent clinical review within one hour is requested, followed by hourly observations to monitor for deterioration. Introducing myself as the caregiver with a simple, “Hello, my name is,” fosters a trusting environment (NHS England, 2014). Person-centred communication will be prioritised by explaining her treatment plan clearly, addressing concerns, and obtaining consent. Given her cultural preference, efforts will be made to assign female healthcare providers where possible. Infection control measures, including rigorous handwashing and personal protective equipment (PPE), will be adhered to as per NICE guidelines (NICE, 2017). Vital signs will be monitored every 30 minutes initially, escalating any concerns using the Situation, Background, Assessment, Recommendation (SBAR) communication tool for effective multidisciplinary collaboration (NHS Institute for Innovation and Improvement, 2008). All interventions will be meticulously documented to ensure continuity of care.
2. Management of Fever and Discomfort
To reduce Ms. Rahman’s temperature, paracetamol will be administered as prescribed every 4-6 hours, following the six rights of medication administration (right patient, drug, dose, route, time, and documentation). Room temperature will be moderated with adequate ventilation to enhance comfort. Hydration will be encouraged, targeting a daily intake of two litres of fluid, with monitoring for signs of dehydration such as dark urine or dizziness. Her family, particularly her sister, will be involved to support this goal. These actions align with evidence suggesting hydration and antipyretics effectively manage fever-related symptoms (Dalal and Zhukovsky, 2006). All interactions will begin with a personal introduction and clear communication, ensuring Ms. Rahman feels informed and supported. Documentation of fluid intake and medication effects will maintain accurate records for the care team.
3. Diagnosis and Treatment of Abdominal Pain
Addressing the root cause of Ms. Rahman’s pain and nausea is paramount. Following clinical review, diagnostic tests (e.g., abdominal ultrasound or blood tests for inflammatory markers) will likely be ordered to identify conditions like pancreatitis or ectopic pregnancy, given her menstrual history. Antibiotics or other treatments will be administered as prescribed if infection is confirmed, adhering to medication safety protocols. Emotional support will be provided to alleviate distress, with reassurance and positioning techniques (e.g., sitting upright) to ease nausea. If gynaecological issues are suspected, a referral to a specialist will be facilitated. These interventions aim to reduce symptom severity within 72 hours, with continuous monitoring and documentation ensuring responsive care (NICE, 2019). Infection prevention through PPE and handwashing remains a priority during all interactions.
4. Long-Term Emotional and Social Support
Over the next three months, the focus shifts to Ms. Rahman’s mental health and social challenges. Involving her in care planning ensures a person-centred approach, building trust through clear explanations and consent. Education on stress management techniques, such as mindfulness, will be provided, alongside a referral to counselling services to address grief and low mood (NHS, 2020). Support groups for stress or bereavement may offer a communal outlet, reducing isolation. Occupational support will include liaising with her employer (with consent) to discuss flexible working arrangements, addressing her fear of being seen as unreliable. A referral to a dietitian will help improve her nutritional habits, tackling identified poor eating patterns. Community nursing follow-ups will assess her progress monthly post-discharge, evaluating emotional well-being and independence. All interventions will be recorded clearly in her notes to support multidisciplinary continuity.
Evaluation of Care
Within 24 hours, Ms. Rahman’s vital signs showed initial stabilisation, with her heart rate and respiratory rate trending towards normal ranges, reducing immediate distress. Clear communication ensured she and her sister understood the care process, fostering trust. By 48 hours, her temperature dropped below 38°C through antipyretic administration and hydration measures, alleviating associated discomfort. Her pain and nausea reduced by over 50% within 72 hours following targeted diagnostics and treatment, although exact diagnosis confirmation remains pending further tests. Emotional support during this acute phase visibly eased her anxiety, with family involvement providing additional reassurance. Over the longer term, post-discharge follow-ups indicate early progress in mental health through counselling, though sustained effort is needed. Participation in support groups has begun to address social isolation, and dietary improvements are underway with specialist input. While immediate outcomes are promising, ongoing evaluation over three months will be crucial to ensure lasting recovery and well-being.
Conclusion
This individual care plan for Ms. Yasmin Rahman demonstrates a structured approach to addressing both acute medical emergencies and underlying psychosocial needs within the framework of health and social care principles. Immediate interventions stabilised her clinical condition, managed fever, and targeted severe abdominal pain, while longer-term strategies focused on emotional well-being and occupational stress. The application of person-centred care, cultural sensitivity, and evidence-based tools like NEWS2 and SBAR underlines the importance of tailored, multidisciplinary care delivery. However, limitations in confirming a precise diagnosis within this essay highlight the need for ongoing clinical assessment. The implications of this care plan extend to broader health and social care practices, emphasising holistic support to enhance patient recovery and quality of life. Ultimately, Ms. Rahman’s case illustrates the critical balance between urgent medical intervention and sustained emotional support in achieving positive health outcomes.
References
- Dalal, S. and Zhukovsky, D.S. (2006) Pathophysiology and management of fever. Journal of Supportive Oncology, 4(1), pp. 9-16.
- NHS England (2014) Compassion in Practice: Nursing, Midwifery and Care Staff. Our Vision and Strategy. NHS England.
- NHS Institute for Innovation and Improvement (2008) SBAR – Situation-Background-Assessment-Recommendation. NHS Institute for Innovation and Improvement.
- NHS (2020) Mental Health Support Services. NHS UK.
- NICE (2017) Infection Prevention and Control. NICE Guideline [NG63]. National Institute for Health and Care Excellence.
- NICE (2019) Acute Abdominal Pain: Assessment and Management. NICE Clinical Knowledge Summaries. National Institute for Health and Care Excellence.
- Royal College of Physicians (2017) National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. Royal College of Physicians.
- Sheikh, A. (2007) Caring for Muslim patients: A guide for healthcare professionals. British Journal of General Practice, 57(538), pp. 412-413.
Word Count: 1512 (including references)
