Participants Involved in Care

Care PlanService User Name:                          


Participants Involved in Care

List known persons currently contributing to the Service User’s care, including the individual and the carer/advocate and the key worker /care plan coordinator/facilitator (e.g. GP, health/community care providers, substitute decision maker, family members, volunteers or friends who provide assistance). Insert rows to specify any additional persons.

NameRole or area of supportPermission to shareParticipant in planning process (yes/no)Copy of plan provided (yes/no)

The Person’s story and reason for plan     

The patient is a 60-year-old who hails from North Queensland. Annie currently resides together with her son’s family and spends most of her time with her granddaughter, Lily. She is a known diabetic suffering from chronic kidney disease in addition to hypertension which she suffers from. From the interview, it is evident that Annie is in a depressed mood, as she feels lonely since she has been separated from her Aboriginal community. Annie also demonstrates a limited understanding of her present medical condition, as she does not know how best to take Caltrate tablets, is not adhering to the diabetic guidelines, and also does not go for regular reviews done by a qualified medical practitioner. Some of the psychosocial issues present in Annie’s case include adjustment failure, the fear of dependency, unemployment, and transport challenges which are negative health determinants (Australian Health Ministers’ Advisory Council, 2017). Through the health belief model, Annie requires to achieve an understanding of the perceived risks and benefits of adhering to a healthy diet (Skinner, Tiro & Champion, 2015). This will be done by educating her on the same benefits such as the proper management of her blood glucose levels, as well as the reduction of the rate of occurrence of complications such as retinopathy, neuropathy, and damage to her kidneys, resulting from diabetes (Gray et al, 2017). Some of the dreaded effects of diabetes include severe epigastric pain that occurs when the lactic acid levels peak, manifesting as bouts of diabetic ketoacidosis (Anupama, Chandrasekhara, Krishnamurthy & Aslam, 2018). This state is brought about mainly by non-compliance. Educating the patient that adhering to a proper diet will save her from such effect and enable her to live a normal life, definitely will aid in promoting her compliance. The patient also requires to know the perceived barriers to her maintaining a proper diet. Some of the barriers include a lack of social support, as evidenced by her current residence, where Tony and Kate are ever busy. The lack of psychosocial support is also seen during her admission where nobody went to visit her in hospital, mainly because everybody was busy. With regard to diabetes, Annie acknowledges she has not been taking vegetables and fruits regularly because Tony and Kate are rarely present to ensure that there is a constant supply of the same at home. The cue to action in Annie’s case is based on ensuring that she has a solid plan on what the plate of a patient with diabetes should contain. This will be done by using the plate method, in which a chart will be used to demonstrate the various proportions of food required. Half of the plate should consist of fruits and vegetables, whereas the other half should be subdivided equally into lean protein and starch (Bowen et al., 2016). The greatest health literacy challenge as seen in the patient is that she does not seem to know the complications of renal disease, as well as how to self-administer her Caltrate medication. She does not seem to understand the correlation between chronic kidney disease, osteoporosis, prevention of osteoporosis, and her hobby, which is talking baby Lilly out for walks. One of the most reliable outcome measures of health literacy levels is the frequency of follow-ups and visits to health centres (Bale et al., 2016). For a patient with chronic illnesses in three major systems, Annie demonstrates low health literacy as she has been to the hospital only once; when getting treatment for chronic kidney disease. She also has no initiative to seek professional guidance from a qualified medical practitioner. The patient is on medication with Caltrate but does not seem to understand the basic pharmacokinetics such as how best the drug is absorbed. This demonstrates that the patient had the drugs prescribed but didn’t have a counselling session to explain how the drugs work. The proper usage of Caltrate in this patient is very important, as the development of osteoporosis would reduce her mobility. Renal disease predisposes to osteoporosis by leading to hyperphosphatemia due to the impaired renal excretory function (Sprague, 2019). The result is excessive bone resorption, which weakens the bone, predisposing to events such as pathological fractures and slipped epiphyses. Vitamin D supplementation through the Caltrate tablets helps to reduce this process by increasing the rate of laying down of bone. The best time to take the Caltrate tablets is during meals, as stomach acid production is highest at this time, increasing the rate of absorption of the Caltrate medication (Kilim & Rosen, 2018). The implications of failure to manage osteoporosis appropriately are that the patient will be prone to more psychosocial challenges such as dependency, which is against the vision of maintaining dignity within the geriatric population (Australia. Department of Health, 2013). Pathological fractures and bone weakness limit one’s ability to perform daily tasks such as walking, cooking, let alone gardening, which Annie enjoys doing (Kazama, Matsuo, Iwasaki & Fukagawa, 2015). It is important to explain this to Annie so that she can take her doctor’s appointments seriously.
Opportunities/problemsPerson-centred Goal Actions to be taken and by whomDesired Outcome
  Compliance challenge. Annie has reduced compliance with effective diabetic management practices.  To enhance the patient’s understanding of the importance of compliance to pharmacological and non-pharmacological management modalities of diabetes and renal disease.        By the care provider: Educate Annie on the advantages of maintaining a positive diet plan in a patient with diabetes. Educate Annie on the risks involved with failure to maintain a positive diet plan in a patient with diabetes. Educate Annie on how to plan her diet.The patient will develop an appropriate daily meal plan. The patient will be able to explain when best to take Caltrate tablets and the importance of taking the tablets at that time.
  Health literacy challenge: The patient has limited knowledge of how to effectively take her Caltrate medication. The patient defaults attending regular check-ups by a medical professional.  To enhance the patient’s understanding of the importance of taking calcium-vitamin D supplements during meals. To enhance the patient’s understanding of the effects of osteoporosis on her lifestyle.    Educate Annie on how to take her Caltrate tablets. Educate Annie on the role of Vitamin D  supplementation to reduce bone resorption. Educate Annie on the complications of chronic kidney disease on the musculoskeletal system. Educate Annie on the need for regular checkups by a health professional.The patient will be able to explain the importance of taking Caltrate tablets along with meals. The patient will be able to explain the role of Caltrate in the prevention of osteoporosis in chronic kidney disease. The patient will attend check-up clinics at the health facility at least four times annually.


Australia. Department of Health. (2013). National Aboriginal and Torres Strait Islander Health Plan: 2013-2023. Department of Health.

Australian Health Ministers’ Advisory Council (2017). National Strategic Framework for Chronic Conditions. Australian Government. Canberra.

Anupama, B., Chandrasekhara, P., Krishnamurthy, M. S., & Aslam, M. (2018). Clinical and laboratory profile of diabetic ketoacidosis in elderly with type 2 diabetes mellitus. BLDE University Journal of Health Sciences3(2), 79.

Bale, C., Douglas, A., Jegatheesan, D., Pham, L., Huynh, S., Mulay, A., & Ranganathan, D. (2016). Psychosocial Factors in End-Stage Kidney Disease Patients at a Tertiary Hospital in Australia. International Journal of Nephrology2016, 2051586. doi:10.1155/2016/2051586

Bowen, M. E., Cavanaugh, K. L., Wolff, K., Davis, D., Gregory, R. P., Shintani, A., … & Rothman, R. L. (2016). The diabetes nutrition education study randomized controlled trial: a comparative effectiveness study of approaches to nutrition in diabetes self-management education. Patient education and counseling99(8), 1368-1376.

Gray, S. P., Di Marco, E., Candido, R., Cooper, M. E., & Jandeleit‐Dahm, K. A. (2017). Pathogenesis of Macrovascular Complications in Diabetes. Textbook of Diabetes, 599-628.

Kazama, J. J., Matsuo, K., Iwasaki, Y., & Fukagawa, M. (2015). Chronic kidney disease and bone metabolism. Journal of bone and mineral metabolism33(3), 245-252.

Kilim, H. P., & Rosen, H. (2018). Optimizing calcium and vitamin D intake through diet and supplements. Cleveland Clinic journal of medicine85(7), 543.

Skinner, C. S., Tiro, J., & Champion, V. L. (2015). Background on the health belief model. Health behavior: Theory, research, and practice75.

Sprague, S. M. (2019). Management of Bone Disorders in Kidney Disease. In Endocrine Disorders in Kidney Disease(pp. 231-242). Springer, Cham.