Patient Care Action Plan

Patient Care Action Plan for: William
Main Contact: Gladys
Main Contact’s Relation to Client: Wife
Council area where client lives: London
Client Address: 49 Featherstone Street, London, United Kingdom

This patient care action plan is for William. William currently has liver cancer and he is very much worried about his condition and how
his wife Gladys will cope with the situation. When William was growing up, he thought that he would live to reach ninety years old, like
his parents, without any serious illness. His dream of living longer has just been shattered after he recently discovered the presence of
blood in his stool. On visiting the hospital, William has received a confirmation from Dr. Maxwell that he has liver cancer. William’s
immediate carer is his wife, Gladys, who provides assistance with daily living activities as well as with social support. Since William’s kids
have their own families and they are mostly committed to work, he has limited access to family support. His living setting is the home

environment, and he frequently visits the hospital from where he is cared for by Dr. Maxwell and nurse Linda. Dr. Maxwell has involved
other physicians in William’s care. The doctor is working together with other highly qualified healthcare professionals to ensure that
William receives the support that he needs for the longest period possible. William’s health condition is not that severe, and his recent
health care trajectory indicates that he has a positive progress. His positive health progress is mainly attributed to good communication and
a positive relationship with his healthcare providers, including the social worker. At the moment, William largely depends on services
obtained from only one GP healthcare resource.

Needs Assessment

From the PCC4U Needs Assessment, it is evident that some of Williams needs have been met while there are others, which have not been
effectively addressed.
 Needs that are currently met

The positive progress that is being observed in the patient is attributed to primary health care services that he is now receiving from the
doctors and nurse Linda (Llobera, Sanso, and Leiva, 2017). Through support obtained from the doctors, William has learned and can apply
various health promotion options that are available to him. Also, William has been informed about the right people he should approach in
case his health condition gets worse.
 Immediate needs that should be met

It is important to prioritize patients’ unmet needs to plan effectively on how to help them manage their health conditions (Khosla, Patel,
and Sharma, 2012). There are two major immediate needs that William should be assisted to meet. During his interaction with nurse Linda,
William explains that he is in a bit of pain and that he still has a lousy appetite. These conditions are common among older people with
terminal illnesses (Goodman, Dening, and Zubair, et al., 2016). In this regard, William should be taught how he can solve his appetite
problems and how he can effectively manage pain.
 Potential needs that might arise
William’s healthcare providers should be prepared to address potential needs that might arise in the course of care. It is important to
identify possible emotional and physical health problems that may arise to formulate strategies that can be used to prevent them early
(Clarke, Bourn, Skoufalos, Beck, and Castillo, 2017). To meet William’s physical and emotional needs, the healthcare providers should
engage specialists in palliative medicine and palliative nursing, as well as family members, to provide necessary care as early as possible
(Llobera, Sanso, and Leiva, 2017).


Local Resources and Services Scan

Service name
and brief

Address/contact details and website URL
(if available)


How to
access (e.g.
is a referral

What needs can
this service help
to meet?

Healthcare team
responsible for


Companions of

110 Gloucester Ave,
London NW1 8HX,

Every day:
9.00 am to
5.00 pm.

No referral

Primary care,
emotional and
social support.

Palliative nurses
are available even
with short notice.

This is a useful back
up for William’s
primary care and
emotional and social


Provides all
primary care
services needed
by patients with
serious illnesses.

Sharon Finn offers
social services
support and can
connect patients
with palliative care
specialists in the

This facility
provides hospice
care that William
may need shortly.

Meadow House

Uxbridge Road, Middlesex, UB1 3HW

Open Monday
to Friday from
8.30 am to
5.00 pm,
Saturday from
12 pm to 2.30
pm, Closed on

Referrals are
From Friday
8.30 am –
16.00 pm by
calling 020
8967 5758

Psychiatric and
primary care

Jane Cowap is the
lead clinician who
specializes in
psychiatric care for
geriatric patients.

This facility will be
appropriate for
William in future
when he will be in
need of psychiatric

Palliative Care

Exmoor St, London W10 6DZ, UK
Open 24
hours daily

No referral

and physical

Doctor Louise
Ashley specializes
in the treatment of
especially for
patients with

A useful facility for
screening and


Marie Curie

11 Lyndhurst Gardens, Hampstead, London
NW3 5NS, UK.

Open Monday
to Friday from
8.00 am to
6.00 pm,
11.00 am to
6.00 pm, and
Closed on

No referrals
are necessary

Offers emotional
and social
support for
patients with
terminal illness
and their

Lead nurse Angel
and Marilyn can
assist patients with
appointments and

William can get
necessary emotional
and social support
from this facility.

Hospice UK 34-44 Britannia St, Kings Cross, London

Open Monday
to Friday from
9.00 am to
5.00 pm,
Closed on
Saturday and

No referrals
are necessary

Provides all
types of home-
based care
needed by
patients with
serious illness.

Carol Warlford is
the Chief Clinical
Officer in charge
of all forms of
palliative care in
the facility.

This facility is
appropriate for
meeting William’s
physical, social,
physiological, and
emotional needs
both now and in

Personal Care

Sydenham, UK
+44 20 8768 4500

Open every
day from 9.00
am to 5.00

No referrals
are required

Offers support
with all forms of
care including
activities of
daily living,
social support,
and emotional

Denise, Maxine,
Tony, and Sandra
are highly trained
to offer palliative
care to all patients
with various needs.

The facility is a
useful back up for
William’s palliative
care needs.

Action Plan

Medication: The nurse should plan a visit to the physician to provide the right prescription for William to enable him to manage pain
effectively (Ramanayake, Dilanka, and Premasiri, 2016; & Al-Mahrezi, and Al-Mandhari, 2016). This arrangement should be made
as soon as possible.
Nutrition: The nurse should contact a nutritionist to help with the development of a feeding plan for William and his wife. Since
appetite is one of William’s problems that should be solved urgently, this action should be started as soon as possible (Forbat,
Haraldsdottir, Lewis, and Hepburn, 2016; & Caccaialanza, Pedrazzoli, and Zagonel, et al., 2016).
Physical Activity: William’s wife should contact a trainer to help William with physical exercise (Lowe, Tan, Faily, Watanabe, and
Courneya, 2016; & Chandrasekar, Tribett, and Ramchandran, 2016). This arrangement should be made before William’s next meeting
with the GP.
Counselling: The nurse should plan a visit to a professional psychologist to plan counselling sessions for William and his family
(Pino, Parry, Land, Faull, Feathers, and Seymour, 2016). This plan should be ready before William’s next meeting with the GP.
Referral to Hospice: The nurse should contact a social worker to provide William and his wife with detailed legal information related
to the procedures he should follow when he will be required to relocate from home-based care to the hospice (Hui and Bruera, 2016).
This arrangement should be made when William will no longer be in a position to make decisions by himself.


Reference List

Al-Mahrezi, A. & Al-Mandhari, Z. (2016). Palliative care: Time for action. Oman Medical Journal, 31(3): 161-163.
Caccaialanza, R., Pedrazzoli, P…& Zagonel, V. (2016). Nutritional support in cancer patients: A position paper from the Italian
Society of Medical Oncology (AIOM) and the Italian Society of Artificial Nutrition and Metabolism (SINPE). Journal of
Cancer, 7(2): 131-135.

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