This seventy-year old gentleman was admitted to the ward from the Renal Unit where he had been admitted to via the Accident and Emergency department with dehydration resulting from acute renal failure.
His past medical history includes Type 2 Diabetes Mellitus, Bells Palsy and Angina. He lives alone and is normally independent with all activities of daily living.
After being treated on the Renal unit with haemodialysis and medication which resolved the acute renal failure, he was commenced on Insulin for hyperglycaemia and throughout the period of hospitalisation his condition improved.
The nursing management for this patient includes a referral to the Diabetic specialist nurse, Physiotherapist and the Social Worker.
Following a period of twelve days in hospital he was discharged home.
Learning Disability Case 01-091
The client is a 19 year old lady with moderate learning difficulties. She was a school pupil until she reached the age of 16, from which she had attended college on a full time basis. Twelve months ago she resided at a private residential home for people with learning difficulties aged between 18/41 years in this area. Previously, she was admitted to a children’s centre for a long placement four and a half years ago due to a breakdown in the relationship between her and her mother. Fifteen months ago she was admitted to the Mental Health Unit under Section 2 of the MHA following a period of very unstable and extremely challenging behaviours towards her mother and staff at the resource unit.
She has a violent relationship with her mother and most of her challenging behaviours are directed towards her. Her mother also has a mild learning difficulty. She is an older carer with mobility problems and other health needs. When Rose was living at home with her, her mother found it arduous to cope with her daughter’s behaviour, her understanding of rules and boundaries are a concept that her mother has trouble managing with and this has consistently been the situation since she was a small child.
She is known to target male support staff with provocative behaviour/ challenging behaviour and to take the hand of male service user and rubbing it on her private areas. Deemed to be at risk from sexual/ financial/ physical/ psychological abuse. Possible risk of exploitation from males in the community.
The story concludes with doing really well both at the hospital and at her visits home.
Profile of Learning Disability Case 01-092
A young boy [referred to as David throughout the case study] diagnosed with ‘conductive disorder syndrome.’ Good evidence of multi agency involvement in this complex case management.
The story begins with reports of a pleasant boy doing well at school. Mum has some relationship problems with her estranged husband affecting her ability to care for her children. The nurse reports that she looked ill and suggested that she sought help from her GP; she is reluctant to do as she feels he will only wish to prescribe antidepressants.
As the story progresses the boy begins to exhibit some very challenging behaviour particularly relating to setting fire to property, placing himself and others in extreme danger, and threats to kill someone: This is poignantly illustrated by one particular case note entry: Fascination with fire - obsession. No lighters or matches at home. Set fire to tent - stamping out fire. Has been helped by medication. Still threatens with bricks, hammers. Language foul - steals - has threatened to kill puppy. Behaviour deliberate - attention seeking. Encouraged by brothers - lots of mixed messages. Attempts at re-integration with school for 18/12 (usually 6-8/52).
Language so foul, threats very frequent. Educated outside then brought in. Short attention span - gradually settled - can stay over whole session. Made distinct improvements. Disruptive - stamping, moving around. Extremely calculating. Steals keys - locks himself in car. Came in to school with lighter - when outside, under hut then started to light it. Has brought full ones in - especially last week. Offered it to police. Also caught with kitchen knife ‘to stab somebody’. Level P5 below average. Very street-wise. Set fire to wheelie bin - stamped out by mother and brother. “Threatening children, lighters and knives…
David has nightmares about a man he calls Sam who comes out of the wardrobe at night. The appearance of ‘Sam’ in David’s life coincides with him becoming fixated on his own anus poking faeces and exposing himself to his brother. The nurse explores whether these behaviours could be associated with sexual abuse but this emphatically rejected by David.
The story concludes with much of the challenging behaviour abating and David once again settled and doing quite well at school.
Profile of Learning Disability Case 01-093
He is a little boy [referred to has Roger throughout the case files] of six diagnosed with autism spectrum disorder who attends Special School.
Exhibits challenging behaviour, temper tantrums, bizarre behaviour, outburst described by the paediatrician as being almost psychotic at times. Mum is exhausted as the child’s sleeping patterns are erratic, settling late and awake early. In sheer desperation she locked him in his room so she could get some respite; he trashed the room smashing the television etc. Has requested extra help from Social Services particularly respite care, someone to look after him while she does the shopping etc. denied as she is already at the maximum allowable two night per month.
Risperidone discontinued by the paediatrician because he felt the bizarre behaviour and outbursts were a side effect of his medication. Risperidone later reinstated to manage the child’s behaviour. Vallergan was prescribed as a night time sedative but mum not compliant with medication prescription, giving doses of Vallergan during the day to calm his behaviour.
The story concludes with Roger’s behaviour becoming more volatile and unmanageable resulting in the decision to prescribe a major tranquiliser: Roger is hyperactive, screaming with lots of spinning and attempting to pick up illusory objects. He is very demanding with lots of jumping and bouncing around, he is aggressive throwing things pulling at people’s clothing and at their skin. He has held his hands round his neck. He has temper tantrums which is really a concentration of all these behaviours some two or three times a day. At home his behaviour is equally bad as it is at school and sometimes his mother says it can be worse. His sleep is interrupted and he if often woken throughout the night and sometimes will not go back to sleep. His appetite is abnormally large but he doesn’t seem to be piling on the weight. It is clear to me that he needs an increase dose of a major tranquiliser and the one that we are giving him, Olanzapine, so far needs to be pushed towards a limit. I have therefore prescribed for him Olanzapine 5mg BD for one week increasing 5mg mane and 7.5mg nocté for a further week and ending finally on Olanzapine 7.5mg BD. I shall see him in three of four week’s time and write to you further.