Download CHC Foundation Module Case Study 1

CHC Foundation Training Module
Case Study 1: Mr Mark Jones
Introduction
Mr Mark Jones
Age 62
Mark Jones had been living in sheltered accommodation in the community for many
years, with sporadic input from the Learning Disabilities team. He was reviewed
yearly by the Social Worker and yearly by Consultant Psychiatrist. He has a
diagnosis of mild learning disability and schizophrenia (well controlled). 5 years ago,
Mark was admitted to a learning disability assessment and treatment unit due to
concerns from his Social Worker around self neglect, poor sleep and behaviour.
Mark was found lying in his own faeces within his flat, with evident very poor hygiene
and self care. He had also lost weight. His admission to the AATU was uneventful
and he remained stable, with no evidence of behavioural difficulties, but a new
placement was required due to evident deterioration in his self help skills. His family
requested he be moved to Happy Hills. This is often referred to in the records as a
general nursing home, but Mark was in fact placed in the residential side of the
house. The placement was a normal residential home and not one specifically for
those with learning disabilities or mental health needs. Mark had been living here for
four years, with reviews undertaken by the Social Worker, CPN and LD Psychiatrist.
There was evidence of a slow and progressive deterioration, not only his physical
health, but also in some aspects of his behaviour, which the home were having some
difficulties in managing. Notice had been served to Mark from Happy Hills, just prior
to his hospital admission, but this was later retracted. Mark was admitted to hospital
following a one month history of non specific physical health deterioration, with a 7
day history of significant deterioration, increased confusion and dehydration. His
MDT felt that Mark now required full assessment for CHC eligibility, prior to his
discharge and a possible new care package to meet increased needs.
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Hospital discharge letter:
Key Points:
Vision: Registered Blind. Hearing: Impaired.
Mobility: Chair bound, Wheelchair bound.
Hygiene requirements:
dress.
Depends on others for aspects of personal hygiene and
Skin condition: Skin intact no redness but fragile.
Mental condition: Confused withdrawn.
Feeding: Needs assistance due to vision.
Communication:
Impaired at present.
sides/protection. Waterlow score: 18.
Nursing
equipment
used:
Cot
Generally unwell.
History of Presenting Complaints: No history of cognitive impairment. Family noticed
a general deterioration in his health over last 7/7. Patient is more confused,
hallucinating. Recently his blood sugars have been poorly controlled. C/o
[complaining of] pain in Left eye, History of glaucoma. Patient has also vomited
today - ?how many times. Patient has complained of headache earlier in the week.
No documentation of diarrhoea/constipation. Patient denying chest/abdominal pain.
Patient also has history of anaemia
Nursing Assessment: Nutrition: Problems with appetite: Yes; Difficulties swallowing:
No; Difficulties chewing: No; Special diet required: No. Mobility: Present level of
mobility: Immobile. Aids used: Wheelchair, Hoist. Breathing: Previous breathing
problems: No. Condition of mouth: Own teeth. Communication: Sight: Glasses,
virtually blind; Hearing: No issues. Speech: basic skills. Needs cot sides whilst in
bed. Pain: Pain Score: No pain 1. Any previous problems with: Anxiety: Yes. Any
evidence of tissue damage or skin discoloration: No. Any problems sleeping: No.
Dehydrated, placed on IV with difficulties due to compliance.
Ultrasound Abdomen and Pelvis. A difficult study as not compliant. Normal kidneys,
spleen and liver. A contracted echogenic gallbladder full of calculi is present.
Normal pancreas and aorta. No mass lesion, ascites or lymphadenopathy and no
pelvic abnormality. Stage 3 chronic kidney disease.
Discontinuation of Metformin during hospital admission, due to unstable blood
sugars. Prescribed Insulin injections. Evidence of ongoing instability at discharge
due to ongoing non compliance with medication and diet.
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Hospital Discharge Summary from Consultant Physician to GP: This gentleman was
admitted from his nursing home feeling generally unwell. He is a known type II
diabetic, on oral hypoglycaemic agents comprising of Metformin and Gliclazide at
admission. He also has a history of iron deficiency anaemia for which he had OGD
and colonoscopy last year which was essentially normal.
He was a poor historian and appeared dehydrated clinically. Nothing specific was
noted on examination and a coincidental note was made of an elevated lactate
levels. ECG was normal. Nothing specific on chest x-ray. Medications at discharge
comprised of iron supplements, Lansoprazole, Flupenthixol and Gliclazide as
charted in his discharge advice letter. No further follow up arrangements have been
made as would be non compliant with advice given.
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Carer’s Perspective
Mark is totally dependant on staff for his own safety. He will isolate himself in his
bedroom listening to the television. He needs help to walk with a Zimmer frame even
to a couple of steps to a wheelchair with 2 staff which is needed to move him around
the care home.
Concerning his behaviour:
Mark is confused due to his failing eyesight. This has caused frequent bouts of
shouting for reassurance from staff. He can be uncooperative because at times as
he does not understand what staff are asking of him. Mark has very little patience
with staff and he will often shout out to staff if they do not attend to him immediately,
any delay will increase his anxiety. He can be verbally aggressive towards staff but
has never physically aggressive towards them. He has many “triggers” which will
increase his anxiety and panic attacks.
Mark had a very good long and short term memory on admission but this has
deteriorated over recent years to a point where he can now no longer remember
previous addresses or lifelong friends.
Mark needs assistance with basic needs and prompting by staff to ensure he is
clean, fed & toileted.
Mark is under the Consultant Psychiatrist from the Mental Health Team for his
schizophrenia and learning difficulties. She has changed his medication regularly
because his anxiety, panic attacks and behaviours change frequently. This has had
a severe impact on his emotional & psychological mind.
Mark’s eyesight has deteriorated rapidly following an eye infection and a spell in
hospital (really not sure what date). The cause of his loss of sight was due to his
diabetes and he has had great difficulties adjusting to his blindness which has
caused severe and emotional & psychological distress to him isolating him to his
world.
Following Mark’s admission to the care home he has lost a lot of weight because he
finds it difficult to feed himself. He has a normal diet and drinks.
Mark is doubly incontinent needing 2 hourly care from staff day and night.
Staff frequently check Mark for any areas of pressure sores and to keep his skin
clean and dry.
Not sure if this will help you:
Past Medical History – had this part from nursing home
Learning Difficulty
Type 2 Diabetic
Schizophrenia
Peripheral Vascular Disease
TIA's
Renal Failure
Blind
Mark has been recently admitted to hospital due to deterioration in his health and
feel that he now meets the criteria for continuing healthcare funding.
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Nursing Assessors report
..... “able to answer simple questions and engage in conversation. He was pleasant
in mood and had just finished lunch, when asked if he was happy in Happy Hills said
“yes, now leave me alone as I want to go to back to sleep”..... Recently commenced
on daily insulin therapy.....episodes of challenging behaviour i.e. episodes of verbal
aggression and use of foul language.....intensity of needs medium......is usually
compliant with medication......there is evidence on occasions when he will
refuse.....immobile but partially able to weight bear.....assisted by two carers, hoist
used for bathing, attendant operated wheelchair...Waterlow score 20 (very high risk)
required 2/3hrly pressure are care by staff....can move himself in bed with minimal
assistance.......requires two carers for personal care intervention due to learning
disability and limited functional abilities.....can be resistive to carers at times, not
keen on washing.......attend to needs in pairs due to previous accusations against
staff members i.e. they hit him, looking at his body, touching him
inappropriately...Social Worker aware and regular reviews undertaken...all
accusations are documented........appetite good... has lost weight.....sleeps well not
on night sedation.....routine checks.....notice to leave served to Learning Disabilities
Team .and requesting additional member of staff from 08.00 – 20.00 but no
response received......assessed by a learning disabilities home and they would be
able to meet needs..... message left for Social Worker by Happy Hills House that
after consideration they were withdrawing notice as “perhaps behaviour would
improve” ....episodes of shouting are unpredictable..... appear to occur around three
times a month......staff feel vulnerable when attending to Mr Jones due to sexual
innuendos and frequently making accusations......high intensity......physical needs
outweighed his mental health needs and Happy Hills Nursing Home are able to meet
these needs........unpredictable periods of confusion, verbal aggressive behaviour
and paranoia.
He has also been diagnosed with diabetes (type 2) and recently commenced on
insulin therapy. He has peripheral vascular disease, a history of anaemia previously
requiring a blood transfusion. His physical and mental health status is unpredictable
(due to haemoglobin levels and episodes of challenging behaviour) and is likely to
deteriorate unless frequent monitoring is undertaken by a Registered Nurse, on an
ongoing basis. His care needs to be assessed, planned, implemented and
evaluated on a regular basis in order to promote his well-being.
Elements of Mark’s behavioural management fluctuate between medium and high
complexity and require appropriate management and the ongoing monitoring by a
Registered Nurse over a 24 hour period. Physical health status is currently unstable
due to capillary blood glucose levels and ongoing monitoring of low haemoglobin
levels and possibility of experiencing potential side effects, close monitoring is
required. Mark has a long history of non compliance with diabetic diet and refusing
medication.
Page 5 of 8
Mark is unable to maintain his own safe environment due to learning disabilities,
physical limitations and immobility. He is at risk of falls, fractures and pressure area
damage. At risk of developing complications associated with anaemia, diabetes and
peripheral vascular disease, close monitoring required.
At risk of hypo/hyperglycaemic attacks, transient ischaemic attacks and also at risk
of elevated blood pressure. A Registered Nurse is required to undertake pro-active
and preventative nursing interventions in order to promote and safeguard Mark’s
well-being and assist in minimising potential complications.
Social Worker report
Current situation: ....history of being a loner and does not seek out the company of
others. He is residing, as Happy Hills Nursing Home a number of years but the
placement is no longer viable as there have been a number of grievances by the
service user and Happy Hills that have impacted on the current placement. Due to
Mental Health issues Mr Jones needs regular monitoring for any deterioration and
regular reviews of his medication. Currently receives monthly depot injections........
recorded history of not mobilising within the home. Mr Jones is often reluctant to
utilise occupational therapy aids, preferring to use the surrounding surfaces.
Historically Mr Jones would very reluctant to move from his couch preferring to lie
prone. Mr Jones has lost a considerable amount of muscle mass from his lower
limbs and this may adversely affect his stability. Mr Jones requires others to provide
meals on a regular basis and encourage a healthy diet that is congruent for a person
with diabetes. Mr Jones chooses to be non compliant with the advice given. Mr
Jones needs to be encouraged to maintain fluid levels. Mr Jones requires to be
verbally prompted and encouraged to maintain a reasonable standard of hygiene.
Would need assistance in all tasks of bathing/showering and shaving and may
require assistance with dressing. Assistance is required as Mr Jones is doubly
incontinent through choice. Mr Jones requires reassurance, support and
encouragement to build relationships and interact with others. Mr Jones will often
indicate that he wishes to be left alone and does not wish to leave the home
environment as others do not talk to him.
Mr Jones withdrawal from
company/interaction needs to be monitored to avoid prolonged periods of isolation,
leading to other concerns i.e. deterioration in mental health. Review yearly or as
required. I do not feel that Mr Jones has a learning disability.
Page 6 of 8
Psychiatric report
Diagnosis:
Mild learning disability
Diabetic Type II
Self neglect
Schizophrenia (controlled)
Peripheral Vascular Disease
Limited vision
Transient Ischaemic Attacks x 3 (one four years ago and two in the past months)
History
Summary: Initial informal admission to learning disability assessment and treatment
unit following social worker concerns regarding self neglect, behavioural difficulties
and sleep disturbance. Had been living in sheltered accommodation for many years,
with limited input. He made good progress on the ward and was discharged to a
general nursing home (not LD/MH specific) at families request four years ago. He
has continued to be monitored by myself every 6 months, the CPN monthly (who
also administers Depixol injection) and the Social Worker has held regular reviews
due to family concerns regarding placement and Nursing home experiencing
difficulties in coping with some of Mr Jones's behaviour. The family have however
refused to move him to a more suitable residential home, who would have the
experience and skills in meeting the needs of someone with Learning Disabilities and
mental health issues.
Reviewed Mark and discussed his progress with his sister and the Staff Nurse on the
ward. Apparently Mark has had physical health problems for the past 1 month or so,
His sister noticed that Mark was more vague with intermittent confusion around mid
April. Gradually he became more unwell and dehydrated and was admitted to
Hospital; with suspected UTI. Apart from raised Urea and deranged blood sugar
levels – no major problems were diagnosed and Mark is to be discharged home after
a few days. Nevertheless, his confusion seems to persist intermittently and he is also
more forgetful and disorientated of late. It was also reported that Mark appeared to
be hallucinating visually at the start of these complaints – stating that he was seeing
people in his room etc. His sister was concerned that he might be having TIA’s or
some other cardiovascular incidents which has not been picked up. I requested a
CT brain scan during hospital admission, however despite medication to calm him
prior to this, Mark refused to comply. Mark’s needs his fluid intake to be very
carefully monitored by the nursing staff within the home at discharge, with advice
that are to seek urgent medical help if he develops similar problems. Mark’s
medication remains unchanged in terms of the management of his mental health. As
there are no current mental health issues, I will next review Mark in the joint review
with Social Services. Mark's longstanding issues remain, as a result of his learning
disability and longstanding personality difficulties. Mr Jones has a history of being a
loner and does not seek out the company of others. His apparent cognitive
deterioration and physical health deterioration requires close ongoing monitoring.
Page 7 of 8
CPN report
Mr Jones has “unpredictable periods of confusion, verbal aggressive behaviour and
paranoia. His physical and mental health status is unpredictable and he continues to
have sporadic (3 or 4) episodes of verbal aggression a month, which would not
warrant the additional request for 1:1 staffing from 08.00 – 20.00 a day. There is
also evidence that Mr Jones had “episodes of verbal aggression and use of foul
language.....intensity of needs medium” and that he can “be resistive to carers at
times, not keen on washing...attend to needs in pairs due to previous accusations
against staff members i.e. they hit him, looking at his body, touching him
inappropriately...Social Worker aware and regular reviews undertaken...all
accusations are documented” and that he slept well at night and required “routine
checks”. Staff feel vulnerable when attending to Mr Jones due to sexual innuendos
and frequently making accusations.
Physiotherapy assessment
Mr Jones had a “recorded history of not mobilising within the home. Mr Jones is
often reluctant to utilise occupational therapy aids, preferring to use the surrounding
surfaces. Historically Mr Jones would very reluctant to move from his couch
preferring to lie prone. Mr Jones has lost a considerable amount of muscle mass
from his lower limbs and this may adversely affect his stability.
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