Jill (not her real name) is a 24 year old female who was sexually abused from age 10 by her father and was taken into care at age 14 when her behaviour became unmanageable in the home setting. When Jill was taken into care the abuse was disclosed. Jill has two older siblings, both female, neither of which suffered abuse, both have IQ’s appropriate their age and development. Jill has been assessed as having a mild learning disability. A mild learning disability as defined by British Institute of Learning Disabilities (BILD) 2004, is a person with an IQ of between 69 and 50.
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The World Health Organisation (WHO) defines learning disabilities as ‘a state of arrested or incomplete development of mind’. Somebody with a learning disability is said also to have ‘significant impairment of intellectual functioning’ and ‘significant impairment of adaptive/social functioning’. Jill was admitted to this service provider due to her challenging behaviour and is detained under section 3 of the mental health act 1983. Challenging behaviour has been defined as culturally abnormal behaviours of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities (Emerson 2001). Jill’s challenging behaviours include physical and verbal aggression towards her peers and carers, destruction of property including her own, stripping and destruction of her clothes, refusal to engage in therapeutic interventions and self injurious behaviours (SIB) mainly cutting of her arms.
Jill is 5ft 7inches tall and weighs 17st 3lb with a Body Mass Index (BMI) of 43.11 making her clinically obese, Jill’s BMI should be between 18.5 and 24.9 meaning she would need to lose 11st to bring her within the recommended BMI range. Jill has recently been diagnosed with type 2 Diabetes, currently controlled with medication, Metaphormine. Type 2 diabetes, (formerly referred to as non-insulin-dependent diabetes (NIDDM)), is due to reduced secretion of insulin or to peripheral resistance to the action of insulin or to a combination of both, British National Formulary (BNF). Jill is also asthmatic.
The nursing assessment process consists of four key elements Assessment, Planning, Implementation and Evaluation (APIE) Brooker & Nichol, 2003. A comprehensive assessment provides a basis from which to make planning decisions, as well as providing a baseline from which to measure the impact of any service provided, Gates (2008). The team used a holistic approach in the assessment of Jill, addressing her spiritual, physical, emotional, psychological and sociocultural needs. For assessment to be comprehensive, it should be undertaken in a holistic manner, Fawcett (2000), cited by Brooker, C (2007) p. 351.
In the case of Jill it was decided to focus on weight loss through diet and exercise as this would have the biggest impact on improving her health and wellbeing. “Health is defined as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”, World Health Organisation (WHO)
The nursing team used the Prochaska, Norcross & Di Clemente Thranstheoretical health belief Model, 1994 (TTM). The model provides health professionals and support staff with a clear plan for working with individuals encouraging change, promote and adopt a healthy lifestyle. The TTM focuses on behaviour change, and assesses an individual’s readiness to act on a new healthier behaviour, it provides strategies, or processes of change to guide the individual through the stages of change. The TTM is comprised of six stages. Pre-contemplation, not currently considering change or unaware a problem exists. Meetings were held with Jill to address her obesity and explain the risk of not changing her life style. Jill was informed of the problems that were arising from her being overweight, diabetes, heart disease and high blood pressure and the risk of stroke, reduced mobility. This was communicated to her in a sensitive way and in a format she could easily understand. Effective communication of information is essential to ensure maximum effectiveness. Complicated health promotion images may be incomprehensible to a person who struggles with concepts. Health promotion messages that focus on giving up existing behaviours may unintentionally imply that to be healthy is to adopt a miserable and undesirable lifestyle. Care should be taken to ensure that people with learning disabilities understand health promotion messages in a balanced way Gates 2007. Jill was encouraged to re-evaluate her current unhealthy behaviour and the multiple benefits she would gain in changing her lifestyle. Jill then entered the Contemplation stage when she started to think about the changes she needed to make to become healthier. Jill was provi The nurse has a responsibility to promote health
This process is supported by a nursing model to produce a care plan, which can be evaluated and changed when necessary to suit the patient’s needs. The model used by this private care provider is the S.H.A.R.E.D Approach model (Supportive Help Achieving Realistic Effective Development). The model incorporates many other models of care, using holistic/humanistic approaches, social learning theory, behaviour profiles and other associated psychological therapies, utilising the Care Programme Approach and Person Centred Planning to best fit the service user, adapted from the La Vinga (1989) model. The service provider has developed this model and created tools in line with the requirements of the service and pursuing up to date clinical and social validity and has a bias towards addressing challenging behaviours. In assessing the patient the nurse should use a holistic approach working in partnership with the individual. Roper et al 2000, cited by Brooker & Waugh 2007, p360 states that the nurse should use the Activities of Living (ALs) approach to systematically assess the person. Roper et al 2000 suggests there are 12 activities essential for survival. Breathing, communicating, eating and drinking, eliminating, mobilizing, sleeping, personal cleansing and dressing, working and playing, controlling body temperature, expressing sexuality, maintaining a safe environment and dying.
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Roper et al 2000 goes on to state there are 5 main factors that can influence ALs that need to be considered when carrying out an assessment, biological, psychological, sociocultural, environmental and politico-economic. Biological factors relate to physical and psychological issues and are usually genetic but may be the result of disease or neglect
The Planning stage based on the assessment identifies the problems and needs of the patient. Nursing diagnoses provide a focus for planning and implementing effective and evidence-based care Dougherty & Lister 2008. Goals should be incorporated into the plan to enable the nurse to measure the effectiveness or otherwise of the nursing intervention. Goals should be SMART, Specific stating clearly what is to be achieved, Measurable, Achievable, Realistic, and time oriented by which the goal can be achieved and evaluated Brooker & Waugh 2007.
The implementation stage is putting the care plan into operation and may involve referring the patient to another health care professional.
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