Additional Case Studies

Chapter 1

Case Study: Ngozi, Faith and their children, pg 37

Ngozi, Faith and their four children have been your next-door neighbours for the last three years. Ngozi has said to you, on numerous occasions, that he has always wanted to be a nurse. Since leaving school, twenty years ago, he has worked in town planning, but spends a great deal of his spare time being active in the local community. He leads the Scout group and is the coach for the junior football team. In addition to this he and his dog, Hector, are PAT (Pets As Therapy) volunteers who make regular visits to the children’s ward at the nearby hospital and a number of nursing homes.

As you are now in the second month of your nursing programme Ngozi and Faith wonder whether you could answer some questions they have about becoming a nurse, because Ngozi is very keen to follow your example and study for a degree in nursing.

  1. Ngozi has found out that there are four fields of nursing and wants to know exactly what the differences are between them.
  2. Although Ngozi feels he has a wide range of life experiences, he does wonders whether he would be able to cope with the demands of being a nurse.
  3. Faith is very supportive of Ngozi’s plans to become a nurse and is very keen for him to apply, but is worried about how they will manage financially whilst he is studying at university and not earning any money. She wonders how she can find out more about this.
  4. Ngozi is unsure what the opportunities for him would be once he had completed his nursing course, as he is not certain he would want to work within a hospital environment.


  1. Ngozi has found out that there are four fields of nursing and wants to know exactly what the differences are between them. 

As Ngozi is aware, within the UK there are four fields of nursing, each being named after the patients which nurses in these fields care for most frequently. These four fields are referred to as mental health, child, learning disability and adult. Whilst there are many aspects of care within each field that reflect the speciality, there are also core elements which underpin the profession of nursing as a whole. So, no matter which field of nursing you work in, it is likely that you will undertake activities such as:

  • assisting patients with physical needs
  • counselling a patient or group of patients
  • supporting patients to recover or to cope with their needs more effectively
  • helping children and young people to manage their health by developing partnerships in care with families
  • delivering educational programmes to promote the health of a community
  • supporting an individual with a long-term condition, such as diabetes, to live independently.

It can be seen that nurses from all fields care for individuals of all ages and cultural backgrounds, who do not have to be sick. However, in considering the differences between the fields, there are certain elements to consider.

  • Learning disability nurses work in partnership with people with learning disabilities, their families and carers in a range of community, residential, and healthcare settings. Learning disability nurses require a range of knowledge and skills, which include good communication skills (including use of alternative communication approaches), assessment skills, person-centred planning skills and values grounded in equality, inclusion and human rights. The central roles include identifying and meeting health needs, reducing health inequalities and promoting better health outcomes which can be achieved through working as a community learning disability nurse, or within an assessment and treatment unit, a secure unit, a nurse therapist, or an acute care hospital liaison nurse.
  • Mental health nurses practise with people of all ages with mental health problems. They care for patients with a wide range of mental disorders using supportive methods to promote positive and therapeutic relationships, which focus on social inclusion, human rights and recovery. This aims to enable a patient to develop the ability to live a self-directed life, with or without symptoms, which the patient feels is personally meaningful and satisfying. The rates of mental health problems in prisons or in other secure services are much higher than the general population, so mental health nurses are often employed to provide direct care or to advise prison officers or other staff on how to respond to mental distress.
  • Children’s nurses care for individuals usually between the ages of birth and nineteen, and their families in range of different settings. They care for well children, promoting their health in the role of a school nurse for example, and for children with special physical or learning needs, mental health concerns or physical illnesses. Children’s nursing occurs in many settings, in a hospital, community, or in the child’s home and children’s nurses can work shifts, including nights and weekends or a more usual working week. Maintaining the normal daily routine is important, because children find being away from their usual environment distressing and disruptive to the life of their entire family. So, working in partnership with a family, empowering them to care for their child is central, as this enables independence and a return to normal routines.
  • Adult nurses normally work with patients from the age of 16–19 upwards, aiming to promote good health by treating patients who have may have acute or long-term health issues. With an ageing population adult nurses are finding their patient population is increasingly the elderly with complex multiple health problems along with the added challenge of dementia. Adult nurses need to be able to prioritize the care they deliver, using a range of skills to achieve this whilst working in partnership with the patient, the patient’s family, carer or friends and other healthcare professionals. Adult nurses provide a wide range of care to improve the quality of patients' lives, sometimes in difficult situations.
  1. Although Ngozi feels he has a wide range of life experiences, he does wonder whether he would be able to cope with the demands of being a nurse.

It is really good that Ngozi realizes that both becoming and being a Registered Nurse is challenging, but most nurses will say that their choice to join the nursing profession is one of the best decisions they have ever made. Studying on a nursing course is not easy, nursing is both physically and emotionally demanding. In real life nursing isn’t often what is shown in popular television programmes, plus a student nurse has to spend many hours gaining the knowledge and skills they will require to deliver effective patient care. Ngozi should talk to as many nurses as he can, from different fields, to hear their views and experiences. It would also be a good idea for him to become a volunteer at his local hospital or at a nursing home, as this would increase his knowledge about exactly what nursing is and what nurses do, before he decides whether it really is for him.

  1. Faith is very supportive of Ngozi’s plans to become a nurse and is very keen for him to apply, but is worried about how they will manage financially whilst he is studying at university and not earning any money. She wonders how she can find out more about this.

Faith is correct to want to find out more about this, as it is important to find out all about the financial implications of becoming a nursing student before deciding to apply for a place. It would be possible for Faith and Ngozi to find out details about the NHS Student Bursary Scheme and to obtain an estimate of the bursary available by visiting

If Ngozi was successful in gaining a place on a nursing degree he would be able to apply to the NHS Student Grants Unit for a means-tested bursary. The means-tested scheme operates alongside the NHS Student Bursary Scheme and can provide financial assistance towards Childcare Costs for students who use OFSTED inspected childcare facilities. In addition to this he and Faith should also apply to the Student Loans Company before Ngozi starts his course if they wish to ensure that they are later eligible to apply for a student loan. Further information is available from:

  1. Ngozi is unsure what the opportunities for him would be once he had completed his nursing course, as he is not certain he would want to work within a hospital environment.

Nursing today is far more challenging than ever, with patients presenting with far more complex healthcare needs. Healthcare reforms have aimed to put patients at the heart of the health service, there is a move away from all care being delivered in hospitals; patients are hospitalized for shorter periods, more care is delivered within the community and some care services are delivered by non-NHS organizations. Such changes have resulted in developments within the nurses’ role, as they now provide care previously delivered by a doctor, or can choose to specialize in a particular area of nursing practice, or become a researcher or lecturer. So, for Ngozi, no matter which field he decides he wishes to care for patients in, if he does not want to work within a hospital setting, there are numerous other settings where patient care is delivered, both in the UK or other countries. Ngozi would have the opportunity to decide whether he wanted to become active in nursing research, as a clinical research nurse or, after gaining experience in patient care and further education, he could become a nursing researcher within a university setting or a nurse lecturer.

Chapter 2

Case Study: Acting professionally, pg 49

During the second week of their nursing course, whilst travelling home on the bus Susie and Ellen discuss the last lecture of the day, which they found very boring and irrelevant. They really couldn’t understand why they needed to listen to what Kate Brown, the lecturer, was saying, and they didn’t think she was a very good teacher. When they get home they continue their discussion on Facebook, as they want to find out what other students on their course think, with Susie posting ‘Kate Brown has to be the most boring lecturer so far – she doesn’t even seem to know what she is talking about’, and Ellen adds, ‘have you seen her shoes?  They are so old fashioned they should be in a museum!!’

Three days later Susie and Ellen both receive letters requesting them to attend a formal meeting with the Head of their School.

  • What do you think is likely to be the reason for this request?


Susie and Ellen have been asked to attend a formal meeting with the Head of their School because they have failed not only to abide by the NMC (2011) Guidance on professional conduct but also their duty of confidentiality. Their Facebook postings do not treat the lecturer in question with dignity or respect and they are not upholding the reputation of their profession by addressing this issue through Facebook. In addition to this, in naming the lecturer they are breaching confidentiality.

All of these issues are very serious. It is likely that the Head of School will consider their actions in light of the NMC Fitness to practise regulations, questioning whether they are both fit to remain on the course. It is possible that, as Susie and Ellen are only at the very start of their nursing course, they may be treated leniently, and could be given a formal warning but allowed to remain on the course as long as they apologize to the lecturer in question and learn from this experience. If they had been more experienced nursing students, further on in year one or years two or three, acting in this manner may well have resulted in them being removed from the course.

Chapter 3

Case Study: Bina’s portfolio, pg 65

Bina is a first year mental health nursing student preparing for her first portfolio submission. Although her cohort has had a lecture on reflective writing, Bina is unsure about how to compose the 1000 word structured reflection she must include about her experience of developing a skill. She makes a start and after two hours’ writing feels confident about what she has written, as she has described her experience of giving her first intramuscular injection and explained how she felt when it happened. She finds an American internet site that describes how to give an injection and so cites this as a reference.

Bina is tempted to put the reflection straight into her portfolio but her academic advisor has asked to see it before submission. She emails it to him and two days’ later he sends it back with comments and suggestions all over it. He points out that Bina has not used a model of reflection and so has written something that is descriptive rather than analytical. He suggests a model by Rolfe et al. (2011) as it is simple to remember and use: What? So what? Now what? Although she has addressed the ‘what?’ as she has described what happened and how she felt, she has not addressed the ‘so what?’ or the ‘now what?’ He also points out that the evidence she has used is from an untrustworthy source. 

Bina feels deflated and struggles not to take the comments personally. However, as she only has two days before the submission deadline, she gets to work on using her academic advisor’s comments to improve the reflection. To address the ‘so what?’ she finds two up-to-date sources of evidence in the library that are on her recommended reading list for the course, which help her to understand better why her mentor had shown her how to prepare and give the injection using an aseptic non-touch technique and why she needed to ‘Z-track’ when she gave it. She thinks for some time about what she has learned from this experience that will inform her future practice to address the ‘now what?’ She realises that the understanding she has gained from giving the injection, from reading the sources of evidence retrieved from the library and from taking time to reflect have made her feel much more confident about giving her next injection. Bina also thinks she will be able to explain comprehensively the theory behind injection-giving when she is assessed on her next placement or if a patient asked her for this information. When she has finished checking her writing for spelling and grammatical errors, Bina cites her sources of evidence and the Rolfe et al. (2011) reflective model in her reference list, using the University guidelines.

Bina passes her portfolio submission and is delighted with the positive feedback she receives about the quality of her reflective writing. She makes a mental note to ask her academic advisor for advice earlier on when she prepares for her next assessment.

How does Bina’s experience compare to your own? 

Chapter 4

Case Study: Josh’s assignment, pg 60 

Josh was a first year adult nursing student. He had achieved the academic requirements for admission to his nursing programme easily, with A level grades of A, A, B in English, psychology and philosophy respectively. He approached the deadline for his first assignment with confidence, knowing how easily he had always found it to construct a logical, coherent argument on paper. The aim of the assignment was to explore the concepts of communication and therapeutic relationship-building in relation to a patient he had cared for. In preparing to write the essay, Josh found not just the recommended reading in the library but also several journal articles, which covered different aspects of the subjects.

Approximately four weeks prior to submission, Josh’s academic advisor emailed Josh to suggest a tutorial to discuss the assignment. At this point, Josh had not written much so could not see the point in wasting her time. He responded accordingly and said that he would contact her when he had more writing down on paper. However, time moved on and Josh’s essay was flowing well so he decided to submit without contacting his academic advisor again.

When Josh received his feedback he was astonished and furious to see that he had failed. He thought there must have been some mistake as he had cited more than thirty sources of information and raised some issues that none of the other students in his cohort had even thought to include. However, when he read through the marker’s comments he understood that although he had undertaken a high quality theoretical exploration and identified his patient in the introduction, he had not attempted to relate the evidence to his patient’s care and had not reflected on his own personal learning at any point. Josh realized that his academic advisor would have advised him about these omissions and he kicked himself for not making use of her support.

Josh addressed the marker’s comments well, having sought advice from his academic advisor, and achieved 83% for his second attempt. However, because it was a second submission his mark was reduced to 40% and he had to pay a £70 resubmission fee, which he could ill-afford. He was determined not to make the same mistake again.

How does Josh’s experience compare to your own? What can you learn from his mistakes?

Chapter 5

Case Study: Arthur Sampson, pg 72 

Arthur Sampson is eighty-four years old and lives independently. He has diabetes for which he receives daily insulin and to date he has been able to administer his own injection and maintain a balanced diet. His diabetes has, therefore, been stable. Recently, however, he experienced a respiratory infection which made him feel very unwell, lose his appetite and therefore experience hypoglycaemia. This resulted in his coming into hospital to both stabilise his diabetes and to treat the respiratory infection. He is now being considered for discharge and is very concerned that the hospital team seem to be suggesting that his recent hospitalisation means that he needs help managing his diabetes and that he will therefore need a district nurse to call. Apart from feeling as though people are trying to make him dependent Arthur resents this as he likes to go out and about seeing his friends and waiting for the district nurse to call will limit his freedom to do this. He has told the team that he is perfectly able to care for himself and that he takes full responsibility for this. However, the consultant has told him that they have a duty of care and need to make sure that he has support.

What ethical principles are being challenged in this case study?

How would you act if you were the nurse supporting Arthur’s care? 

Chapter 6

Case Study: Amelie, pg 85 

Amelie is 14 years old and attends the Walk-in-Centre alone. She states that she had unprotected intercourse with her boyfriend last night at a party and is worried about getting pregnant. She therefore asks if she could be given emergency contraception, but does not want her parents to be informed of her visit.

  1. What legal issues does this scenario encompass?
  2. Does Amelie’s age change how the nurse should respond to her care? 


This scenario encompasses issues of Consent and Confidentiality, but there are specific differences when children are concerned. In Scenario 2 in the chapter, there was a presumption that Joe was competent to make decisions concerning his treatment, but that the onus fell upon the healthcare professionals to overturn this presumption. For children below the age of 16, there is a presumption in law that they are not competent to make such decisions and that somebody should make them on their behalf (usually a parent or legal guardian). This presumption can also be overturned, however, but once again the healthcare professionals must be able to justify why they have done so.

The leading case dealing with this issue was that of Gillick v West Norfolk and Wisbech Health Authority [1985] 3 All ER 402 [HL], in which it was stated that ‘the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves a sufficient understanding and intelligence to enable him or her to understand fully what is proposed’. This principle has been given statutory authority in Scotland by means of The Age of Legal Capacity (Scotland) Act 1991, but remains a common law principle in England and Wales.

How healthcare professionals make an assessment of competence in a child is not entirely clear, although Lord Fraser (in the Gillick case) laid down some guidelines relating to issues of contraception:

            The healthcare professional must be satisfied that:

  1.  She understands the advice given to her.
  2. She cannot be persuaded to tell her parents (or allow the healthcare professional to tell them).
  3. It is likely that she will have sexual intercourse whether or not she receives contraception.
  4. Her physical and/or mental health might suffer if she is refused contraception.
  5. It is in her best interests to receive contraceptive treatment and advice, and this should be given without informing her parents.

In addition, the healthcare professional must satisfy him/herself that the child has fully understood the information and there needs therefore to be two-way communication to ensure that this has taken place.

Some have argued that the threshold of competence for children is much higher than that of adults, but a competent child is able to enter into a relationship of confidentiality and is entitled to expect the same rights as anybody else. A breach of confidentiality in this instance (i.e. by telling Amelie’s parents) would fundamentally destroy her trust in healthcare professionals and she would therefore be less likely to seek medical attention in the future.


Chapter 7

Case Study: Georgina, pg 127

Georgina was a student nurse who had significant problems with her academic studies throughout her programme, often failing her assignments at the first attempt.

In her first year she had been seen by one of the academic staff to discuss the fact that she had a high level of similarity in her assignment to one of her colleagues. After both students had been seen they admitted to working together on the assignment and agreed that there were many similarities in their work. The view of the academic staff was that there was evidence of collusion and the students had their assignment grades reduced to a bare pass. A lengthy discussion took place around the pitfalls of working too closely with colleagues on assignments and strategies to ensure that allegations of collusion did not occur in the future.  

During her second year Georgina was found to have extensively copied from a book in her assignment and had to attend an academic misconduct panel at the university. Georgina said that she had been having a lot of problems at home as her partner had left her and she was trying to manage caring for her two children who were under five years of age and attend university and practice. She had got behind on her work and was worried about failing her assignment and admitted that she had failed to reference the book appropriately. The committee decided to award the assignment with a grade of zero and Georgina was required to resubmit her assignment for a second attempt. She was referred again to the academic skills centre in the university and asked to complete the on-line plagiarism tutorial on the university website. Through discussion with Georgina it was clear that she had poor referencing skills and had failed to reference the work she had used correctly and also had trouble in summarising or paraphrasing work she had read.

Georgina was also asked whether she should consider taking a break from her studies but said that it was important to her to finish on time for the sake of her children.

In her final year Georgina failed her dissertation at the first attempt and when her second attempt was submitted it was found to have high levels of similarity with another student’s who had passed at the first attempt. Investigations were undertaken. Georgina initially first denied any wrong doing but when informed that unless there was evidence to the contrary the other student would be deemed to have colluded by giving her the assignment and be referred for misconduct, Georgina then admitted that she had borrowed a friend’s assignment without her knowledge when she had visited her flat one evening. Georgina was referred to the university Fitness to Practise panel who upheld the allegation of cheating. When the panel was informed of Georgina’s prior offences their decision was that she should be discontinued from the programme.

Critical Reflection

Review the NMC Code and identify what sections Georgina had breached.

Consider how you prepare for assignments. Have you ever been at risk of being accused of collusion or cheating?

What steps will you take to ensure that you would never be referred to an academic misconduct committee?

Chapter 8

Case Study: Abha, pg 137

Abha is a Child Health nursing student at the beginning of her programme. Nursing is not as she had expected and she has experienced the distress of the children she has cared for during her placements as very difficult to cope with. Abha has also found herself making unhelpful judgements about the parents who she has met during her first placement. Abha was hospitalized for long periods herself as a child and is wondering if her own experiences are impacting on her ability to cope with her initial experiences on her programme.

  • Who could Abha discuss her current feelings with?
  • What support is available at your university to help Abha ensure her personal experiences do not negatively impact upon her nursing programme?

Chapter 9

Case Study: John, pg 151

You are a student nurse working under supervision on an acute orthopaedic ward. One of your patients is John, a 30-year-old man who has a learning disability. During handover, you are given the information that John has Attention Deficit Hyperactivity Disorder (ADHD), and Autistic traits. He has difficulty with social communication, social interaction and social imagination. He lives with his family. His mother is his main carer. John has had minor surgery earlier on in the day to correct a Hallux Valgus (bunion). The nurse handing over John’s care reports that since his return from theatre, John has been settled and pain free. As yet he had not wanted to eat or mobilize.

During the handover period, John’s mother arrived on the ward. She has sought you and your mentor out immediately after handover to complain about the care given to John. She is visibly distressed and reports that John is distressed and in acute pain. Your mentor explains that the nurse handing over John’s care had communicated that John has been pain free since return to the ward.

She demands to know how the nursing staff have assessed his pain. Your mentor shows John’s mother the pain assessment tool that has been used. John’s mother responds that the tool is totally inadequate to assess John’s individual response to pain due to his communication problems and requests for a more appropriate tool suitable to John’s needs to be used. You explain that this is the only pain assessment tool used on the ward. John’s mother becomes agitated and complains that the ward staff are not competent to provide the care that John needs.

  1. What do you think could be the main issues/problems regarding John’s care and experience?
  2. What immediate actions could you take to improve the quality of John’s care and experience?
  3. What actions could you take to influence innovative change using a bottom up approach?

Suggested solutions

  1. What do you think could be the main issues/problems regarding John’s care and experience?

The main issue is that John and his mother have not had a positive experience of care. There are a number of factors that will, potentially, have impacted on their experience of the treatment and care they received. Within this scenario, there appears to be little evidence of the availability or application of any national regional or local standards or policies to provide a framework for the development of good practice by staff for the delivery of quality services to people with a learning disability in the acute setting. 

Barriers to good practice, concerning John’s care, could have been influenced by discriminatory attitudes, values and beliefs of staff regarding people with a learning disability. Alternatively, staff may have had little education or training regarding caring for people with a learning disability or people with challenging behaviour and communication problems. In addition, although a pain assessment tool has been used it has been an ineffective tool in assessing John’s pain due to his difficulty with social communication, social interaction and social imagination. The impact of not recognizing and managing John’s pain has not enhanced John’s recovery from his surgery.

  1. What immediate actions could you take to improve the quality of John’s care and experience?

Your first action should be using good communication skills. By listening to John’s mother you will be able to understand not only what went wrong with the quality of John’s care but what interventions you could put in place immediately to improve his care.

In order to enhance John’s care and recovery you will need to pay attention to addressing his pain assessment and management. This should involve working in partnership with John’s mother to adapt the current pain assessment tool to take into account John’s difficulty with social communication, social interaction and social imagination. This short-term reactive approach to change would demonstrate compassion about the care that John has received by developing a relationship based on empathy and respect.

  1. What actions could you take to influence innovative change using a bottom up approach?

You could research national, regional and local best practice guidelines based on best evidence that address the need for reducing inequalities and monitoring safe, effective, patient-centred, timely, efficient and equitable quality care for adults with a learning disability, communication difficulties and challenging behaviour. These policy drivers could provide you with a vehicle to communicate the need for change to your mentor. They would also help you to communicate what could be changed, how it could be changed and who would be best placed to implement the change. You could also investigate whether there is a currently a named acute learning disability liaison nurse or a Learning Disabilities nurse co-ordinator role employed by the trust to provide support for ward staff to develop service improvement change. By researching the drivers for change you could suggest strategies for improving the care and experience of adults with a learning disability, communication difficulties and challenging behaviour. Your strategies would need to consider include using appropriate service improvement tools to:

  • Develop patient forums for developing and evaluation of services
  • Develop care pathways which includes the pre-admission and discharge planning, a risk assessment and use of a patient passport
  • Develop the provision of education or training/resource packs and address potential values, attitudes and beliefs of staff
  • Develop and implement appropriate evidence-based pain assessment tools  
  • Develop appropriate qualitative and quantitative feedback measurements to assess the impact of change and to drive forward sustainable improvements.

This approach to change management would demonstrate that you have developed some effective leadership competencies and behaviours which could impact on motivation and energy to plan, implement, evaluate and sustain change which will impact positively on the care and experience of people with learning disabilities or people with challenging behaviour and communication problems.


Chapter 11

Case Study: Bruno and Anna, pg 179

Bruno and Anna moved from Italy to the United Kingdom (UK) five years ago. Bruno works as a senior manager in a large international finance corporation. Anna gave up her job as a teacher when she moved to the UK. Bruno and Anna speak English fluently. They have a six-year-old son, Luca, who attends the local primary school. Luca is bilingual and is a very happy boy who has made friends with several of his classmates. He enjoys sports and attends after school activities several times a week. Luca has recently been diagnosed with asthma. Anna has discovered that she is pregnant but is anxious as she has just celebrated her 41st birthday and is concerned that she has a higher risk of giving birth to a child with Down’s Syndrome. Bruno’s mother, who is 70 years old, also lives with the family and she is becoming increasingly forgetful and argumentative. Bruno has made an appointment with the general practitioner in order to discuss his concerns in relation to his mother’s health. Bruno and Anna have no other family members living in the UK but have established a network of close friends.

Reflective Practice

Reflect on the above scenario and identify what you think are the main issues from your field of practice. You may choose to utilize a model of care in order to focus your reflection.

Discuss these issues with your mentor/peers and decide how you would ensure the delivery of effective care.

No specific response has been provided as a variety of field specific responses is anticipated.

Chapter 14

Case Study: Jag, pg 216

My name is Jag, I am sixteen years old and recently I have been diagnosed as having diabetes. I had been feeling very tired and unwell for some time and my mum put this down to the fact that I had been growing a lot recently, doing a lot of sports and also working hard at school for my exams. However, when it seemed to be going on she decided that I needed to go to the doctors. They did some tests and also sent me to the hospital where I was told that I had diabetes. I was really shocked when they told me this because I thought that diabetes was something that only happened to older people who were overweight. I was also really scared as I thought it was going to stop me doing a lot of things I enjoyed. I didn’t want to be seen as different or ‘ill’. However, the specialist nurse saw me both on my own and with my mum. She explained to me the type of diabetes I have and also what it would mean to me day to day. She explained in a way that I could understand but didn’t treat me like a child which was good: she stressed that I would need to take responsibility for managing my condition but there would be a lot of support for me. As I like being active she explained to me the importance of making sure that I eat the right foods, monitor my blood glucose levels and told me what to do if the levels go too high or go too low. Like most teenagers I like using my mobile phone a lot so we sorted out together how I could use my phone to set reminders to do things like checking by blood glucose and taking my insulin. With my mum she also explained these things and told her what she needed to do to help support me. This was really helpful as although it was good to be treated as an adult it was also good to know that there was someone else at home who understood what I needed to do. So far I have managed quite well – although it has meant a lot of changes the fact that things were explained to me has helped a lot. Also I know that if at any time I have got any questions or concerns I can always get in contact with the nurse as she gave me her phone number and email address and I have these on my mobile phone. It feels as though we have a partnership which helps me deal with my diabetes.

How do you think this nurse has empowered her patient?

What elements of care could you emulate in your own practice? 

Chapter 15

Case Study: John Smith, pg 230

John Smith is a 65-year-old MH patient who is admitted to a medical ward with a chest infection. John has Parkinson’s disease and usually lives at home with his wife; he is usually mobile with the assistance of a frame although this is currently limited due to him feeling so unwell.

On admission the nurse (Sam) greets John and his wife, who accompanies him. Sam talks to John and explains what is going to happen in terms of his admission and assessment process over the next few hours. Sam orders John’s medical notes and then gathers all the equipment she will need to assess him, closes the curtains around John and sits next to him. Sam asks John why he thinks he has been admitted to the ward and asks what has happened today leading up to this. John explains that he has been feeling unwell over the past three days and has today developed a productive cough and has felt hot, they visited his GP who arranged for John’s admission to the ward. John becomes breathless after he has talked so his wife also provides some information, to which John nods to in agreement. A letter from the GP accompanies John, Sam reads this which confirms the events already explained as well as providing additional information on John’s usual drug regime; past and present medical conditions. 

Sam explains it would be useful to perform some basic observations on John, which he agrees to and she measures his temperature, pulse, respiration rate, blood pressure. As Sam put the blood pressure cuff on John’s arm she notices he feels warm to touch and has a reddened face, his temperature recording confirms he is pyrexial (an elevated temperature). Following a full assessment of John, Sam identifies he has a pyrexia and is breathless. Sam is able to discuss these needs with John who agrees to feeling hot and short of breath, rather weak, although feels well otherwise. The goals set aim to reduce John’s temperature to below 36.8ᴼC and for him to feel comfortable and for John to have a respiratory rate of between 12–16 breaths per minute; with oxygen saturations >94% and for him to state he does not feel short of breath. Sam prescribes and implements actions which will help achieve these goals, ensuring the actions are realistic and evidence based. After 24 hours of care, John feels much better; his temperature and respiratory rate have reduced to within normal limits although he states he feels more breathless than usual. Sam and John discuss John’s progress and decide to evaluate in another 24 hours.   


Highlight in this case study the aspects which pertain to assessment, planning, implementation and evaluation. Think about how Sam has accomplished APIE, involving John and his wife, and consider how you might have done it differently.   

Chapter 16

Case Study: Rob, pg 241

Rob is twenty-nine years of age and he lives in his own flat with 24-hour support. He has a moderate learning disability but has major difficulties with communication, e.g. he is unable to express himself verbally and can understand basic home language only. He has managed to learn a few signs but unfortunately most of his carers are unable to understand them. Rob enjoys the company of others and participates well in his local community. He does not usually present with any challenging behaviour but on the odd occasion may show some aggression, which his carers are at a loss to understand. One Tuesday afternoon Rob’s carer is getting ready to take him on his usual trip to the local college. Unfortunately and unbeknown to the carer Rob isn’t feeling too good. The enfolding scene is as follows:

  • Rob has a headache.
  • Rob does not have the communication skills to be able to tell his carer he has a headache.
  • Rob’s carer asks him to get his coat on to go out.
  • Rob usually loves to go out – but Rob has a headache, he doesn’t feel like going out.
  • Not only can Rob not tell his carer he has a headache, he also can’t tell him he doesn’t feel like going out because of the headache.
  • The carer persists in asking Rob to get his coat on, raising his voice a little.
  • Rob wants the carer to go away, he is getting anxious and his head is now throbbing.
  • The carer persists in asking Rob and then moves towards Rob.
  • Rob can’t stand any more so he does the only thing left to him, he lashes out at the carer.
  • The carer shouts ‘No’ and tells Rob in no uncertain terms that he is not going anywhere now. The carer puts the coat away shouting at Rob that he is not allowed to go out.
  • Robs sits back to relax his aching head.

The next day Rob’s headache had gone, he felt much better and wanted to go out. He got his coat and took it to his carer as this usually prompted the carer to take him out. The carer firmly informed Rob that he was not going anywhere, he wasn’t allowed to and that he should go and watch television. Rob did not want to watch television, he wanted to go out. His coat was taken away from him and the carer left the room. Rob was annoyed, he felt it was unjust to stop him from going out. Rob ran after the carer to make him understand and grabbed his coat from the carer, twisting the carer’s arm. The carer, in pain, raises his voice to Rob and tells him to go to his room. Rob runs to his room and slams the door. The carer then locks the door to protect himself against further harm. Rob proceeds to kick his wardrobe and throw everything from his dresser onto the floor. 

The daily report by the carer read: ‘’Rob is completely out of control, his behaviour is becoming unacceptably violent. Unprovoked attack on carer. Incident report completed. Telephone call to Dr Blake to put him on medication for his challenging behaviour. He will visit tomorrow at 2 pm.’ 

What went wrong in the communication process between Rob and his carer?

Looking back at the chapter on basic communication skills what strategies could have been put in place that might have prevented this outcome?

Chapter 19

Case Study: Mary Davis, pg 287

Mrs Mary Davis is a sixty-year-old woman with mild learning disabilities who has been admitted to a general ward after a road traffic accident. She suffered an injury after hitting her head on the steering wheel while coming home after a night out on the town. The car she was driving crashed into a tree and she was later found to be over the drink drive limit. Mary is from a close knit community and is very assertive in expressing her needs. She did not really want to be admitted to hospital but her family insisted that she stay in for at least one night. The other patients did not take to her as they felt she was too overbearing. She woke early in the morning with a headache and painful shoulder and neck. She made her way to the nurses’ station to complain to the nurses about the noise from the other patients keeping her awake. There was a difference of opinion over who was making the noise as the other patients complained about Mary’s behaviour. Mrs Davis insisted on being moved to another ward or side room. There was a shortage of beds that day and patients were waiting to be admitted from the Accident and Emergency department and other hospitals. At breakfast Mary did not like the breakfast and threw it on the floor still complaining about her pain. The Duty doctor was called and Mary was prescribed a muscle relaxant and stronger analgesia on regular prescription for the next 24 hours instead of her as required milder analgesia. She went off to sleep later that afternoon. Staff nurse, Peter Williams was on duty from 8am–4.30pm.

Activity: Critical Thinking

Compare and contrast entries A and B regarding the above case study and decide which one most meets the NMC (2009) guidance on record-keeping. Make a note of both good and bad points . 

Entry A





The patient got up in a foul mood and was very abusive to staff. There was no good reason for this or why she threw her dinner over the floor other than she has a learning disability. The other patients dislike her and have asked me to move her off the ward as she scares them. In the afternoon she was given her prn meds as she was still very moody and not at all remorseful for her actions.




Entry B



















Mrs Davis awoke at 0430 hours and got out of her bed and walked to the nurses’ station. She alleged that she had been woken up by two of the patients snoring and that ‘they were doing her (she used F word) head in’. She also stated that she wanted to be moved to a (she used F word) side room so that she can get some sleep. It was explained to her that there were no free side rooms at present and she would have to wait until one became available but that would be dependent on other patients needs. 


At approximately 0830Hours Mrs Davis threw her breakfast plate, full of food onto the floor shouting that her (she used F word) head was killing her. The duty doctor was called at 0900Hours


Duty doctor arrived at 1200 hrs midday and prescribed Ibuprofen 400mg and Diazepam 2mg every 8 hours a day after examining her (see medical notes for full account). He felt that Mrs Davis had a neck spasm due to the accident and also poor sleeping posture although she insists it was due to the noise made by two other patients. These two patients blamed Mrs Davis for the noise and disruption on the ward. At 1430Hours she was given her medication of Ibuprofen 400mg and Diazepam 2mg (see drug chart for full prescription details).


At approximately 1500Hrs Mrs Davis rested on her bed, appeared pain free and eventually went off to sleep.

Susan Harries

Night sister




Peter Williams

Staff nurse


Peter Williams

Staff nurse





Peter Williams

Staff nurse



You should have noticed that entry A was not very good in terms of accuracy, errors and providing personal opinion. There were no times provided and just two letters in terms of staff identification. The most concerning aspect was the negativity towards Mrs Davis by the nurse making the entry. It was very one-sided, personalized and seemed to imply that Mrs Davis was not very popular and was very troublesome possibly due to her learning disability. If you contrast this entry with entry B then a more balanced approach has been adopted. Dates, times and the individual nurse making the entry are clearly identifiable. The events are put into order and a number of entries are made during the span of the nurse’s shift. The nurse Peter Williams has provided factual information and has resisted the temptation to take sides and give an opinion. He has also included swearing used but has stopped short of the actual spelling out of the full term. Some clinical areas insist on this and others do not and are content for just an F word was spoken. There is an assumption that everyone knows what F word was spoken. However, even with this entry you are left wondering what other care has been provided other than the incidents and visit from the doctor. For example, did Mary have another breakfast or drink? Was she seen by a physiotherapist or pharmacist? 

Considering the reason Mary was admitted to hospital was due a car accident, would you know if this was Mary’s usual behaviour or could it be a sign of a head injury? Both record entries do not tell us what observations had been undertaken or her current neurological status. There is also no indication of any other care she actually received besides what has currently been recorded. Both records fail to identify any pain assessment despite the fact Mary complains that her head is ‘killing her’. Can you tell from these records Mary’s problems and responses to interventions? Finally, as Mary has a known learning disability, there is no recorded evidence that her capacity to make decisions has been assessed.

Remember that if it is not recorded it is deemed not to have taken place.

Chapter 20

Case Study: Tina, pg 302

Tina is a twenty-six-year-old female who attended the doctor’s surgery with her four-year-old daughter, Flora, for her pre-school booster immunisation. On arriving at the clinic, Ben, the nurse, commented to Tina that she did not appear well and asked if she was OK. Tina stated that she woke up that morning with left-sided lower abdominal pain and had vomited once. She thought she may have a ‘tummy bug’.

Although the appointment had been made for Flora to have her pre-school injection, Ben focused his attention on Tina as he felt that something was seriously wrong. A medical history and physical examination of Tina’s abdomen was undertaken. They revealed that Tina had an appendisectomy at aged 17yr. and that she was on the combined oral contraceptive pill. Tina said she had not missed any pills and was in a long-term sexual relationship. A urine sample was taken to test for possible infection and to exclude pregnancy. The test showed no signs of infection and the pregnancy test was negative. Tina’s vital signs were Temperature 37.1, Resps 20, BP 146/88, Pulse 108 (regular). Tina experienced severe pain when the left lower aspect of her abdomen was palpated.

Ben made an urgent referral to the hospital as he felt Tina could have an ovarian cyst or ectopic pregnancy. At the hospital Tina’s Beta HCG was positive and a transvaginal ultrasound confirmed an ectopic pregnancy.

  • How did Ben make the decision to refer Tina to the hospital?
  • Reflect on a nursing situation where you made a decision.
  • What factors influenced your decision? Was it based on objective tools, evidence or on your personal judgement and beliefs?


Chapter 21

Case Study: Mr Patel, Jay and Craig, pg 318

Wheatley, a small village in rural Oxfordshire has an amateur rugby team, comprised mainly of regulars from the Kings Arms public house. One evening, after practice, Mr Patel, the coach and some of the players start talking about men's health in relation to prostate and testicular problems. There seems to be some confusion about the different disorders, the risk factors and ages at which these occur.

Mr Patel says he is worried because at 70 he is beginning to have trouble wanting to urinate but not being able to 'go' when he gets to the toilet. He thinks this means he has cancer. Jay Brown at 19 says he thinks he will not get testicular cancer because, like prostate problems, this is an 'old man's disease'. His friend Craig, who is 20, shyly reveals that he has had a swelling 'on one side' for three months and has told no one because he is afraid it might be cancer. Mr Patel tells him it is normal and nothing to worry about.

None of the men are correct in what they say.

  • How could health promotion be used in this setting? What resources and methods would you suggest could be used to raise awareness of these conditions?
  • What if these conversations were taking place in a residential home for men with learning disabilities. How would you adapt the health promotion project to raise awareness of these health issues in this setting?
  • Imagine children having a similar conversation with various misunderstandings and inventions. How would you adapt a health promotion project to meet their needs?


Chapter 22

Case Study: Rose, pg 331

Rose is a fifty-six-year-old lady who has a number of physical health issues which over the years have impacted negatively on her mental health. She has low self-esteem and has been addicted to lorazepam for over 25 years and is currently being treated for depression. Her physical health problems include arthritis, asthma, obesity, heart disease and most recently psoriasis. On average she takes about six different medications each day for these ailments as well as being a moderate smoker. She does not like taking medication and feels that some of drugs interact and make her feel worse. Both her grown-up children have left home and she has a carer Josh who is a nineteen-year-old man with Aspergers syndrome. He seems to enjoy spending time with her and running errands, cooking and doing the shopping. He is there most days even though he does not get paid for all the hours. On occasions Rose looks after her grandchildren, when their mother has to work late or goes out for the evening. She looks forward to seeing her grandchildren although Jack her grandson is very demanding as he has recently been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). In the past Rose suffered from agoraphobia but managed to overcome this with the help of a community mental health nurse who developed a good rapport with her. She does not really get on with her new mental health nurse and has been asking Josh to do more and more errands and she now hardly ever leaves her flat. This is due in part to her psoriasis which has spread to her face. When she has felt able to venture outside, she has been subjected to verbal and physical abuse by local youths who make fun of her physical conditions.

  1. What do you consider the safeguarding issues to be?
  2. What would be the short- and long-term safeguarding issues that needed to be addressed?
  3. What do you feel about the suitability of Josh being Rose’s carer?

Suggested Solution

  1. There are a number of safeguarding issues with this case study. There are the obvious abuses such as Rose being subjected to abuse in the locality. There are also safeguarding issues with regards to her health with the use of polypharmacy (use of many medicines). Each medicine is being used to address a single condition but the combination may be doing overall harm to both her physical and psychological health. This can be a problem in health care as specialists or practitioners treat individual parts but never the whole. There are also potential safeguarding issues with two young children being cared for by someone with obvious health issues. One of the children has ADHD so would be a challenge for any carer let alone someone with these many health issues.
  2. Some of the short-term safeguarding approaches would be to address the community issues. A community police officer could be contacted to have a word with the youths and support from neighbours could be sought. A medication review would need to be taken as a matter of urgency to ensure that medications were not interacting with each other and making matters worse for Rose. She may need to make compromises in terms of the conditions that can be treated. For example, she may be able to have acupuncture for pain rather than painkillers for arthritis. A careful assessment of risk for the child minding activity would need to be undertaken or additional advice or support provided to both Rose and the grandchildren’s parents. Longer-term strategy would involve building up Rose’s self-esteem and confidence in order to improve her mood and limit the reoccurrence of her anxiety state in going outdoors. Remember that safeguarding is about being proactive and empowering the client and carers/family. Obviously, her weight would need to be reduced in order to potentially make some of her physical health conditions better such as asthma, arthritis and heart disease. It would also help in reducing the risk of developing other conditions such as diabetes. Improvements in these areas may well have a knock-on effect of improving mood. 
  3.  Some of you may have had real concerns about Josh being Rose’s carer as he has Aspergers syndrome. It is important to see beyond this label and diagnosis and make an objective appraisal on his effectiveness. There are many people with disabilities who make a significant contribution to society and often their biggest limitations are the negative opinions and low expectations of members of the general population. Josh will have some difficulties (as we all do) particularly with social interactions but in some circumstances this can be viewed as a positive rather than a negative. As some individuals on the Autistic spectrum have difficulties understanding social rules of interaction they often do not understand why people develop prejudices against others. For example, they may not pick up on the non-verbal signs of prejudice or engage in anti-oppressive behaviour. They would need to be specifically taught to hold negative views about others when most of us pick this up incidentally from others as we are socialized into developing our own values and beliefs about the world. People with disabilities can teach us a great deal on how to value others if we are prepared to listen and act on what they tell


Chapter 25

Case Study: Angus, pg 404

Angus is a seventy-eight-year-old man who used to be the presenter of a very popular, iconic radio show, and ended up owning his own radio station. He now resides in a retirement home with fellow entertainers, but lives within his own world, endlessly reciting memories of his celebrity past. He has experienced periods of severe depression over the last ten years, for which he has taken medication and during the last five years his physical health has gradually deteriorated with a history of poorly controlled non-insulin dependent diabetes (diet controlled) and hypertension. In the last six months he has been admitted twice to an acute hospital with cardiac failure.

Angus finds it difficult to follow the diet he knows would assist to control his blood sugar, saying,

‘…pleasure is so important in life. Good food is a necessity! This is, of course, along with a decent bottle of claret to get me through the day. Wine, women and song have helped me to get to where I am – but these days I can only manage the wine… Then there is a jolly good bottle or two, of champagne to celebrate the weekend. I plan on ending my days enjoying the things that are special to me…’

Angus has tried to quit what he refers to as a ‘40-a-day, or sometimes a few more, smoking habit’ numerous times, but many of his fellow retired entertainers smoke, and he finds it difficult to say no.

He is being monitored by daily weight and b.d (twice daily) blood glucose monitoring.

  • Why would daily weights be used to assess Angus’ fluid status rather than a fluid chart?
  • How can it be ensured that there are no long-term injuries to Angus’ fingers when he is having frequent blood glucose samples taken?

Case Study: Kevin

Kevin is a seventy-year-old gentleman with known moderate heart failure. He retired five years ago following 45 years working as a train driver. Since his retirement his health has gradually deteriorated with a medical history of poorly controlled non-insulin dependent diabetes (tablet controlled) and hypertension. In the last six months he has been in hospital twice with heart failure.

Kevin finds it difficult to control his diet, as he admits he likes his food and a few beers at a weekend. He has tried to quit smoking numerous times, but his wife and most of the family smoke, so he relapses quickly.

Kevin  who is on daily weight and b.d (twice daily) blood glucose monitoring at home, has arrived at the GP surgery for a check-up. You are asked to educate John on the importance of daily weights and to check his knowledge of how to take a blood glucose measurement.


Explain to Kevin why daily weights are important in managing his fluid status and how to monitor them effectively.

In heart failure the heart is impaired as a pump. If there is an increase in fluid volume the heart function deteriorates further causing an excess of fluid in the lungs and tissues. Explain to Kevin that steady weight gain over a few days can indicate fluid retention which may cause him to become acutely unwell, necessitating a hospital admission. Ask Kevin to weigh himself each morning, after waking and urinating, but before breakfast. Heart failure specialist nurses call it the 3 Ws, Wake, Wee, Weigh. If there is a weight gain of over 2–3lbs (1–2kgs) over 3–5 days advise Kevin to contact his heart failure nurse as his medication may need altering. A sudden weight change of more than 5lbs over or under his normal weight means he needs to contact his GP immediately.

How can Kevin  ensure that he monitors his blood glucose accurately?

Advise Kevin to test his blood glucose before breakfast and before tea on one day and then before lunch and before bed on the next. Then continue to alternate these testing times.

If he still drives a car then again he should test before getting behind the wheel to ensure that his blood glucose level is above 5mmol/l.

After the acute episode he could reduce testing to daily and alternate all four times of day. Explain that only testing before breakfast will lull him into a false sense of security as fasting levels are normally the lowest of the day.

Ask Kevin to follow these steps below to ensure accuracy of blood glucose testing at home:

Wash hands with soap and water and dry thoroughly prior to test. This is to ensure that your hands are free of any trace of sugar/glucose, which could lead to a falsely raised result. DO NOT use baby wipes, alcohol gels, etc. to wash hands as these also impair blood glucose results.

  1. Remove a test strip from its container and close the lid tightly.
  2. Insert a test strip into the meter until you hear a beep and the meter turns on.
  3. Insert a lancet into your finger pricker device and adjust the lancet depth to a comfortable penetration level – start at 2 or 3 and adjust accordingly. For tougher skin dial to a higher number.
  4. Place finger pricker firmly against the edge of your finger, press the plunger/button until you hear a click. Remember to only use the edge of your fingers, to rotate the sites for testing and to avoid the thumb and forefinger.
  5. Allow 10 seconds for site to bleed, if more blood is needed for testing milk the finger from base to tip.
  6. Touch the blood drop to the front edge of the window of the test strip. DO NOT put blood on top of test strip.
  7. The meter beeps when enough blood has filled the test strip.
  8. The test result will appear on the display.
  9. Record the result in blood glucose monitoring booklet and act according to his instructions if blood glucose outside of target range.
  10. Dispose of used test strip and lancet in sharps bin.

Chapter 26

Case Study: Kevin, pg 418

Kevin is a sixteen-year-old boy diagnosed with Sickle Cell Disease and has attended his local A&E with his mother complaining of pain due to vaso-occlusive crisis. His mother says that he has been experiencing pain over the last few days in his back, chest and both lower legs. Kevin has been verbally uncommunicative since birth due to cerebral palsy but his mother explains that he has been lying around the home a lot, moaning when touched and on mobilization and that today his breathing is noisy and appears difficult. His mother has been giving him Ibuprofen and hydroxyurea as directed by his medical team but Kevin seems to be getting worse.

On examination Kevin is of normal weight, appears quiet/withdrawn, is pyrexial (temperature is 37.2ᴼC) and has an increased heart rate. His knees are hot to the touch and when examining him Kevin moans loudly and tries to push the nurse away.

  1. What are the immediate and long-term health concerns for Kevin? 
  2. What are the priorities in Kevin’s care? 


  1. Pain assessment: discuss with Kevin’s mother how he usually demonstrates that he is in pain and what his usual treatment regimen is.
  2. Acute Pain Management: administer analgesia as prescribed. Involve acute pain service to establish an effective method of maintaining pain relief.
  3. Involve multidisciplinary team (medicine, haematology, paediatric, nursing, Acute pain service, physiotherapy, pharmacy, social work and psychology).
  4. Involve physiotherapist for chest physio. Discuss with Kevin’s mother any non-pharmacological pain management strategies that they use.
  5. Involve social work for assessment of family coping, financial support for medications at home.
  6. Chronic Pain Clinic referral for long‐term pain management plan to prevent frequent admissions.
  7. Psychological therapy and physical therapy for exercise programme 

Chapter 28

Case Study: Mrs Ahmed, pg 461

Mrs Ahmed is sixty-seven years old and suffered a stroke three months ago which left her with a left-sided weakness, although she remains independent and is able to mobilize around her house and small garden with the aid of a stick. Her family drive her to see relatives once a week and they do her shopping. Good quality frozen meals are delivered fortnightly and she can make snacks and cups of tea, but normally spends most of her time in an armchair watching television or listening to the radio.

Mrs Ahmed is 5ft 4” and weighs 9st having lost 2 stone since the stroke. In the past two weeks she has been feeling unwell with a cough and has not been eating much or going out. Two days ago she was unable to get out of bed without help and the GP prescribed oral antibiotics as she had a pyrexia of 38oC, pulse 90 beats per minute, blood pressure was 120/80, and she was perspiring. Her cough has become worse and she is expectorating green sputum.

Her most comfortable position in bed was sitting up with the aid of three pillows, a position she was reluctant to move from as other positions, such as lying on her side, increased her coughing. She had little appetite and was drinking fluids only when encouraged by her family.

Mrs Ahmed refused to be admitted to hospital, insisting that she wanted to stay at home, so she is being cared for by her family with support from the District Nurse (DN). When the DN inspected her skin she found a wound on the left side of her sacrum. It was a shallow wound with the appearance of a ruptured blister. The wound measured 3x4cm, her skin was red and shiny for approximately 3cm around the wound. The sheets were soiled with exudate from the wound. Mrs Ahmed did not complain of pain in her left sacrum. The right side of her sacrum was red and remained red when light finger pressure was applied by the DN.

  • The DN has found that Mrs Ahmed has two pressure ulcers on her sacrum. What category would they be according to the EPUAP (2009) categories?
  • Mrs Ahmed is pyrexic and her skin is constantly damp from perspiration. How might this moisture contribute to skin damage and how would you protect her skin from further damage?
  • Why is it important that Mrs Ahmed has enough food and fluids? What would you do to encourage her to eat and drink?

Case Study: Mr Owusu

Mr Owusu is thirty-six years old and has Down’s syndrome with significant learning difficulties. He is also hearing impaired and often removes his hearing aid, is morbidly overweight and has type 2 diabetes.

His blood glucose levels were erratic for several years but recently this has become under control with very careful monitoring of his diet. Mr Owusu lives in a community home and tends to walk around, either indoors or around the grounds, barefoot. The staff are not concerned about him doing this because, even when walking on a stony path, he does not seem to feel any discomfort.

Yesterday a carer noticed some blood on the floor when Mr Owusu walked past. On examination Mr Owusu was found to have blood seeping from the ball of his foot. It was difficult to see where this blood was coming from due to layers of very dry, hard skin. A plaster was applied and Mr Owusu was advised to rest. The next morning the foot smelled malodourous and the skin on one area of his foot was red and felt ‘boggy’ when touched.  The carer also noticed that Mr Owusu was very pale, sweating and felt hot to touch.

The GP was called and she spoke to the diabetic foot clinic at the local hospital. The community home staff were very surprised when they were asked to take Mr Owusu to the diabetic foot clinic straight away.

  • Why might Mr Owusu have been able to walk on the stony path without feeling discomfort?
  • Why did the GP arrange for the patient to be seen immediately?
  • What will be done about the hard skin (callus) at the hospital and why?
  • How can Mr Owusu be helped to protect his feet?

Chapter 29

Case Study: Abeeku, pg 489

Abeeku is seventy-nine, he has dementia and is cared for by his extended African family. He is not able to communicate verbally and is frequently agitated, which he expresses by spitting and biting. Abeeku was admitted to hospital for further assessment of his condition following a series of falls at home. He prefers to stay in bed, but frequently slides down the bed and needs help to sit up again. You have noticed that he becomes distressed and agitated when he see the nurses preparing to sit him up, which they do by grasping him under both his axilla and dragging him up the bed.

  • How would you respond if you witnessed this event and were asked by the staff to help move Abeeku in this manner?
  • Why do you think Abeeku becomes distressed and agitated when assisted to move?
  • What solution can you offer to improve Abeeku’s care?


Chapter 30

Case Study: Marjory, pg 515

You are on your first day of a new placement. Marjory, one of the patients, suddenly starts coughing and she looks distressed and slightly panicked. One of the other patients shouts that you need to go and help Marjory.

  • What do you need to clarify with Marjory?
  • How would you initially assist Marjory?
  • If your initial care was unsuccessful what physical interventions could you provide?
  • If Marjory was to lose consciousness how would you continue her care?  

Chapter 32

Case Study: Lachlann, pg 553

Lachlann has just been admitted to your ward. The lunch trolley was removed from the ward an hour ago. Lachlann tells you that he has missed lunch and you are aware that he is diabetic, taking oral hypoglycaemic medication.

  • Thinking about your most recent placement area, how would you have got an appropriate lunch for Lachlann?
  • If Lachlann’s relatives had brought lunch in for him would you be allowed to re-heat it in a microwave?
  • How should food for patients be stored?

Chapter 34

Case Study: Daisy, pg 592

Daisy is twenty-seven and is a patient on an orthopaedic ward. She has been on strict bed rest for the last three days following surgery on her back. Daisy normally washes her hair every day and says that not being able to do this is making her feel ‘really unclean’, because it looks ‘greasy, messy and dirty’. Daisy has shoulder length hair, which has been in a plait since her operation, which now looks untidy, greasy and lank. Daisy’s family have brought her favourite hair shampoo, conditioner and styling products, plus her brush and comb in to the ward and Daisy has asked whether her hair can be washed today.

  1. What actions would you take before agreeing to wash Daisy’s hair?
  2. What equipment would you need to wash Daisy’s hair?
  3. How would you wash her hair whilst she is on bed rest and how should it be cared for on a daily basis?


  1. Before agreeing to wash Daisy’s hair it is necessary to ensure that doing this will not cause any potential problems following her recent surgery, that she is able to move her neck freely and tolerate the procedure, without being in pain.
  2. You would need the following equipment to wash Daisy’s hair
  • Bed hair-rinser
  • towel x3
  • large incontinence pads
  • Daisy’s shampoo, conditioner and styling products
  • brush and comb
  • bowl x2
  • warm water
  • jug
  • mirror
  • hairdryer if local policy allows
  1. Daisy’s hair should be washed following the ‘Step by step clinical skill: Washing a patient’s hair (in bed)’. As Daisy is being cared for in an acute ward setting it is likely that you will be able to arrange her bed-space with minimal effort to enable you to follow the procedure and set the height of her bed to care for your back.

Caring for Daisy’s hair on a daily basis involves brushing and combining it daily, plus other times as required, styling it as she desires and shampooing it as needed to ensure it remains clean. Brushing and combing Daisy’s hair should be part of her routine care, as this will not only make her feel better but also stimulates circulation, distributes natural oils evenly and removes dust. Always handle her hair gently when brushing and combing, if the hair is thick divide it in to sections and work on one area at a time. Observe the appearance of her scalp and hair whilst you are doing this and always clean the comb or brush after using them, remembering only to use her brush and comb, never to share.

Chapter 37

Case Study: Adrianne, pg 645

You are working with your mentor, Adrianne, on a medical ward in a hospital, and are about to discharge a seventy-nine-year-old patient to his home. He has COPD and this is his third admission this year.

  • What might you include as part of his discharge plan?

Chapter 38

Case Study : Kevin, pg 653

(Adapted from a scenario used within the mental health team, Faculty of Health, Social Care and Education.)

Kevin is a twenty-nine-year-old single gentleman of African Caribbean heritage who was born and brought up in a care home in London. Kevin’s mother had mental health problems and a complex social life and could not manage to look after Kevin at the time. His father is unknown. He experienced a number of challenges growing up and despite demonstrating a good level of ability he did not do well at school. Later it was discovered he was Dyslexic and he has continued to experience difficulty reading and writing. On a number of occasions he became involved in fights with other boys and was in contact with the police regularly for smoking cannabis. At the age of nineteen years Kevin was detained under the Mental Health Act and spent six months in hospital. He had a further admission at the age of twenty-two years and was diagnosed with Schizophrenia. Kevin found these admissions traumatic and openly admits to not trusting mental health workers. Kevin has a great interest in music and plays the guitar. He moved to a 24hr-supported home three years ago and has enjoyed his independence. Last year he made friends with a girl called Gemma, who has visited him on several occasions. They get on well and Kevin values his relationship with her. Kevin had made great improvements in his ability to live independently and was moved to his own flat three months ago. He was seeing his Community nurse regularly and continued on Risperidal Consta injections.

Today, Kevin failed to turn up for a routine visit. Gemma telephoned you and the team yesterday expressing concern that Kevin was struggling to manage at home and had been increasingly paranoid stating his flat had been bugged and he had experienced voices outside his head telling him about a conspiracy set up to kill him. She noted he was behind on his utility bills and was in debt to a short-term loan company. His use of cannabis had also increased. 

  1. Which services would you contact?
  2. Which professionals would be involved in Kevin’s care?
  3. How would these differ if Kevin also had learning difficulties?


To include:


The police

 If Kevin is in a private dwelling then the police may not be able to do anything so would contact the mental health crisis team for urgent re-assessment under the mental health act.

If Kevin is not in private dwelling then the police may be able to detain Kevin under section 136 of the mental health act.

Social services

They may be able to help with finances, flat, etc.


Psychiatrist – to help assess Kevin

Mental health community team – to help assess Kevin. Kevin may also be familiar with some of the team so would provide reassurance.

GP – needs to be aware of Kevin’s condition and may be able to shed light on condition.


Would also involve the community disability mental health team.

May involve a patient advocate depending on Kevin’s disability.

Chapter 39

Case Study: Rowan, pg 669

Rowan is a seventy-nine-year-old widower living at home with recent onset severe rheumatoid arthritis. When visited by the nurse he described how helpful his daughter was in terms of transport and providing companionship. He also mentioned his daughter lived next door but it quickly became apparent that the supportive daughter lived many miles away and the daughter next door provided little support.

  • How can the nurse ensure she is asking about functional support rather than just the social network?  

Chapter 40

Case Study: Jasmine, pg 687

Jasmine Jones is fourteen years old and has recently moved with her family to a new town. This means that she has had to start a new school which has been difficult. She and her parents have always lived in the UK, her grandparents came to England in the 1960s from Jamaica, and within the school she has just started there are very few children from minority ethnic groups. Jasmine has therefore been subjected to bullying because she is seen as different and this has caused her a great deal of stress. What the other children didn’t know until today is that she also has epilepsy and that although her seizures are generally well controlled stress can trigger them. This lunchtime other girls were calling her names and it got too much for her: she had a tonic-clonic seizure. When she came round from the seizure she could hear other pupils making fun of her and shouting loudly that she had wet herself. She recovered well and then was taken home where she said to her parents that she didn’t want to go back to school ever again. This led to a row as her parents place a high value on education and tell her that she has to go if she is ever going to make anything of herself. They say that they were also teased at school because of their ethnicity and that the only thing to do is to stand up to the bullies. They do, however, concede that her epilepsy is a concern and say that they will talk to the teachers to see if she can be watched during break times in case she has another seizure. They stress that she must tell other people so that they can help her.

  • What might be the advantages and disadvantages for Jasmine of telling other pupils about her epilepsy?
  • If one of the aims of education is to socialize children and young people into acceptable ways of behaving what might the school’s responsibilities be in relation to bullying?
  • What does Jasmine’s story tell us about how society responds to some differences?

Chapter 42

Case study: Theo, pg 684

Theo is twenty-four and has just started the second year of his adult nursing course. He recently attended an information session run by his university about international elective placements where he found out that at the end of his second year he has three weeks of ‘independent study’ time, which he can use to undertake a placement in any clinical area he wishes.

For as long as he can remember Theo has wanted to work as a nurse for an international aid agency, but as he left school without any qualifications, this did not seem achievable. However, after being made redundant from his retail job he decided to return to college to gain the qualifications required to become a nurse. Theo has raised funds, over £15,000 to date, for Médecins Sans Frontieres since he learnt about their activities when he was completing his access to nursing course and is now very knowledgeable about their activities. Theo is very keen to undertake a placement in a developing country, as he feels this would enable him to increase his practical understanding of nursing in resource-poor environments. The opportunity of doing this during his nursing course seems to be too good an opportunity for him to miss.

At the information session Theo was told that he would need to pay for his return travel to the placement area, accommodation, travel and living expenses whilst he was away, plus any inoculations/medications/health checks and visas required. He is concerned that he has only very limited funds and is aware that the injections required to ensure he remains healthy during his visit to a developing country, in addition to all the other costs, are likely to be expensive.

  • What are the first steps Theo should take to investigate whether it will be feasible for him to undertake an international placement?
  • Are there any sources of funding that Theo could investigate to try to add to his limited amount?


The first steps Theo should take to investigate whether it will be feasible for him to undertake an international placement are:

  1. Talk to his tutor. He may be able to take part in a project that already exists between his university and a healthcare organization in another country. Theo will also need to consider what he wishes to achieve from this experience, link this to the learning on his course and gain the support of his university before he goes. If there is not a project Theo could become involved in he should consider whether he has any links with other organisations that may be able to include him in a project. Some local NHS Trusts have ongoing relationships with healthcare professionals in other countries and many towns/cities are twinned with towns/cities in other countries (details of this will be available from the town/city hall).  Theo also has existing links with Médecins Sans Frontieres so he should contact them. Finally, if Theo has friends or family living abroad they might be able to assist him to find and contact a placement area.
  2. Decide exactly where he wants to go and then consider the impact of his visit on his host. Theo must be certain that his visit will be as positive for his host as it is for him before proceeding any further with his arrangements.
  3. Work out the cost of everything he needs to finance for his placement. It may not be possible to be exact, but Theo needs a clear idea of how much money he will need.

What sources of funding could Theo investigate to try to add to his limited amount?

  1. Before approaching any funding source Theo needs to think carefully about and write down exactly what the benefit of the international placement will be, considering the benefit in terms of the patients he cares for in the future, for him now and during his nursing career and for any future employers. He needs to have a clear idea of how much money he needs and demonstrate that this experience is so important to him that he is prepared to fund as much of it as he is able.
  2. Theo should talk to his tutor, who may be able to provide him with the details of financial assistance available from local sources, such as specific financial awards or grants he can apply for in his university, local NHS Trusts or charitable organizations.
  3. As Theo is a student member of the Royal College of Nursing (RCN) it would be sensible to also ask for their advice, as some RCN branches have funds available to their members.
  4. There are also publications which Theo could consult which identify potential sources of funding. These are likely to be available in his university library. Examples of such publications are The Grants Register (published annually) by Palgrave Macmillan, The Directory of Grant-Making Trusts (published annually) by the Charities Aid Foundation and Charities Digest (published annually) by Waterlow Professional Publishing.
  5. Another possible source of funding Theo could investigate could be drug or medical equipment companies, UK companies who also operate in the country he wants to visit or companies based where he is undertaking his nursing course.
  6. Theo could also undertake some sponsored activities, such as baking cakes or putting to use any other marketable skill he has, to raise funds for his placement. If he does this, contacting his local radio station or newspaper, with the support of his university, would be an excellent idea, as they might be interested in reporting his plans, publicising any fundraising events he is undertaking or even contributing to his fund.