Case Study 1
Case Study 1
It is known that people with long-term physical, neurological problems and learning disabilities are more likely to encounter problems with incontinence or access difficulties.
This case study highlights some of the issues in relation to continence that affect people with learning disabilities and in particular, for the individual, the benefits of a multi-disciplinary assessment and management plan discussed and agreed with the person affected.
The white paper Valuing People: A new strategy for Learning Disability for the 21st Century (DOH 2001) states that a learning disability includes the presence of:
- a significantly reduced ability to understand new or complex information, to learn new skills with
- a reduced ability to cope independently
- which started before adulthood.
In the case study, we will explore some of the issues encountered when assessing people with learning disabilities. The case study will demonstrate how a multi-disciplinary approach is essential in the assessment and treatment of continence issues with people in this group.
Jane is a 20-year-old woman with Cerebral Palsy, mild learning disability, communication difficulties and she uses an electronic communication aid. She has dysphagia and all her dietary and hydration needs are met through a gastrostomy tube. She is unable to walk and is a wheelchair user and has a hoist for moving and handling needs. She lives in a supported environment with full-time care.
A multi-disciplinary continence assessment found that Jane had faecal and urinary incontinence and experienced episodes of constipation. With Jane’s agreement, a plan of increased exercise and dietary changes was implemented. Jane’s dietician recommended increasing her daily fluid intake and adjusted her gastrostomy feed to boost the daily fibre content. The increased exercise resulted in severe muscle spasm preventing the physiotherapist from supporting the exercise so Jane was prescribed Lioresal to reduce the spasm. Her mobility improved and the physio was able to walk Jane using a walking harness. Lioresal can have gastrointestinal and urinary side effects.
Jane’s urine output and bowels were monitored by staff using a bladder diary and The Bristol Stool Form Scale.
An evaluation of the monitoring sheets showed that Jane was continuing to pass urine without difficulty, however, in more than one episode her bowels had only opened once in a 10-day period; this was Type 1 on the Bristol Stool Form Scale.
Jane was experiencing severe discomfort and the nurse asked Jane for permission to examine her to determine the extent of the constipation. An abdominal examination and a digital examination of the rectum were undertaken. The digital examination revealed that Jane’s rectum was full of hard bulky stools.
It was felt that there was no need for a manual evacuation but that Jane might benefit from a change of position to support her to defecate.
Jane had never sat on a toilet and was unable to assume this position. Since birth, Jane had passed faeces into a pad and no attempt had ever been made to assist Jane to use a toilet. The nurse felt that Jane might benefit from a position change, this being sitting on a toilet or toileting aid to attain a good position to aid defecation. Jane was very keen to try this and an occupational therapy assessment was carried out.
A Seahorse toileting aid was found to be suitable for Jane and the care staff were shown the best position for Jane to have her bowels opened. Unfortunately, even after assessment and probably as this was a new experience Jane found sitting on the Seahorse uncomfortable and was unable to have her bowels opened in this way.
She continued to experience constipation but wanted to carry on taking Lioresal to improve her mobility so she started taking Movicol regularly. Jane wanted to continue to try and use the Seahorse toileting aid and so a further assessment was carried out and some adjustments were made to the Seahorse and Jane’s positioning. The monitoring sheets indicated that Jane usually had her bowels open after breakfast, so Jane decided she would only use the Seahorse at this time and she gradually implemented this new regime.
A multi-disciplinary approach involving assessments from a Nurse, Dietitian, Physiotherapist, Occupational Therapist and General Practitioner contributed to improved mobility and played an important part in the alleviation of Jane’s constipation, a significantly improved quality of life and increased self-esteem.