The Nursing Care Management - Case Study Example

Care Study: Person Centred Care Scenario for Care Study 0701Cohort Introduction: This is care study related to a patient whose identity will remainundisclosed for confidentiality and ethical reasons. For the purpose of this work of care analysis, her case will be taken, and she has been nicknamed Patricia. In this work, she will be referred to as Pat. Before going into analysis of her care, her history can throw some light on to what this work will be studying. Pat is a 35-year-old woman with learning disabilities and in need of support. The need for support gets accentuated when her mental condition deteriorates. She has been diagnosed with manic depression. Over the top of it, she has been suffering from complex partial seizures. For all these reasons, she has been on medications. Recently she has gained a lot of weight, and for her, this obesity may end up causing type 2 diabetes. She has a belief that her medications are real culprit for such things (Marshall, McConkey, and Moore, 2003, 147-153). She has been in a semi-supported accommodation in her own bedsit in Middlesbrough for last 2 years prior to her stay at a share house with people with learning disabilities in a more rural setting. Pat is pretty social and has made many friends. For example, her friend Mary from her previous share house accommodation had been pretty close to her, and they used to be in touch and with regular visits from both ends. Currently, Mary has been hospitalized for terminal cancer, and Pat has been unhappy about that. It seems Pat likes to make friend with people, and she enjoys her stay at the bedsit due to the company with the friends she had made. Pat's medical condition precludes her to have any job or to have any other regular activities. While she is in a relationship with Jim, another tenant in her bedsit, she would like to have Jim's company all the time, she feels bored staying at one place all the time, and this has created conflicts and problems in the relationship. The care she gets is semi-supported, meaning she is entitled to receive support and help from the support workers between 7 am and 9 am and 7 pm and 11 pm. For emergencies only, there is one sleep-in support staff who is not supposed to be contacted for help otherwise. When she is stressed, anxious, or having manifestations of manic depression despite having regular medications, extra support from a community nurse is available on the grounds of deterioration of her mental health. In this work, the care of Pat will be analyzed on the basis of the theoretical framework of nursing process where the role of learning disability nurses would be examined as far as clinical governance, ethical issues, and evidence from current research are concerned. This would also include critical analysis of emerging issues and implications on professional practice when it is delivering a care that is person-centred along or in collaboration including therapeutic interventions that are suggested by evidence from research. The planned care would then be critically analyzed and evaluated based on the principles of clinical governance and research evidence. Finally, everything should culminate into learning as far as learning disability nursing is considered. Theoretical framework to provide structure: This is the story of a young woman with learning disability, where her clinical situation has been complicated by detection and diagnosis mental health disorder such as manic depression and other medical disorder. This is a complex process due to her limited vocabulary and insights, and skill deficits. Therefore, the nursing assessment process that would lead ultimately to a care plan would need to include details of her skills and abilities, nature and pattern of behaviour in a diverse range of environments, relationships and understanding of her own emotions and of other people around her. To be able to implement these in practice, a theoretical framework is very necessary. These theoretical frameworks for practice have been derived from nursing theories. Nursing theories address the phenomena of interest to nursing, including the focus of nursing; the person, group, or population nursed; the nurse; the relationship of nurse and the nursed; and the hoped-for goal or purposes of nursing (Aggleton and Chalmers, 2000, 1-31). Introduction to the Care Study: The examination and use of nursing theories are essential for closing the gap between nursing theory and nursing practice. In Orem's Self-Care Deficit Nursing Theory, individuals throughout their life cycles are viewed as having a continuing demand for engagement in self-care, in care of self; the constituent action components of the demand together are named the therapeutic self-care demand. Nursing is required when individuals cannot meet their self-care demands in whole or in part, in time-place frames of reference in an adequate level because of health state or health-care-related conditions. Self-Care Deficit Nursing Theory offers the explanation that both internal and external conditions related to health states of individuals can bring about limitation of actions of individuals to engage in care of self. These may be reflected in lack of knowledge or developed skills or lack of energy. This theory suits well with the nursing process approach for nursing care. Within the nursing profession, the nursing process has consistently been used as the basis for nursing practice. The nursing process is a derivation from the theory of Orem in the sense that self-care deficits would lead to healthcare needs, and the nursing process includes identifying needs of patients, responses of the nurse, and nursing action (Whelan, 1984, 342-345). Nurses use the scientific process and creative abilities to provide nursing care to the patient, and the nursing process incorporates these abilities, thereby improving the care of the patient. In reality, nursing practice is guided by a linear nursing process approach whereby the patient's problems are assessed, a plan of care is drawn up, interventions are undertaken and the results are evaluated. Within this framework, the care of Pat will be analyzed and evidence will be sought from it. By providing a systematic basis for assessment, planning, implementation and evaluation, theories are seen to offer a way to 'revitalise' the nursing process. Therefore, in order to be implemented successfully and to have meaning for practitioners, the nursing process as a problem-solving approach must be framed within a nursing theory. As a supplement to this role, nursing theories also stress the importance of the wholeness and integrity of the person, thus further enhancing the practitioner's ability to provide individualised care (Taylor et al., 2000, 104-110). Department of Health has defined learning disability. A person is described as having learning disability if he/she has significantly reduced ability to understand new or complex information, to learn new skills and a reduced ability to cope independently. These respectively are impaired intelligence and impaired social functioning that started before adulthood, with a lasting effect on development (Department of Health, 2001, 1-149). The learning disability nurses encounter people now in the community care settings as in the case of Pat, not very frequently any longer in the specialist hospitals. This shift also indicates a change in the philosophy of care, where the nursing now seeks actively to work with the person, to enable him/her to develop a greater level of independence with meaningful power and control over the decisions taken within his/her life. To this end, an approach called 'person-centred care' currently influences how nurses plan and deliver support with these individuals, such as, Pat (Jones, 1999, 61). These patients have special needs, specially when they have other complex associated psychiatric or other diseases as Pat has. Taking her case, her learning disability is clearly a developmental disorder that had onset before adulthood and is long lasting. She has impairment of cognition due to her intellectual deficits, problems with impulsivity and mood lability due to dysfunction of brain and associated less effective controls (Alaszewski et al., 2001, 1-14). Due to these reasons, Pat is expected to experience the social consequences of her disability. As far as learning disability nursing is concerned, Pat would have difficulty in establishing a trusting relationship with others due to her dependence on others for basic needs, care, and protection. In case of Pat and as in reality, in addition to the diagnosis of learning disability, some individuals have associated neurological or psychiatric abnormalities that contribute to the nature of manifestation of mental health disorders in them. There is evidence in literature about association between learning disabilities and depression. It has been reported that people who find it difficult to express their emotions verbally may exhibit it in multiple ways other than the classic feelings of hopelessness as in classical depression. The diagnosis of mental health disorders in people with learning disability is a complex process in itself since there are multiple presentations of symptoms and conditions. Researchers have also indicated that if a person with learning disabilities has sudden episodes of depression lasting few days or weeks combined with incontinence and refusal to eat, it may actually indicate signs of epilepsy, rather than a depression (van Schrojenstein et al., 2000, 405-407). While this case does not provide such symptomatic details, it is to be acknowledged that existence of multiple disorders in Pat, such as, manic depression and complex partial seizures complicate her learning disability further making the task of a caregiver very complicated and difficult, calling for a very careful and detailed assessment. This assessment is required to provide enough information to decide whether there is a disorder and if so what kind of disorder and to formulate a care plan to help the patient's nursing care (Elliott, Hatton and Emerson, 2003, 9-17). Learning disability nurses play a significant role in coordinating, planning, and conducting this assessment process. It is evident, only scientific knowledge is not important here since all these conditions would be manifested in a manner beyond expected classical form. It is due to this reason; a care planning would need to arise out of a person-centred approach. A person-centred approach to planning means that planning should start with the individual and her wishes and aspirations reflecting the needs and preferences of a person with a learning disability and covers such issues as housing, education, employment and leisure. It is therefore clear what is expected from the learning disability nurses; their activities and work of caregiving should be a result of a process that keeps the person at the centre (Duffy and Sanderson, 2004, 12-16). The focus of the service provision for people with learning disabilities is now on needs assessment and person-centred care planning. The Department of Health defines need as the requirement of individuals to enable them to achieve, maintain, or restore an acceptable level of social independence or quality of life (Gray, 2003). If it is person centred, this should suit individual needs or preferences. Thus the proper assessment of need and good care or case management are indeed the cornerstones of caring for people with learning disabilities. Professionals and nurses as well in the field of learning disability care have used needs assessment to explain needs for services and needs for individuals with learning disability. Starting from this point, the role of nursing in learning disability can be enumerated as to provide assessment of need, health surveillance and health promotion, development of personal competence using enhanced therapeutic skills, managing and leading teams of staff, enhancing the quality of support, enabling and empowerment, and coordinating services (Aldridge, 2004, 169-181). While catering care to the people with learning disability, the nurses in the discipline need to pay extreme respect to the issues of accountability and clinical governance. This is necessary since people with learning disabilities continue to be misunderstood and subsequently experience prejudice and exclusion from their communities and society (Brown & MacArthur, 1999, 48-49). In addition, it has been well established that this group of people is susceptible to many forms of abuse due to their vulnerable status. These abuses may take any or many of the following forms, physical, sexual, emotional, and financial abuse. Regrettably, it is a fact that they are more at risk of abuse from their care givers, and in these abusive environments, to prevent such, a strong philosophy of care and a sense of accountability are necessary (Klotz, 2004, 93-94). While this explains the relevance of the issues of accountability and clinical governance for health and social care professionals while working with people with learning disabilities, the Department of Health has placed considerable emphasis on these. They emphasize that people with learning disabilities have the same right of access to the range of healthcare services offered to the mainstream population. The care services to the people with learning disabilities must respond to the existing legislation in order to bring about the inclusion of their clients into this affair. Despite implications of these legislations on practice, it is to be remembered that learning disability nurses work in many different settings and for different agencies (Department of Health, 2001, 1-149). Their practice is often in disparate services spread over large geographical areas with complex roles ranging from care managers through to specialist clinical nurse practitioners. To enable uniform and fair practice, a number of quality improvement and accountability procedures can be found within learning disability care settings (Kneisl et al., 2004, 1-78). These include clinical audit, research, evidence-based practice, quality assurance, complaint procedures, risk assessment and management, clinical supervision, continuing professional development, and life-long learning. The idea of clinical governance is that it is a framework of agenda that when implemented in practice together, would lead to consistent excellence in care delivery (Gates, Wolverson and Wray, 2004, 117-122). This can be viewed as a change process underpinned by the framework with an aim to assist practitioners in the maintenance and improvement of standards of care with the person with learning disabilities as the central focus (Barr, McConkey, and McConaghie, 2003, 577-598). This also requires all practitioners to regulate their practice up to the appropriate standards and guidance for professional practice at set by the professional regulatory body, NMC. The process of clinical governance thus can be guided by three principles, promoting good practice, preventing poor practice, and intervening in unacceptable practice (Thompson and Cobb, 2004, 12-20). Identified Health Needs Learning Disability: The problem with Pat was diagnosed when she was 3. She has the characteristic short attention span, impulsivity, and distractibility, and has led ultimately to her lifelong dysfunction. In her case the other co-morbid disorder is bipolar disorder. This diagnosis has been made 10 years back, but her learning disability was established when she entered school. Even now, she has stubbornness, negativism, temper tantrums, obstinacy, inability to tolerate frustration, deficit in judgment, poor self-image, and aggressiveness. Her inattention was characterized by failure to complete a task, pay attention, or listen; distractibility, inability to concentrate, and difficulty participating in activities for a period of time. The hyperactivity was evident during the interview as fidgeting, inability to sit still, running, climbing, or moving during sleep, and behaviour indicating being in high gear. Impulsivity was indicated by failure to think before acting, frequent shifting from one activity to another demonstrating poor attention span, and inability to organize work (Brittle, 2004, 28-29). Manic Depressive Disorder: Pat had activity Intolerance related to inactivity secondary to depression. During these phases, she used to have imbalanced nutrition, where she used to take less than body requirements related to anorexia secondary to depression or manic state of bipolar disorder. During the manic state she would be having fatigue related to hyperactivity secondary to manic state of bipolar disorder. During other times, she could have hopelessness related to poor self-concept secondary to depression and impaired verbal communication related to inability to concentrate secondary to depression worsening her baseline poor verbal communication with learning disability. Sometimes there would be evidence of ineffective coping related to delusions of grandeur secondary to manic state of bipolar disorder. As she was demonstrating low frustration tolerance, with her current relationship with Jim and not being able to get his company when she is bedsit bound and simultaneously not being able to socialize with Mary has put her into a very vulnerable situation. This could originate from and may lead to situational low self-esteem related to feelings of failure secondary to depression, disturbed sleep pattern related to hyperactivity secondary to manic state of bipolar disorder, and social isolation related to fear of rejection secondary to low self-concept. She is on continued medications, but during exacerbation of her symptoms, she may need further and elaborate assistance than that could be provided by her bedsit. This assistance would provide support to her ineffective coping related to poor impulse control secondary to manic behaviour. During these episodes, she would need assistance in self-care deficits in grooming and dressing related to mixed episodes of depressed mood and manic behaviour (Birmaher & Brent, 2003, 466-483). Seizure Disorder: Her symptoms of complex partial seizure vary but usually include purposeless behaviour. Pat may experience an aura and exhibit overt signs, including a glassy stare, picking at her clothes, aimless wandering, lip-smacking or chewing motions, and unintelligible speech. Her seizure may last for a few seconds or as long as 20 minutes. Afterward, mental confusion may last for several minutes, and she has no memory of her actions during the seizure. It has been observed that her seizures occur when she has less sleep, more anxiety and stress. She has been told not to discontinue her medications for this seizure, and she is worried and anxious about what is that. Obviously this anxiety is related to deficient knowledge and fear and may be ineffective coping. This also puts her into the risk of injury if unsupervised and invariably aggravates her social isolation further (McKenna, 2003, 19-25). Disturbed body image: Perhaps due to psychotropic medications and antiepileptic medications, she has been gaining a lot of weight recently, and this obesity may predispose her to type 2 diabetes (Marshall, McConkey, and Moore, 2003, 147-153). The other factor that may be causative in this issue is her lack or exercise and bed-bound status in her bedsit. The nursing diagnosis would be imbalanced nutrition with gain in weight related to medication intake (Casey & Long, 2003, 89-99). Social Isolation: Her life in the community setting in a bedsit dedicated to people with learning disability is itself a situation of social isolation comparison to normal individuals in the society. She has a good coping mechanism in place in that she has been able to make social exchange with friends picked up there. However, her friend's recent illness of cancer and related hospitalization has made that impossible now. Although she is in a relation with Jim in her current stay at the bedsit, all her conditions may predispose her social isolation to be accentuated. Her learning disability makes her communication difficult, and learning of social skills will be difficult further. This is a condition that can produce enormous social isolation in itself. However, as elicited in the nursing diagnosis of manic depressive disorder, this condition is also prone to develop social isolation related to loneliness secondary to mixed episodes of depression and manic behaviour. The complex partial seizures also create isolation. Therefore given her condition, the factors that prevail upon her social isolation are deficit about ways to enhance mutuality, communication barriers due to her condition affecting ability to communicate, disturbance of self-concept, absence of significant other, limited physical mobility, sociocultural dissonance, environmental barriers, and disturbed thought process (Arthur, 2003, 25-30). Care Plan: Therefore the care plan must consider these issues, keeping Pat and her needs at the centre. This care plan would guide the goals in her care and determine the interventions. An evaluation would be necessary to see whether care goals have been achieved or not. Care plan would include reinforcing areas of communication, self-care, living arrangements, social and interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety (Chambers, Davren, and Jackson, 2003, 25). She has poor awareness about the needs of others and has self-care deficits. Therefore, she needs supervision due to that. Under social stress as in her condition due to separation from a close friend and being forced to stay away from the significant other, she would need supervision and guidance. However, studies have shown that with her grade of learning disability, she may profit from vocational training and can function in sheltered workshops as unskilled or semiskilled persons. Although she is not able to learn academic skills, she may learn to talk and can be trained in elementary hygiene skills or activities of daily living, and as in her case, she would require complete supervision in a controlled environment. A trial should be made to teach her some productive skills so she can do some job (Crumlish, 2003, 29-39). As evidenced by the assessment, she is also prone sometimes to express over activity, distractibility, poor concentration, sudden unprovoked anger or fear, or aggressive outbursts, although it is not clear whether these are happening due to her manic depression. The care plan must also include other factors such as disturbed sleep pattern and risk of injury related to her poor safety awareness. Due to her complex partial seizures, she is in risk of other-directed violence related to aggressive acts. This may further be accentuated if this coincides with her manic phase of mood disorder. The most profound would be impaired social interaction related to alienation from others secondary to impulsive behaviour and overt hostility or hopelessness in the phase of depression. Moreover, there is a possibility of chronic low esteem and disturbed personal identity. Her thought processes may be disturbed. All of these could lead to impaired social interaction, ineffective coping, ineffective health maintenance and ineffective role performance (O'Dowd and Strachan-Bennett, 2004, 10-11). Key Outcomes: Effective management of a learning disability patient requires an interdisciplinary team approach that provides complete, continuous, and coordinated services. A primary goal is to develop the patient's strengths as fully as possible, taking into account her interests, personal experiences, and resources. Another major goal is the development of social adaptive skills to help the patient function as normally as possible. Clearly, she requires special education and training. An individualized, effective education program can optimize the quality of life for even the profound disable. The success of the management is related to timing and aggressive treatment, personal motivation, training opportunities, and associated conditions than to the learning disability itself. With good support systems, Pat can become a productive member of society. Successful management leads to independent functioning and occupational skills for some and a sheltered environment for others (Hollins & Sinason, 2000, 22-36). The key outcomes related to her learning disability would be that she will perform bathing and hygiene activities to the fullest extent possible, demonstrate age-appropriate skills and behaviours to the extent possible, perform dressing and grooming activities to the fullest extent possible, perform health maintenance activities according to level of ability, participate in decisions on care as possible. Contacting a support group or other community resource will prove beneficial. Pat will participate in developmental stimulation program to increase skill levels (Sinclair, 2003, 632-701). Her mood disorder nursing care plan outcomes are that she will voice feelings related to self-esteem; express positive feelings about self, maintain orientation to person, place, time, and situation; demonstrate effective social interaction skills as her condition permits; identify effective and ineffective coping techniques; recognize symptoms and comply with medication regimen, and through these she will maintain usual roles and responsibilities to the fullest extent possible. In relation to her seizure disorder, she will be able to express feelings of decreased anxiety. She will be encouraged to communicate her understanding of the condition and the treatment regimen. If she has any fear, she will be able to identify those. She will be encouraged to use support systems and develop adequate coping. She will remain free from injury and she will resume active participation in social situations and activities. To be able to identify her isolation better, she was encouraged to verbalize feeling of discomfort about social situations, which will be observed to note any causative factors, recurring precipitating patterns, and barriers to using support systems, so identification of areas of concern is possible that could suggest possible ways to learn new skills (Slevin, 2003, 762-774). Ethical Issues: While planning an intervention, it is important to attend the ethical issues of mental disability nursing. The issues of confidentiality can be taken care of the nurse. But while autonomy and consent are considered for intervention, the question of competence arises. Quality studies have concentrated upon issues that are important to professions. This is challenge to the staff in that they must be able to utilise normalisation to construct quality of care through improvement of quality of life in residential settings, often for people living in long-stay institutions. It is important to involve Pat in this process since the definitions of quality of care and quality of life for people with learning difficulties should be dominated by her views. However, the nurses can work with Pat to establish the most likely set of outcomes with realistic goals set within meaningful timeframes, and this should be a nursing process that emanates from the need for ongoing support in order to adjust her life to changes that explore newer opportunities that can be seen through an ongoing support of a care worker without the thought of prognosis or end of care. For giving an informed consent to this process, the competence of Pat will be necessary, and determination of competence can be very complex given Pat's clinical situation. These interventions may involve major life decisions for Pat, which could have implications on her ability to make decisions that are very complex and with unpredictable outcomes even for normal individuals. Thus ideally, Pat before giving an informed consent must be assessed regarding judgment dependent on the context of a specific task, relevant abilities, stability and variability of abilities, and degree and extent of relevant abilities. While this judgment may become erroneous an alternative is to document fully the process of decision making that relate both to informed choice and informed refusal. Documentation establishes the accountability of the practitioner in that it makes both the judgment and its circumstances and the basis of those judgments. While granting autonomy, it is important for the nurse to avoid paternalism and promote personhood (Thompson, Pickering, and Russell, 2001, 201-213). Nursing Interventions: The improvement in communications skills can be fostered through appropriate use of language. When Pat indicates her needs correctly, positive reinforcement must be provided through both verbal and physical reinforcement. All opportunities should be taken to encourage development of self-esteem (Toppelberg & Shapiro, 2000, 143-152). It is to be demonstrated to Pat that she is very much acceptable as a person. If she sits on the floor, the nurse should do the same. Her self-care should be encouraged through demonstration. She should be taught to identify signs of excessive stress and coping skills that can be used under these circumstances. She should also be helped to understand that cause of her condition is unknown. While caring it is to be remembered that Pat having learning disability has all the ordinary needs of a normal person of her age plus those created by her handicap. She will be less able to cope if rejected, overprotected, or forced beyond her abilities (Thiru, Hayton. and Stevens, 2002, 10-13). It has been found that these individuals will need, acceptance, stimulation, and prudent, consistent discipline. Her other associated illnesses may bring on some regression in behaviour and skills, but there is no harm continuing the training programmes. Her auditory perception, visual perception, integrative processing, memory, expressive language, motor skills and abilities, and depending on the findings teaching sessions, tactile learning, multisensory approaches including print materials such as lists and calendars to organise tasks and activities will be used. For motor and expressive deficits, the skills and projects will be broken down to multiple component parts, and she will be provided extra time to perform (Smith, Kernohan & Hasson, 2003, 98). She will be provided a structured environment free from clutters as much as feasible to reduce her distractibility. Contact with support and resource groups will be made so they can support. In Pat's situation, Jim can be trained to provide support so she can be de-isolated through that relationship. Other Issues Related to her Care: During her manic phases, she tends not to eat. The varying physical needs of Pat are needed to be remembered. During the manic phase, she would be involved in gross motor movements, and she should be encouraged to eat. High-calorie food at that time is necessity. She would be encouraged to have short day time naps with help for personal hygiene. She should be protected from overstimulation such as noisy place or large groups. Emotional support should be provided along with setting up a calm environment, and a realistic goal for behaviour can be set with her. Limits of her demanding, hyperactive, manipulative, and acting-out behaviours at this stage will be set, so she knows that the nurse will provide security and protection by refusing inappropriate and possibly harmful requests. For management of this state, collaboration with other staff members to provide consistent responses to the patient's manipulations or acting out will be necessary (Maxwell and Barr, 2003, 51-64). Injury is very possible, and to prevent these, help of staff members who have practiced as a team can work effectively to prevent acting-out behaviour or to remove and confine her in a safe environment (McConkey et al., 2003, 78-93). When the incident is over and she is calm and in control, the nurse need to discuss her feelings with her and offer suggestions to prevent recurrence. In the depressed state, the intervention must avoid overwhelming the patient with expectations. In this state, she would need continual positive reinforcement to improve her self-esteem. It would be wise to provide a structured routine, including activities to boost confidence and promote interaction with others such as Jim and to keep reassuring her that her depression will lift. The nurse should assume an active role in communicating such as encouraging her to talk. She should be listened attentively and respectfully, allowing her time to formulate her thoughts if she seems sluggish. Observations and conversations should be recorded to assist in the evaluation of her condition (Paul, 2002, 612-621). To prevent possible self-injury or suicide, harmful objects should be from the patient's environment; she should be observed closely, and her medications should be strictly supervised. Suicide precautions should be instituted. Her physical needs must be remembered in terms of personal hygeine and sleep. Given her reluctance to use medications, she should be taught the importance of continuing her medication regimen even when she doesn't feel a need for it. Emotional support is the key to her nursing management, and she would be encouraged to express her fears and concerns. She has been taking anticonvulsants, and she should be constantly monitored for signs and symptoms of toxicity, such as slurred speech, ataxia, lethargy, dizziness, drowsiness, nystagmus, irritability, nausea, and vomiting. Regarding her complex partial seizures, she should be provided adequate support by developing an understanding of epilepsy and the myths and misconceptions that surround it. She has many questions, and answering them would help her cope. Dosage instructions should be reinforced with stress on the importance of taking the medication regularly at a scheduled time, so she can remember the timing for intake. Even though she is at risk of type 2 diabetes, the physician intervention is necessary for control of diet since reduced blood sugar levels may worsen her seizures. Her area of living would be cleared of hard objects and risk of injury should be eliminated (Martin, 2005, 49-58). Nursing Issues: Medical history indicating stressors of long-term illness of complex partial seizures, mental illness of manic depression, medications against mental illness and seizures, and learning disabilities. A combination of these would lead to emotional disabilities. Conditions such as these can isolate individual who feels disconnected from others, resulting in difficulty relating in social situations (Matthews and Hegarty, 1997, 138-143). Presence of visual or hearing impairments are to be noted since presence of these in her case may lead to a situation where she may find communication barriers are increased, social interaction is affected, and interventions need to be designed to promote involvement with others in positive ways. It is to be ascertained whether there is any pattern in her behaviour, and the observations of prevalent patterns are noted since identification of patterns will help with plan for change. Pat will be encouraged to verbalize feeling of discomfort about social situations. Noted are any causative factors, recurring precipitating patterns, and barriers to using support systems. She would be encouraged to verbalize perceptions of reasons for problems. These would cover active listening noting indications of hopelessness, powerlessness, fear, anxiety, grief, anger, feeling unloved/unlovable; problems with sexual identity; or hate. These feelings arise from the anxiety that comes with the need to participate with others in social situations and begin to interfere with work, friendships, and life in general (Moore & McLaughlin, 2003, 145-152). She would be observed in terms of social/interpersonal behaviours in objective terms, noting speech patterns, body language in the therapeutic setting and in normal areas of daily functioning. This would provide information about the extent of anxiety that the client experiences in different settings and suggest possible interventions. Lastly, the efficient care would depend on her use of coping skills and defence mechanisms. Symptoms associated with social anxiety affect ability to be involved in social situations, making client's life miserable and seriously interfering with her life (McConkey & Nixon, 2003, 132-146). Conclusion: The nursing care management must take care of the need to establish therapeutic relationship using positive regard for the person, active-listening and providing safe environment for self-disclosure. Client who is having difficulty interacting in social situations needs to feel comfortable and accepted before she is willing to talk about self and concerns. Client needs to learn social skills, because she has never learned the elements of interacting with others in social settings. Role-playing one-on-one is less threatening and can help individual identify with another and practice new social skills. Having client to participate in a controlled group environment, for example Pat and Jim, provides opportunities to try out different behaviours in a built-in social setting where members can make friends and provide mutual advice and comfort. Positive reinforcement for improvement in social behaviours and interactions should be provided since this encourages continuation of desired behaviours/efforts for change. Pat may not be able to interact appropriately because of disabilities in group interactions, but involvement in the group provides an opportunity to practice and relearn skills to enable reintegration into social situations. Lastly, she must be worked with to alleviate underlying negative self-concepts because they often impede positive social interactions. By replacing negative thoughts with positive messages, client can reduce anxiety and develop a positive sense of self-esteem. 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