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Case History Review


Nursing management of chronic illness and providing optimal care to people with a functional disability requires a good understanding of key principles of practice by nurses in conjunction with other multi-disciplinary healthcare team members (Smith, et al., 2014). In this work, we provide a critical analysis of the health effects of a 45-year old man with Down syndrome, moderate intellectual disability, and type 1 diabetes, and the impact of my ability as a nurse to promote the health and wellbeing of this person by managing his holistic care needs. The man lives in a community group home with staff support and attends a disability-specific day program Monday to Friday.

Health challenges that may arise across the person’s lifespan as a result of his Down Syndrome (DS), moderate intellectual disability, and Type 1 Diabetes Mellitus (Type 1 DM)

Virtually, in addition to developmental and intellectual disability, persons with Down syndrome are at risk for certain health problems. Some of the health challenges that the 45-year old man is likely to develop during his lifespan as a result of Down syndrome include: heart defects, vision problems, hearing loss, infections, hypothyroidism, blood disorders, hypotonia, problems with bones in the upper spine, sleep disorders and disrupted sleep patterns, dental problems and gum disease, epilepsy, digestive problems, celiac disease, mental health problems (dementia), emotional problems, and psychiatric or neurobehavioral disorders. Heart-related problems may result in heart failure (Tracy, 2011). Loss of hearing can affect listening skills, while poor muscle strength, unstable joints, and weak ligaments causes spine problems. The person may experience change of behavior, or stop doing things that he used to do and instead, require a lot of support. According to Taggart, Coates, & Truesdale-Kennedy (2013), he may also become overweight.

Having moderate intellectual disability is caused by mental health problems which is associated with persons with Down syndrome. The man is likely to experience depression, anxiety, and Attention Deficit Hyperactivity Disorder. The impacts of these health challenges include: displaying repetitive movements, autism, psychosis, aggression, or social withdrawal. The man may have a lot of difficulty coping with these problems in a positive way. Certain biological differences and everyday stresses may make the man to become susceptible to emotional, mood, and mental health problems (Taggart, Coates, & Truesdale-Kennedy, 2013).

Type one diabetes has a number of health challenges that may develop into serious health problems. The diabetic complications can either be short-term or long term, and can be categorized into either neuropathic or cardiovascular complications. Some of the complications that the man may develop due to having type 1 diabetes include: Diabetic ketoacidosis (DKA), hypoglycemia, heart disease and stroke, kidney disease (nephropathy), neuropathy, foot ulcers and amputations, retinopathy and eye complications, alzheimer’s disease, respiratory and urinary tract infections, depression, osteoporosis and possible bone fractures. Other health challenges that the man is likely to encounter are loss of hearing, periodontal disease, nonalcoholic fatty liver disease, uterine cancer, colorectal cancer, carpal tunnel syndrome, and related nerve entrapment syndromes as the risk for these conditions are increased by having diabetes type 1. These health problems can damage nerves, blood vessels and other organs, which may reduce the normal lifespan of the individual (Monaghan, Helgeson, & Wiebe, 2015).

Activities and Participation of the individual using the ICF Model

Learning and Applying Knowledge: This adult with DS is likely to develop depression and behavioral disorders due to mental ill health. Visual impairment and loss of hearing are frequent among adults with DS. Mental ill health is more prevalent in adults with intellectual disabilities than in adults without. Type 1 DM also affect the mental domain which may often lead to anger, denial, depression, and fear. These health problems may affect the person’s ability to learn and apply knowledge (Lloyd, 2016).

General tasks and demands: The person may not have any difficulties in performing general tasks such as walking, carrying light objects such as books etc. However, he may not be able to participate in high energy demanding activities such as sports or lifting heavy objects due to lower overall cardiovascular and respiratory fitness. Combined intellectual disability and DS can reduce the person’s heart rate to 10% lower than individuals without these conditions.

Communication: In terms of communication, most individuals with Down syndrome are good communicators. However, the man may experience auditory short-term memory, auditory processing and speech intelligibility due to mental disability. However, this area of weakness will not have a significant effect across his lifespan.

Mobility: DS is associated with abnormal collagen, a condition that affects the bones and joints of persons with DS. The resulting effect is increased laxity of the ligaments that attach bones and muscles together. The combined ligamentous laxity and low muscle tone have a significant contribution to orthopedic problems. Type 1 diabetes may increase the problem of mobility as the man becomes older (Dhaliwal & Weinstock, 2014).

Self-care: Adult people with DS tend to be independent, often taking charge of more aspects of their lives, even when they move to a community nursing care home. However, due to moderate intellectual disability and type 1 diabetes, the person may require assistance in taking care of some aspects of his well-being.

Interpersonal interactions and relationships, community and social life: The person may find difficulty in participating in social relationships, community life, recreational activities etc. than he participates in other daily activities such as personal care and communication. Participation in social interactions and relationships may be influenced by the physical environment – including community organization services and public infrastructure.

Intervention/Strategy to manage Type 1 DM for the 45-year old man

Intervention: Blood sugar level and medication management

This intervention involves managing the level of blood sugar by use of lifelong insulin therapy. The 45-year old man will require daily insulin injections, with medication doses adjusted depending on self-monitored blood glucose levels in order to effectively control the life-threatening condition. The long-term management of his condition requires a multidisciplinary approach that includes nurses, dietitians, physicians, and other specialists.

As a nurse taking care of the man, my role and that of the staff at the community care is to support him in managing his health condition more effectively. Nursing care requires a coordinated multidisciplinary approach to reduce fragmentation of services, to better assess, plan, implement and integrate healthcare and effective support for the individual (Johnson & Chang, 2014). This will be my pivotal role in ensuring that the person gets appropriate intervention within a reasonable timeframe. Therefore, the following management practices will be implemented in controlling the condition:

  • Replacement of insulin through lifelong insulin injections.

  • Regular monitoring of blood glucose levels.

  • Ensuring that the person follows a healthy diet and a good eating plan.

  • Involving the person through regular exercise.

I will be monitoring the blood glucose levels of the person as close to the right and safe target range as possible (4-6 mmol/L before meals, 4-8 mmol/L after meals). This may depend on the individual circumstances. Monitoring blood glucose may be up to 6 times a day, or as may be directed by a doctor. The possible times to test this will be: Before breakfast, before lunch, 2 hours after taking a meal, before bed, before an exercise, and when the person is not feeling well. Regular testing of blood glucose level pattern changes will enable me to alert the multidisciplinary team of a possible need for a change in managing the person’s diabetes condition.

If the glucose levels are below the safe level, then there will be need for administering insulin by either daily injections, insulin pump therapy, or insulin jet system. The type of insulin administered will also depend on patient circumstances (Aathira & Jain, 2014). Too low blood sugar level than the required level can result in a condition known as hypoglycemia, and the person may require glucagon when he loses consciousness. Monitoring and controlling the blood sugar levels will be the key to managing the person’s diabetic condition. If the blood sugar levels become too high – a condition known as hyperglycemia, there will be need to adjust the person’s dosage of insulin or his diet in order to maintain stable glucose levels and prevent diabetic ketoacidosis, which may eventually cause unconsciousness or even death (Amiel, Lawrence, Pursey, Higgins, & Dawoud, 2015).

In addition to monitoring the person’s blood glucose stability level, I will also do regular health assessments to monitor signs of risk of health problems that are associated with persons with type 1 diabetes, such as diabetic ketoacidosis (DKA), hypoglycemia, eye complications etc.

The other possible ways that I can adapt include developing and helping him have a healthy diet and a good eating plan, alongside having a regular physical exercise. In case of a hypoglycemia condition, the person will require a sugary diet to increase the blood sugar level (Diabetes Australia, 2017).


The case study of this man provides a good support for understanding the nursing care requirements and the impact of interventions on the life of persons with DS, intellectual disability and DM. Down syndrome and diabetes are conditions that cannot be cured, but can be managed to help the person to live a productive life. Management of type 1 diabetes largely focuses on insulin injection. Having a healthy diet and regular physical exercise are the other interventions available for managing the condition. The challenge of the nurse is to provide and implement models of care that are focused at preventing, reducing, or possibly eliminating modifiable risk factors and promote sustainable health of the individual.


Aathira, R., & Jain, V. (2014). Advances in management of type 1 diabetes mellitus. World Journal of Diabetes, 689–696.

Amiel, S. A., Lawrence, R., Pursey, N., Higgins, B., & Dawoud, D. (2015). Diagnosis and management of type 1 diabetes in adults: summary of updated NICE guidance. British Medical Journal, 351 :h4188 .

Dhaliwal, R., & Weinstock, R. S. (2014). Management of Type 1 Diabetes in Older Adults. Diabetes Spectrum, 27(1), 9–20.

Diabetes Australia. (2017). Food choices for people with diabetes. National Diabetes services scheme, 2-6.

Johnson, A., & Chang, E. (2014). Chronic illness and disability: on overview. In A. Johnson, & E. Chang, Chronic illness & disability : principles for nursing practice (2nd edition) (pp. 1-15). Australia: Sydney Churchill Livingstone/Elsevier.

Lloyd, M. (2016). Physical Activity of Individuals with Intellectual Disabilities: Challenges and Future Directions. Current Developmental Disorders Reports, 91–93.

Monaghan, M., Helgeson, V., & Wiebe, D. (2015). Type 1 Diabetes in Young Adulthood. Current Diabetes Reviews , 239–250.

Smith, S. M., James, A., Mitchell, G., Bissett, M., Zakrzewski, L., Wright, A., . . . Hughes, M. (2014). Role of the interdisciplinary/multidisciplinary team. In S. M. Smith, A. James, G. Mitchell, M. Bissett, L. Zakrzewski, A. Wright, .M. Hughes, Chronic illness and disability: principles for nursing practice, 2nd edn (pp. 16-36). Sydney: Elsevier.

Taggart, L., Coates, V., & Truesdale-Kennedy, M. (2013). Taggart, L., Management and quality indicators of diabetes mellitus in people with intellectual disabilities. Journal of Intellectual Disability , 1152–1163.

Tracy, J. (2011). Australians with Down Syndrome: Health Matters. Australian Family Physician, 202-208.