Important Nursing Care Essay In Care Plan.

This essay is aimed at identifying and prioritizing the most important nursing care issues in the care plan of the patient in the provided case study. The purpose of the paper is to utilize two theoretical frameworks- Miller’s Functional Consequences Theory (Hirst, Lane & Miller, 2015) and and Levett-Jones’ Clinical Reasoning Cycle (Dalton, Gee & Levett-Jones, 2015) to identify the care plan of an 83 year old widower diagnosed with Multiple Sclerosis. These frameworks are used to identify the influences impacting on the older person and their level of function and as a tool to drive the process of identifying and assessing, implementing and evaluating care. The essay will begin by identifying three nursing care priorities of Mr. Dinh. This will be followed by choosing the top priority of care and then using the remaining 4 steps in the Clinical Reasoning to establish goals and achieve best patient outcome while maintaining the dignity of the Mr Dinh and considering the cultural background throughout the process of assessment and care provision.

This is an 83 old patient – Mr Dinh Nguyen. He has been diagnosed with multiple sclerosis and is experiencing symptoms of numbness in his face, blurred vision, and an “electric shock” type of feeling while moving his limbs and head movement. The “electric shock” stimulus often radiates to his lower limbs and back which affects his ability to walk and hand movements. Dinh lives alone, his wife died a year earlier and he did not have any children. He has a brother who lives nearby. Nguyen noticed a marked decline in his health with ongoing worsening exacerbations of his MS. Other modifiable and non-modifiable changes include:

Age-related changes (not modifiable) for example reduced tone and breathing muscle performance; reduced sensitivity of chemoreceptors to low oxygen conditions , expanded chest wall consistency and reduced number of cilliary cells (Hirst, Lane & Miller, 2015).

Risk factors (modifiable) his ongoing pain and misery of losing his life partner and increased social isolation has a marked decline in his health with ongoing worsening exacerbations of his MS. Moreover, living alone in a two-storey house, with blurred vision can increase the risk of fall related injury (Dalton, Gee & Levett-Jones, 2015).

Negative Functional Consequences – He will be facing trouble in performing activities of daily living. Also, he is at a risk of being socially isolated and despair.

Dinh had a history of osteoarthritis diagnosed four years ago. He has multiple sclerosis since six years. Dinh feels tired easily and has difficulty bending forwards. Dinh has difficulty in performing his activities of daily living such as tasks such as cooking, showering, and dressing, particularly bending down to do up his shoe laces (Williams, 2015). Dinh has also started to experience some episodes of urinary incontinence. Because Dinh perceives that his disease process is worsening, he is starting to wonder how he can face the uncertainty of his future. Five stages of a person’s lifespan as per Roper-Logan-Tierney model include- infant, child, adolescent, adult, elderly. Depending upon the stage, ADLs are affected. Mr Dinh is an elderly male and is suffering from multiple sclerosis which is categorized as a neurological deficit. He also has difficulty in walking and urinary incontinency. He is emotionally unstable and he requires assistance both physically and emotionally (Williams, 2017).  Dinh requires proper treatment plan to prevent the worsening of multiple sclerosis. Currently, he is emotionally disturbed after the death of his wife. Also, he is feeling uncertain for his future. He is confused, agitated and mentally disturbed. He is not able to perform the activities of daily living such as showering, dressing, brushing and even walking. He will have difficulty to get up from bed and all other activities that require bending forwards. He will face difficulty in maintaining his personal as well as oral hygiene if he is not provided any assistance in time (Healey et al., 2016).

The chief problems that Mr Dinh is facing include- worsening of multiple sclerosis, urinary incontinence and difficulty in walking. The symptoms that MR. Dinh is experiencing are related to his underlying ailments. These include the following:

Blurred vision, numbness in his face, and an “electric shock” type of feeling –These symptoms are related to worsening of multiple sclerosis. Multiple sclerosis is a neurological disorder which is caused due to demyelination of neural cells in brain and spinal cord. Du to demyelination nerve conduction capacity of neural cells is disrupted. This results in various signs and symptoms including physical or psychological. Mr. Dinh is experiencing physical symptoms such as blurred vision and numbness on his face (Colhoun et al., 2015). The electric shock like feeling while bending forwards is also caused due to neurological deficit arising from inability of nerve conduction due to demyelination of neural cells.

Urinary incontinence – related to multiple sclerosis and nerve degeneration. Involuntary leakage of urine is known as Urinary incontinence. It can occur due to various factors such as stress, pelvic organ prolapse (POP), and obstetrical surgeries. Urinary dysfunction can hamper social relationships of Mr Dinh. It can also impact his activities of daily living.

Movement and gait difficulty –It is related to multiple sclerosis, osteoarthritis and nerve degeneration (Hedström, Olsson & Alfredsson, 2015). Knee osteoarthritis (OA) is a difficult and crippling condition that affects a huge segment of the adult population. Shockingly, knee tissues have limited the adaptation limitation, and some factors such as aging, weight gain, or knee injury can alter the multi-parametric link on these knee-tissues causing OAs.

Most significant problems and issues faced by Dinh include:

An “electric shock” type of feeling and blurred vision – This is related to multiple sclerosis. The patient is experiencing severe pain while bending forward. The electric shock type stimulus then radiates towards his lower limbs. He is not able to perform his ADL due to this constant painful stimulus (Crawford, Jewell, Mara, McCatty & Pelfrey, 2014).

Urinary incontinence – related to multiple sclerosis, stress and nerve degeneration. Due to nerve degeneration involuntary leakage of urine from urinary bladder is caused. This problem can affect his social relationships and ADL (Teunissen, Stegeman, Bor & Lagro-Janssen, 2015).

Movement and gait difficulty– related to multiple sclerosis, osteoarthritis and nerve degeneration. Although his osteoarthritis is controlled at the moment, but; chronic osteoarthritis along with multiple sclerosis can affect his movement and gait. Risk factors such as ageing and obesity are primarily linked to osteoarthritis (Porten & Carrucan-Wood, 2017).

Part B- The top priority of care and remaining 4 steps in the Clinical Reasoning Cycle

Considering Dinh’s age, his diagnosis of multiple sclerosis, psychological depressed mental state, isolated environment, life style, and social relationships it is important to establish precise, assessable, attainable, realistic and judicious goals with the help of clinical reasoning cycle.

The goals for managing symptoms due to worsening of multiple sclerosis could be:

Mr. Dinh’s blurred vision and frequency of electric shock stimulus like symptoms will be reduced to the level that he can tolerate within a month.

The goals for managing Urinary incontinence could be:

Mr. Dinh will be able to control his Urinary incontinence within two weeks ( Zarowitz et al., 2015).

The goals for managing Movement and gait difficulty could be:

Mr. Dinh will be able to walk without any difficulty and perform his activities of daily living such as showering, dressing and brushing within a month (Dalton, Gee & Levett-Jones, 2015).

Preventing worsening of Multiple sclerosis:

Many patients will have trouble accepting the diagnosis of MS and will be undetermined and highlight the possibility of inability. All individuals in the multidisciplinary group may be associated with offering development and adaptation of methodologies but occasionally it is useful to contact a neuropsychologist or counselor (Teunissen et al., 2015).

The multiple side effects of MS can be treated with drugs commonly used in various diseases; e.g. drugs used in the treatment of epilepsy, are routinely used for the treatment of neurological aggression experienced in MS and antidepressants can be used to treat tangible inconveniences (Crawford et al., 2014).

In intensive recurrence, corticosteroids are usually used to reduce worsening and shorten the duration of any new side effects. The main person who has to pay attention to the retreat is a regular MS Pro employee who will initially ensure that he has no prolific pollution. The medical service will inform about subsequent effects on steroid treatment and their use.

Prevention of urinary incontinence:

Urinary tract infections and incontinency can be expected which can be managed by using large administrations and nursing care plans (Crawford et al., 2014).

Holistic patient assessment can alert the nurse to any signs or side effects and an appropriate course of action can be taken, for example, the arrangement of pressure relief equipment and the referral to a nurse and physiotherapist consultant (Teunissen et al., 2015).

Prevention of movement and gait difficulties:

MS nurse professionals, physiotherapists and occupational therapists can offer fatigue management procedures.

In addition, weakness has different manifestations that are silent or shielded, such as pain, change of sensation, bladder incontinence, sexual dysfunctions, and intellectual problems. It is vital for the patient to ask for them when assessing the patient (Teunissen et al., 2015). Falls’ risk assessment is mandatory in elderly patients (Pfortmueller, Lindner & Exadaktylos, 2014). ADLs assessment and organizing a carer to assist Mr. Dinh with ADLs if compulsory.

Mr. Dinh is able to walk without any assistance and is able to dress himself with minimal discomfort

Mr. Dinh is able to climb stairs to reach first floor of his home without requiring any assistance.

Mr. Dinh is not facing any problem related to urinary incontinence (Crawford et al., 2014).

Next time, I would be aware about the sign and symptoms that are related to multiple sclerosis. I will have knowledge and experience to deal with patients suffering from such debilitating neurological disorder.

I should have used evidence based practice approach to gain information regarding neurological disorders that present similar signs and symptoms so that next time I am able to make a differential diagnosis myself (Strickland & Baguley, 2015).

If I had used EBP to make an intervention plan for Mr Dinh, it could have helped me in making a better intervention plan and increased my understanding about this debilitating condition (Healey et al., 2016).

I now understand that nerve demyelination is responsible for deficit in neurological communication. This leads to symptoms of “electric shock” like stimulus while perform activities of daily living. It impairs a patient’s life both physically and mentally (Rahn et al., 2018). I now understand the effects of long term osteoarthritis and MS. I also have understood the effects of MS in limiting ability to carry out ADL.

Two theoretical frameworks- Miller’s Functional Consequences Theory and and Levett-Jones’ Clinical Reasoning Cycle have been used to identify the care plan of an 83 year old widower-Mr. Dinh diagnosed with Multiple Sclerosis. Nursing care priorities in such patients should include identification of critical problems faced by the patient which hampered his activities of daily living. After clear identification of nursing care priorities, the nurse is ought to establish precise, assessable, attainable, realistic and judicious goals with the help of clinical reasoning cycle. This clinical case scenario has helped in understanding the etiology, pathogenesis and treatment of multiple sclerosis. Multiple sclerosis is crippling condition that can affect a person’s ADL as well as mental health state. Nurse should comply by the NMBA standards and use EBP to identify the latest technologies that can improve the patient outcome. Establishing clear goals can help in making an accurate and precise intervention plan to achieve the desired patient outcome.

Colhoun, S., Wilkinson, C., Izat, A., White, S., Pull, E., & Roberts, M. (2015). Multiple sclerosis and disease modifying therapies: results of two UK surveys on factors influencing choice. British Journal of Neuroscience Nursing, 11(1), 7-13.

Crawford, A., Jewell, S., Mara, H., McCatty, L., & Pelfrey, R. (2014). Managing treatment fatigue in patients with multiple sclerosis on long-term therapy: the role of multiple sclerosis nurses. Patient preference and adherence, 8, 1093.

Dalton, L., Gee, T., & Levett-Jones, T. (2015). Using clinical reasoning and simulation-based education to'flip'the Enrolled Nurse curriculum. Australian Journal of Advanced Nursing, The, 33(2), 29.

Healey, E. L., Main, C. J., Ryan, S., McHugh, G. A., Porcheret, M., Finney, A. G., ... & Dziedzic, K. S. (2016). A nurse-led clinic for patients consulting with osteoarthritis in general practice: development and impact of training in a cluster randomised controlled trial. BMC family practice, 17(1), 173.

Hedström, A. K., Olsson, T., & Alfredsson, L. (2015). The role of environment and lifestyle in determining the risk of multiple sclerosis. In Emerging and Evolving Topics in Multiple Sclerosis Pathogenesis and Treatments (pp. 87-104). Springer, Cham.

Hirst, S. P., Lane, A. M., & Miller, C. A. (2015). Miller's nursing for wellness in older adults. Wolters Kluwer.

Pfortmueller, C. A., Lindner, G., & Exadaktylos, A. K. (2014). Reducing fall risk in the elderly: risk factors and fall prevention, a systematic review. Minerva Med, 105(4), 275-81.

Porten, L., & Carrucan-Wood, L. (2017). Caring for a patient with multiple sclerosis. Kai Tiaki: Nursing New Zealand, 23(6), 16.

Rahn, A. C., Köpke, S., Backhus, I., Kasper, J., Anger, K., Untiedt, B., ... & Heesen, C. (2018). Nurse-led immunotreatment DEcision Coaching In people with Multiple Sclerosis (DECIMS)–Feasibility testing, pilot randomised controlled trial and mixed methods process evaluation. International journal of nursing studies, 78, 26-36.

Strickland, K., & Baguley, F. (2015). The role of the community nurse in care provision for people with multiple sclerosis. British journal of community nursing, 20(1), 6-10.

Teunissen, D. T., Stegeman, M. M., Bor, H. H., & Lagro-Janssen, T. A. (2015). Treatment by a nurse practitioner in primary care improves the severity and impact of urinary incontinence in women. An observational study. BMC urology, 15(1), 51.

Williams, B. C. (2015). The Roper-Logan-Tierney model of nursing: A framework to complement the nursing process. Nursing2018, 45(3), 24-26.

Williams, B. C. (2017). The Roper-Logan-Tierney model of nursing. Nursing2018 Critical Care, 12(1), 17-20.

Zarowitz, B. J., Allen, C., O'Shea, T., Tangalos, E., Berner, T., & Ouslander, J. G. (2015). Clinical burden and nonpharmacologic management of nursing facility residents with overactive bladder and/or urinary incontinence. The Consultant Pharmacist®, 30(9), 533-542.