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Inquiry for Chronic Care Care Planning 

You have commenced your clinical placement at Curtin Hospital on Ward 9A Medical Ward. Following handover you have been allocated Heather Cook, aged 48 years, diagnosed with Multiple Sclerosis. Heather was admitted earlier this afternoon to Ward 9A for management of her Stage 1 pressure injury.

You have been asked by your buddy nurse to write Heather’s care plan from admission to discharge. Your buddy nurse completed the nursing assessment following Gordon’s Health Assessment Framework which is provided below.

Four of the most important nursing problems need to be identified and written appropriately as nursing diagnostic statements.

You will need to write one expected outcome for each nursing diagnostic statement identified.

Four nursing interventions for each nursing diagnostic statement need to be identified.

One scientific rationale needs to be provided for each nursing intervention. Each rationale will relate to, support and provide validity for the intervention. Each rationale is to be referenced.

You will need to include one handover of care using iSoBAR for the next shift.

You will need to include one discharge plan for all identified nursing problems.

Nursing Diagnostic Statement 1

Patient has a risk for fatigue as evidenced by the long time spent on the wheelchair before admission due to shift change of patient’s community nurse.

Patient will show sign of better sense of increased energy and will express lack of fatigue. Patient will also be able to maintain their desired level of daily activity.

Nurse will study the patient and decide the need for aids regarding daily activities like walkers or wheelchairs.

Fatigue generally reduces the patient’s endurance level. Aids like walkers, wheelchairs can help to lower the fatigue level and to improve the sense of comfort and independence (Khan, Amatya & Galea, 2014). This will also improve patient’s safety.

Nurse will use cooling vest to lessen the fatigue level.

Study have shown that symptoms of multiple sclerosis get worsened with increased temperatures. This phenomena have been reported by multiple sclerosis patients. Cold temperature helps patients to tackle their symptoms better. Although, according to the researchers this might be temporary. This is comparatively easier treatment, so researchers have developed cooling vest in which cooling fluid pumps through the vest to reduce the temperature of wearing patients (Sedal, Wilson & McDonald, 2014).

Nurse will accept and assist the patient when she is incapable to perform daily activities.

Patient with multiple sclerosis’ ability to perform daily activities varies from one moment to another. Fatigue generally gets worse late in the afternoon along with the increased body temperature (Nogueira et al., 2013). This may leads to patient’s inability to perform daily activity. Accepting it without any judgement and providing the patient with required care will help the patient with a sense of independence.

Nurse will plan to accommodate rest period between activities and persuade to have afternoon sleep. 

Taking a nap is an effective way to tackle fatigue related to fatigue. Short sleep break helps to lessen the fatigue level of the patient and also helps to reduce the muscle aggravation. At afternoon, most patient with multiple sclerosis complains about the aggravation symptoms. Hence, a short nap in the afternoon often is helpful in tackling fatigue (Clancy, Drerup & Sullivan, 2015). However, some patients reported that afternoon rest does not restore their energy level. Fatigue does not damage and harms the nervous system. Therefore, patient should not push themselves and rest between activities might be enough.

Patient has risk for acute pain as evidenced by pressure injury in right ischial tuberosity, stage one and 7 out of 10 pain score at the time of admission.

Patient will be in position to feel gradual relief or reduction of pain.

Nurse will check the vital signs like increased respiration, hypertension and heart rate. Nurse will check these signs even though the patient report no pain.

First sign of acute pain is that changes in the vital signs like increased respiration, hypertension and heart rate. Changes in these vital signs indicates discomfort and surge of acute pain. Some patients may demonstrate lower blood pressure which generally returns to normal with the reduction in pain (Gold et al., 2014).

Nursing Diagnostic Statement 2

Nurse will administer local pain relief method to injured area which is pressure injury in right ischial tuberosity.

Patient’s injury in her right ischial tuberosity, so local pain relief method like heat and ice can be administered to lessen the pain. Ice and heat are effective in case of relieving pain in joints and muscles. Relaxation methods and massage can also be applied to reduce the pain or will help the patient to deal the pain better (Ehde et al., 2015). There is none conclusive proof that shows that these measure help the patient to overcome their other multiple sclerosis pain but these methods might be helpful to patient to deal with the pain better and enhance their pain tolerance threshold.

Nurse will eliminate or reduce factors leads to increase in pain and to provoke behaviours which are conditioned to relaxation like abdominal breathing, deep breathing or music therapy.

Factors (such as fatigue, fear, lack of knowledge) that may leads to increase in pain should be avoid to improve whole pain management. For example, total immobility (if possible) or restrained mobility will help to stop aggravating the affected area. This will also help to heal the affected area faster. Relaxation methods promotes the reduction of muscle tension which in turn helps in reduction of pain intensity. Relaxation techniques like music therapy acts as a distractor from hospital cacophony and therefore help the patient to reduce pain and anxiety (Gali?ska, 2014).

Nurse will administer 1g Paracetamol for pain as prescribed and as required.

Paracetamol has been used as analgesic for tackling moderate pain and other acute pain. Generally, paracetamol is the most used analgesic to reduce pain and it has very rare side effects in adults (Moisset et al., 2013). Paracetamol is mostly safe for most people except people with kidney or liver problems.  Dosage of paracetamol should not increase four gram over twenty four hour period.

The patient has a risk for impaired urinary discharge as demonstrated by use of long term in situ catheter.

 Patient’s bladder will be emptied completely and regularly. Patient will also be free of urinary tract infection and urine leakage.

Nurse will be noting the urinary urgency, frequency, incontinence and burning sensation. Nurse will also palpate bladder after discharge.

Urinary urgency, frequency and burning sensation will provide the information about whether there is a urinary tract infection or not. Generally, a burning sensation during urination indicates to infection. Palpation of bladder will be done to examine whether there is any urine retention after voiding which might require nursing intervention (Kantor et al., 2015).

Nurse will persuade the patient to intake adequate amount of fluid, limit drinking coffee with sugar.

Staying hydrated and drinking adequate amount of liquid regulates sufficient amount of output which also helps in preventing infection. Also, patient taking drugs needs sufficient amount of liquid to proper excretion drugs which will also reduce the collective effects. Along with that, sugar or sugar substitute may act as an irritant which in turns leads to bladder dysfunction (ORASANU & MAHAJAN, 2013).

Expected Outcomes

Nurse will administered proper technique and timings of voiding and also recommend good hygiene procedure.

Proper timing and voiding technique will help to minimize the incontinence occurrence as well as diminish the chance of bladder infection or partial emptying of bladder. It will correspondingly help to restore sufficient functioning of bladder. Proper hygiene method will lessen the chance of infection as well as reduce coincidental skin irritation (Phé et al., 2016).

Nurse will supervise the consumption of 10 mg Ditropan oral tablet as prescribed and as required.

Ditropan belongs to the Oxybutynin groups. The medicine Oxybutynin works to lessen the symptoms of a hyperactive bladder like leakage, urinary frequency and urinary urgency. Working mechanism of this medication is to relax the bladder muscles which lead to lessening of the urge to urination, bladder spasms and urination frequency (Adamec & Habek, 2013). It might be harmful to the patients if it is not prescribed by medical practitioner.

Patient has a risk for self-care insufficiency as demonstrated by the patient’s need of assistance in mobility and maintaining personal hygiene like showering.

Patient will be able to perform her own self-care activities within her own capability and be able to better understand and identify the community services that provides support.

Nurse will examine the physical state and present activity level and assess it using zero to four scale of her functional impairment.

Information gathered from the examination will help to understand and to develop better plan for rehabilitation. However, caregiver should keep it in mind that motor skills less likely to enhance compared with the sensory ones (Feinstein, Freeman & Lo, 2015). Nevertheless, overall procedure will help to develop better rehabilitation plan.

Nurse will assist the patient as much as her disability demands while allowing maximum autonomy possible.

Patient with multiple sclerosis need some help regarding their daily activity as performing some task is out of their ability. Caregiver should allow as much autonomy as possible become patient might become impatient and frustrated because of their lack of independence and participation (Acaster, 2013). Assisting to perform their undoable activity will also help the patient to maintain their hygiene.

Nurse will allow enough time to perform their daily activity and illustrate patience and compassion while patient’s movement are slow.

During multiple sclerosis patients generally lost their ability to perform motor skills like regular person. Spasticity might interfere with their ability to perform even the simplest task (Klaren et al., 2013). Thus, it is necessity for the caregiver to allow adequate time to the patient to perform their own activities as it will increase their self-esteem.

Nurse will anticipate the patient’s hygienic needs such as showering, hair, nail and assist her patiently as required.

Caregiver’s attitude and handling of this situation in calm and sensible manner can exempt the patient from being embarrassed for not being able to perform such menial task. Apart from that, it will also help to maintain the hygiene of the patient, thus removing the chance of infection (Topcu et al., 2016).

Nursing Interventions

My name is -------- -----------, I am on clinical placement at Curtin Hospital on Ward 9A Medical Ward. I am calling regarding Heather Cook a 48 years old female with URN: 12345678.

Mrs Heather Cook was admitted to the Curtin Hospital by ambulance earlier this afternoon to Ward 9A for management of her Stage 1 pressure injury with her husband in attendance. Reason of this calling is that I am concerned about Mrs. Cook’s stage one pressure injury on her right ischial tuberosity.

Mrs Heather Cook has a pain score of 7 out of 10 at the time her admission. The area of the injury is 2 cm X 3 cm. During the initial exam, it was revealed that Mrs Cook has noticeable non-blanchable redness over her right ischial tuberosity. Skin was intact on her injured area. According to Mrs Cook, her backside has become sore on her right side over the past week and it hurts if she spent too much time on wheelchair. She also requires hoisting during her transfer.

Mrs Cook was diagnosed with multiple sclerosis when she was 30. She was hospitalized multiple times owing to this reason. She has no previous record of injuries or accidents. Height and weight of Mrs Cook is 174 cm and 65 kg respectively. As per as Mrs Cook, she has no allergies.

I am calling to have Mrs Heather Cook assessed as I think Mrs Cook needs immediate attention regarding her pressure injury which has been sustained for over a week despite the regular consumption of analgesic (1g Paracetamol) tablets.

Presently, Mrs Heather Cook is awaiting medical review from a physiotherapist.

You have a stage one pressure injury with multiple sclerosis. Here are some suggestions that you can administer to lessen the problem for you identified problems:

  • Fatigue: Plenty of rest is advisable as fatigue is a general symptom of multiple sclerosis and also avoid extreme heat. Try to plan your activities in advance and allot a sufficient amount of time between activities.
  • Pain: consume the medicine as provided the medical practitioner and contact the healthcare provider as soon as possible if the pain persists.
  • Impaired urinary discharge: Try to drink at least 6 - 8 glasses of water each day. Make an effort urinate every three hours during day time. Urinate before going to bed and also avoid consuming liquid before going to bed. Take the medicine prescribed and use a catheter if necessary.
  • Self-care deficit: to manage your stress level performs the activities that relaxes you. Get in touch with local community and support centre if support from family member is not sufficient.

Along with the above, please do not hesitate or delay to call the healthcare provider if any of these symptoms occurs: high fever, extreme weakness or tiredness, vision impairment or unusual or confusing behaviour.


Acaster, S., Perard, R., Chauhan, D., & Lloyd, A. J. (2013). A forgotten aspect of the NICE reference case: an observational study of the health related quality of life impact on caregivers of people with multiple sclerosis. BMC health services research, 13(1), 346.

Adamec, I., & Habek, M. (2013). Autonomic dysfunction in multiple sclerosis. Clinical neurology and neurosurgery, 115, S73-S78.

Clancy, M., Drerup, M., & Sullivan, A. B. (2015). Outcomes of cognitive-behavioral treatment for insomnia on insomnia, depression, and fatigue for individuals with multiple sclerosis: a case series. International journal of MS care, 17(6), 261-267.

Ehde, D. M., Alschuler, K. N., Osborne, T. L., Hanley, M. A., Jensen, M. P., & Kraft, G. H. (2015). Utilization and patients' perceptions of the effectiveness of pain treatments in multiple sclerosis: A cross-sectional survey. Disability and health journal, 8(3), 452-456.

Feinstein, A., Freeman, J., & Lo, A. C. (2015). Treatment of progressive multiple sclerosis: what works, what does not, and what is needed. The Lancet Neurology, 14(2), 194-207.

Gali?ska, E. (2015). Music therapy in neurological rehabilitation settings. Psychiatria polska, 49(4), 835-846.

Gold, R., Comi, G., Palace, J., Siever, A., Gottschalk, R., Bijarnia, M., ... & FIRST Study Investigators. (2014). Assessment of cardiac safety during fingolimod treatment initiation in a real-world relapsing multiple sclerosis population: a phase 3b, open-label study. Journal of neurology, 261(2), 267-276.

Kantor, D., Chancellor, M. B., Snell, C. W., Henney III, H. R., & Rabinowicz, A. L. (2015). Assessment of confirmed urinary tract infection in patients treated with dalfampridine for multiple sclerosis. Postgraduate medicine, 127(2), 218-222.

Khan, F., Amatya, B., & Galea, M. (2014). Management of fatigue in persons with multiple sclerosis. Frontiers in neurology, 5, 177.

Klaren, R. E., Motl, R. W., Dlugonski, D., Sandroff, B. M., & Pilutti, L. A. (2013). Objectively quantified physical activity in persons with multiple sclerosis. Archives of physical medicine and rehabilitation, 94(12), 2342-2348.

Moisset, X., Ouchchane, L., Guy, N., Bayle, D. J., Dallel, R., & Clavelou, P. (2013). Migraine headaches and pain with neuropathic characteristics: comorbid conditions in patients with multiple sclerosis. PAIN®, 154(12), 2691-2699.

Nogueira, L. A. C., Teixeira, L., Sabino, P., Filho, H. A., Alvarenga, R. M. P., & Thuler, L. C. (2013). Gait characteristics of multiple sclerosis patients in the absence of clinical disability. Disability and rehabilitation, 35(17), 1472-1478.

ORASANU, B., & MAHAJAN, S. T. (2013). Bladder and bowel dysfunction in multiple sclerosis. Multiple sclerosis and related disorders: Clinical guide to diagnosis, medical management, and rehabilitation, 200-210.

Phé, V., Pakzad, M., Curtis, C., Porter, B., Haslam, C., Chataway, J., & Panicker, J. N. (2016). Urinary tract infections in multiple sclerosis. Multiple Sclerosis Journal, 22(7), 855-861.

Sedal, L., Wilson, I. B., & McDonald, E. A. (2014). Current management of relapsing?remitting multiple sclerosis. Internal medicine journal, 44(10), 950-957.

Topcu, G., Buchanan, H., Aubeeluck, A., & Garip, G. (2016). Caregiving in multiple sclerosis and quality of life: A meta-synthesis of qualitative research. Psychology & health, 31(6), 693-710.

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