Patient Background and Medical Condition
Aging related changes have a great impact on both cognitive function and physical activity of the older people, Miller 2012. Miller developed wellness as a concept where he observed that older people are less valued in our society despite goals to extend life expectancy getting achieved. Levett-Jones’ Clinical Reasoning Cycle is an important tool that help to identify, assess, implement and evaluate care hence promoting the wellness and value of this older people. Levett-Jones’ Clinical Reasoning Cycle first four steps include, considering the patient, collecting cues and information, processing information and then identifying issues, (LeMone, Burke, Dwyer, Levett-Jones, Moxham, & Reid-Searl, 2015). Levett. The purpose of the assessment to be discussed here is to measure the capability of a learner to identify and prioritize the most important nursing care that a client requires. The two theories, Miller’s functional consequence theory and Levett-Jones’ Clinical Reasoning Cycle will be the key theoretical frameworks to help identify and prioritize nursing for the client referred to in the case scenario.
Mr. Dinh Nguyen, 83-year-old widower was diagnosed six years ago with multiple sclerosis (MS) and also four years ago was diagnosed with osteoarthritis. He is currently under medications, Panadol Osteo 6/24 oral prn (maximum of 6 tablets per day), Teriflunomide 14mg Oral daily, Prednisolone 25mg Oral BD (during an exacerbation). MS is a chronic progressive degenerative disease that affects myelin sheath and conducting pathways of CNS (Swann, 2008). Osteoarthritis on the other hand is a common form of arthritis and is thought of as a degenerative disorder that results in breakdown of articular (hyaline) cartilage in the synovial join or the entire joint organ, ( Carlos, 2018). He is experiencing some blurred vision, numbness in his face and also an “electric shock” type of feeling when he moves his head and neck which radiates downwards to his back and legs leads to alteration in his movement and gait. This makes his daily activities such as cooking, bathing and clothing difficult especially when bending down. Nguyen has also been experiencing some episodes of urinary incontinence.
He lives alone in his own two story building since his wife died twelve months ago and they did not have any child hence no immediate family. He however has a brother, Bao who lives with his family close by, but Dinh does not want to bother them with his daily life. With his ongoing grief and increasing isolation, Dinh has noticed a decline in his health which has led to exacerbations of Multiple Sclerosis. He gets income from his self-managed pension however this caters for his expenses only because of reduced investment returns. He goes for holiday once every year but could not manage this year due to his difficulty in movement. Dinh is starting to get anxious because he perceives his disease process is worsening.
Mr. Dinh blurred vision is related to multiple sclerosis that he is suffering from. MS is a disease that affects central nervous system which includes the optic nerve that functions to transmit light and visual images to the brain. Inflammation of the optic nerve is among the first symptom in MS patients during their disease process. Optic neuritis leads to sudden loss of vision mostly in one eye; blurred and eye pain on movement. Numbness of face is another symptom that Dinh has developed due to MS. It’s usually also among the first symptoms to appear in MS patients. This is due to damage of the nerve surrounding the face, facial nerve as the body’s immune system attacks the layer that protects the nerve fibers. The electric shock sensation that Dinh experience is described as Lhermitte’s sign and is also associated with MS. It is related to demyelination of the nerves due MS. These nerves that have been damaged respond to even slight movements of the neck, which in turn causes sensation from the neck to the spine. This may also cause the same feeling in arms, legs, fingers and toes hence leading to alterations of movement and even gait. The shock like feeling is usually short and intermittent but can be very powerful when experienced.
Nursing Care Priority 1: Self-care Deficit
The episodes of urinary incontinence experienced by Mr. Dinh occurs when MS lesions block or delay nerve signals transmission in the central nervous system area that controls the bladder and urinary sphincters. This leads to a spastic bladder which is unable to keep normal amount of urine or retain some urine in it during emptying which can cause symptoms like; frequency of urination, delay in starting urination, frequent urination during night, incontinence.
Mr. Dinh is encountering self-care deficit since he has difficulty in performing tasks of dairy living such as self-feeding, dressing, toileting, and even walking. This is because of joints impairment and shocking sensation related to multiple sclerosis. This appear among the top nursing care since he lives independently and have no immediate family having lost his wife twelve months ago and they had no child. The nurse however should coordinate to maximize the independence of the client and make sure that the surrounding environment is safe and supportive to the special needs. The nurse should also assist the client to accept necessary amount of dependence where he cannot perform. Moreover, privacy should be provided when necessary for example during dressing and toileting.
Anxiety is another nursing care to be prioritized. With the worsening disease process being perceived by Mr. Dinh, he is beginning to get anxious of what the future holds. The fact that his pension also no longer caters for most of his expenditures might also be another source of worry to him. The nurse therefore should consider this as a major area to provide care for him because anxiety can become quite uncomfortable for the client. It can become pervasive and disabling to the patient. A nurse should therefore help the patient in identifying and recognizing the factors that elevate anxiety and introduce the alternative methods to prevent anxiety from manifesting in the client. this ability to recognize anxiety symptoms earlier enables the patient to intervene faster to manage the anxiety.
Urinary incontinence is also another priority nursing care to be keenly monitored. Urinary incontinence can be very embarrassing to the client since urine may involuntarily leak. This can lead to social isolation and also some psychological disturbance. The nurse should promote perineal care for the client to reduce skin irritation and risk of ascending infection. Continue mobility should also be encouraged to decrease risk of developing urinary tract infection.
The most important nursing care priority for Mr. Dinh is self-care deficit. He has impaired ability to perform many task such as cooking, dressing, showering and specifically bending down to tie his shoe laces. This is related to neuromuscular impairment due to multiple sclerosis and also decreased strength and discomfort. The desired outcomes for this care include; to identify the client’s areas of weakness/needs, to show him tactics that will change his lifestyle to meet his needs, to safely perform self-care activities and also to identify any resources that can provide assistance. The nurse should firs assess the client’s ability to perform dairy activities regularly in order to determine the self-care that is problematic to this client. The main rationale for this, is that the client may only require assistance with self-care measures. The nurse should therefore encourage him to safely perform self-care to the best of his ability to promote independence and sense of control in order to decrease feeling of helplessness.
Nursing Care Priority 2: Anxiety
The nurse should ensure that activities of daily living are scheduled early in the day or time when energy level is best. Enough time should be provided to him while performing tasks and patience displayed when movements are slow.
Some devices can be provided to aid in some tasks these include; shower chair, elevated toilet seats with arm supports. These devices help reduce fatigue hence promoting participation in self-care. Providing massage on a regular schedule can also help maintain muscle strength and tone and also joint mobility.
Collaborative management can be involved in this management. Therefore, an occupation therapist will be of much importance in identifying devices or equipment that relieve spastic muscles and also preventing muscle atrophy and contractures thus promoting independence and increasing sense of self-worth.
Drugs administration should also be considered very important in promoting self-care. Mr. Dinh has been prescribed Panadol osteo which is an important drug in management of osteoarthritis. It provides long lasting relief from persistent pain. Relief of pain enables him perform his daily duties with ease.
On evaluation after one week, Mr. Dinh was able to perform most of his daily activities with minimal assistance. He was also able to accept dependence since he leaves alone. Within our care Mr. Dinh was also able to show a positive coping mechanism because he was able to identify a problem that was causing stress. He was also able to use problem solving ability when his anxiety level was low. Mr. Dinh was also able to perform most of his daily activities in the morning when energy level was high and also adhered to medications.
I now understand that nursing care for a patient with multiple sclerosis is very important and must be sorted out in order of priority so that effective nursing care can be provided without leaving out those which are necessary. I also have understood that taking care of older people is one of the key aspects in provision of nursing care. They have to be valued and served with dignity.
In conclusion, miller’s functional consequences theory and Levett-Jones’ Clinical Reasoning Cycle greatly helps in nursing management of aging patients. The process of identifying and coming up with priority nursing care for a client is also vital since urgent issues will get to be managed first and hence improving the wellness of a client. Collaborative management must also be included in management of a client since one health staff is not sufficient enough to provide all the care of a particular client. With this better health care services will be achieved.
References
Carlos J Lozada, MD (2018). Osteoarthritis. online journal
Hunter,S.(Ed). (2012). Miller’s nursing for wellness in older adults. Sydney: Woters Kluwer/Lippinot, Williams and Wilkins.
LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L., & Reid-Searl, K. (2015). Medical-surgical nursing. Pearson Higher Education AU.
Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S. Y. S., Noble, D., Norton, C. A., … & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’patients. Nurse education today, 30(6), 515-520.
NANDA. International. (2012). Nursing Diagnoses: definitions & classification 2012-2014. Wiley-Blackwell.
Swann, J. (2008). What is multiple sclerosis? British Journal of Healthcare Assistants, 2(4), 168-170.
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