The impact of a severe or a delimiting disease is extreme on the patient, affecting the lifestyle and abilities of the patient. However, for diseases that are intricately associated with bringing forth nerve damage, the impact of the nerve damage causing disease is far more deleterious on the patients (Dendrou, Fugger & Friese, 2015). Researchers are of the opinion that for the patients that are elderly and are suffering from the co-morbid disorders, the care planning must be patient centered and individualized. The clinical reasoning cycle serves as a potent framework or tool that helps the nurses address each and every care need on a priority based format, delivery care and reflecting on the procedure so that the care is safe, effective and individualized for the patient (Levett-Jones, 2013). This essay will attempt to utilize the clinical reasoning cycle to address to the care priorities that the patient is suffering from with respected to the Miller’s functional framework taking the aid of the case study of Dinh Nguyen.
The first and foremost, the nurse while assessing the patient considering the patient situation is extremely beneficial for the nurses to attain a basic understanding of the issues presented by the patient (LeMone et al., 2015). Here the patient under consideration is an 83 year old patient named Dinh Nguyen, an old Widower who had been a diagnosis of Multiple sclerosis 6 years ago. The comorbidity that Dinh had been suffering from includes osteoarthritis which is medically managed. Dinh has been living alone in the two storied house since the death of his wife and even though he has a brother, he is not willing to involve him with his life. He has some extent of financial independence and he is careful with money but with reduced investment returns, his earnings are only covering his own expenses.
The next step is for the nurse to collect and process all different kinds of information about the patient and then review and process the information to arrive at a verdict regarding bthe cared needs expressed by the student (Dalton, Gee & Levett-Jones, 2015). Considering the past medical history, it has to be mentioned that Dinh had a diagnosis of multiple sclerosis 6 years ago and has also been suffering with osteoarthritis from last 4 years. The presenting symptoms of the patient includes blurred vision, numbness in the face, feeling of electric shock while moving head and neck that travels down his neck and into his legs and associated activity intolerance, affecting his ability to cook, shower or dress up.
Processing the information, it is crucial for the nursing professional to interpret, discriminate, relate, infer and match the collected cues with best practice evidence to be able to arrive at an outcome. In this case, the most important health issue that Dinh is facing is the Multiple sclerosis which is also causing most of the symptoms for him. As mentioned by Dendrou, Fugger and Friese (2015), symptoms such as blurred vision, numbness, and electric shock sensation and unsteady gait are very common symptoms of multiple sclerosis and resultant brain lesions. Along with that, the impact osteoarthritis have also been reported to deteriorate the gait balance and mobility status of the patient, which can be the case for Dinh as well. On a more exploratory note, the impact of multiple sclerosis on the normal physiology of an adult body and its possible link with the osteoarthritis symptoms cannot be ignored either. Montalban et al. (2017), have mentioned that the risk factors of the osteoarthritis include muscular weakness, especially in the quadriceps which has been reported to be caused by MS. Along with that, people suffering with MS often have affected knee joints due to gait imbalance and muscular atrophy which leads to joint degeneration associated with OA.
The next step of the care planning will need to focus on the identifying the care needs based on the cues collected and processed by the nurse. In this case, the first and foremost care need for him is the mobility restriction and the fall risk. Dinh had been suffering from mobility resistance due to his MS symptoms which is known for causing unsteady gait. Along with that, his diagnosis of osteoarthritis and blurred vision will also facilitate a significant restriction in functional mobility for him. He lives in a two storied house alone, the mentioned health issues can potentially lead to considerable fall risk for him (Dennett, Coulter, Paul & Freeman, 2017). The second care issue that needs priority based intervention is the self-care deficit; as mentioned in the case study, Dinh had blurred vision and electric shock sensation which is caused by the multiple sclerosis which has affected his ability to move and participate in activity drastically. As a result, he is incapable of cooking, showering and dressing himself which is indicative of his self-care deficit affecting his hygiene and activities of daily living (Munsell, Locklear, Phillips, Frean & Menzin, 2015). The third care priority for him is the depression and anxiety that he is facing due to his perception of worsening symptoms and the uncertain future due to his disorders. Exploring further, it is very important to analyze that old age and loneliness can have a significant impact on the mental health of the patients, coupled with a deteriorating MS, the inabilities, restrictions and uncertainty of the future can lead to depression and anxiety disorders easily, further deteriorating his conditions. In this case, the self-care deficit has the most pressing potential to harm the patient causing nutritional imbalance, skin integrity issues and irritability and behavioral issues further complicating the situation, hence the chosen care priority is self-care deficit (Ma, Chan & Carruthers, 2014).
Establishing care goals is a crucial step of the care planning scenario, especially for the patient population of older adults, the care goals need to be definite and in accordance with the age related changes and restrictions (LeMone et al., 2015). Dinh is an 82 year old patient who is suffering from two delimiting health disorders, and the impact of aging is needed to be taken into consideration while establishing the care goals. The theory of functional consequences by Miller can be incorporated to understand impact of aging on Dinh and his disease and inabilities. The theory of functional consequences by Miller states that older adults experience functional consequences caused by age derived changes coupled with additional risk factors (Hunter, 2012). Exploring further, the impact of these functional consequences are negative and they require interventions. For the nursing care to be effective and functional the nursing professionals also require to recognize the functional consequences, both positive and negative and address them in the care goal establishment. In this case, the care priority selected is self-care deficit, caused mainly due to osteoarthritis related mobility deterioration and the clinical manifestation of multiple sclerosis. Multiple sclerosis most common demyelinating disease of the CNS, although age has no associated with the HLA DR15 phenotype, although aging can deteriorate the symptoms of MS by the normal physiologic changes (Marrie et al., 2015). Along with that, osteoarthritis, on the other hand is the result of age derived joint degeneration, hence this factor acts as a potent negative functional consequence for Dinh, contributing to his activity intolerance and self-care deficit. Hence, the care goals will have to address both multiple sclerosis symptoms and the age derived osteoarthritis to help him recover completely. The care goals for him will be:
The next step in the procedure is taking actions or implementing interventions to achieve the care goals that has been developed for Dinh (Dalton, Gee & Levett-Jones, 2015). The first and foremost treatment interventions that is important for Dinh is symptom management for his multiple sclerosis. The disease modifying drugs or the DMDs or the disease modifying drugs such as ocrelizumab which helps in slowing down the worsening disability. However, along with that oral corticosteroids such as prednisone can help in reducing the nerve inflammation which in turn will help in decreasing the intensity and frequency of electric shock sensation causing the activity intolerance (Feinstein, Freeman & Lo, 2015). Along with that as Dinh had been fatigued the aid of muscle relaxants and medication to reduce fatigue will also be administered to him. Lastly, I would also arrange physical therapy for Dinh by collaborating with a physiotherapist involving Dinh in stretching and strengthening exercises which will help him with his osteoarthritis and help him in completing daily tasks. I will also arrange for a support worker to help Dinh with his activities of daily living and go through a fall risk assessment to ensure his safety (Munsell, Locklear, Phillips, Frean & Menzin, 2015).
In the next step, the framework of clinical reasoning allows the nurse to focus on evaluating the outcome of the interventions implemented to improve practice and enhance efficiency of the care provided (Levett-Jones, 2013). After the implementation of the care interventions, there had been a marked difference in the activity tolerance of the patient. The pharmacological interventions were helpful in reducing the intensity of the electric shock sensation that he had been experiencing. The aid of physical therapy also helped him regain his strength slowly and improved the activity tolerance gradually (Rathert, Williams, McCaughey & Ishqaidef, 2015). Although, in the initial stage, it was difficult for him to carry on ADLs and the aid of support worker was beneficial but with perseverant utilization of treatment interventions he required lesser and lesser assistance in self-care activities with time.
The last step of the complete care planning activity is the reflection stage. I would like to state that this had been a reveling experience for me and it has helped me tremendously in understanding how to implement clinical reasoning and decision making while I am required to make judgments for providing care to a patient with severe health issues. Now I understand the impact of multiple sclerosis on the ability of patients to complete ADLs, and the exact issues of Dinh and associated care interventions has helped me understand how to design the care interventions to address the care needs of patients (Fredericks, Lapum & Hui, 2015). I did not have an experience of care prioritizing either, however, I have learned it while going through with this activity and I believe this exercise will help me exceptionally in my future practice.
On a concluding note, it has to be mentioned that is crucial for the nurses to understand the impact of chronic diseases such as multiple sclerosis on the life of the patient and living condition. It must not be ignored that for chronic illnesses, the patients often experience care needs and demands that are unique for them. Similarly, the care plans must include interventions that are individualized with patient centered care interventions so that each and every care intervention can be provided to the patient. This case study involved an elderly patient who had been suffering from the co-morbid disorders; in such cases, care planning for such patients must take into consideration not just addressing the symptoms that the patient is suffering from, but helping the patient cope with each and every change that has been brought forward by the disease in their lives. The clinical reasoning cycle and functional consequences theory by Miller helped in designing a curated individualized care plan which is essential for care provided to be safe, effective and patient centred.
References:
Afrasiabifar, A., Mehri, Z., Sadat, S. J., & Shirazi, H. R. G. (2016). The effect of orem’s self-care model on fatigue in patients with multiple sclerosis: a single blind randomized clinical trial study. Iranian Red Crescent Medical Journal, 18(8). doi: 10.5812/ircmj.31955
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. Retrieved from https://search.informit.com.au/documentSummary;dn=018184224173600;res=IELHEA
Dendrou, C. A., Fugger, L., & Friese, M. A. (2015). Immunopathology of multiple sclerosis. Nature Reviews Immunology, 15(9), 545. Retrieved from https://www.nature.com/articles/nri3871
Dennett, R., Coulter, E., Paul, L., & Freeman, J. (2017). Participants’ Experience of a Web-based Physiotherapy Programme for people with Multiple Sclerosis (MS): Does it impact physical activity levels?. Retrieved from https://hdl.handle.net/10026.1/10876
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. Doi: 10.1016/S1474-4422(14)70231-5
Fredericks, S., Lapum, J., & Hui, G. (2015). Examining the effect of patient-centred care on outcomes. British Journal of Nursing, 24(7), 394-400. Doi: 10.12968/bjon.2015.24.7.394
Hunter, S. (Ed.). (2012). Miller’s nursing for wellness in older adults. Lippincott Williams & Wilkins. Doi: 10.1111/ajag.12387
LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L., & Reid-Searl, K. (2015). Medical-surgical nursing. Pearson Higher Education AU. Retrieved from https://books.google.co.in/books?hl=en&lr=&id=MDXiBAAAQBAJ&oi=fnd&pg=PP1&dq=clinical+reasoning+levett+jones&ots=UI7W5Ii36h&sig=M1jPIusYgYK48SvgDhv1xFNFA5o
Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Pearson Australia. Retrieved from https://books.google.co.in/books/about/Clinical_Reasoning.html?id=rwc0MwEACAAJ&redir_esc=y
Ma, V. Y., Chan, L., & Carruthers, K. J. (2014). Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the United States: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Archives of physical medicine and rehabilitation, 95(5), 986-995. Doi: 10.1016/j.apmr.2013.10.032
Marrie, R. A., Cohen, J., Stuve, O., Trojano, M., Sørensen, P. S., Reingold, S., … & Reider, N. (2015). A systematic review of the incidence and prevalence of comorbidity in multiple sclerosis: overview. Multiple Sclerosis Journal, 21(3), 263-281. Doi: 10.1177/1352458514564491
Montalban, X., Hauser, S. L., Kappos, L., Arnold, D. L., Bar-Or, A., Comi, G., … & Lublin, F. (2017). Ocrelizumab versus placebo in primary progressive multiple sclerosis. New England Journal of Medicine, 376(3), 209-220. Doi: 10.1056/NEJMoa1606468
Munsell, M., Locklear, J. C., Phillips, A. L., Frean, M., & Menzin, J. (2015). An assessment of adherence among multiple sclerosis patients newly initiating treatment with a self-injectable versus oral disease-modifying drug. Neurology, 84(14), 3. Doi: 10.1177/0269215517730670
Rathert, C., Williams, E. S., McCaughey, D., & Ishqaidef, G. (2015). Patient perceptions of patient?centred care: empirical test of a theoretical model. Health Expectations, 18(2), 199-209. Doi: 10.1111/hex.12020
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