Promoting Health In Extended Care: Managing Multiple Sclerosis And Osteoarthritis In Older Adults

Nursing Care Priorities

Multiple sclerosis and osteoarthritis are commonly diseases of old age. Multiple sclerosis is a degenerative disease which affects the myelin sheath and conducting pathways of the central nervous system. There is demyelination of the white matter in the cerebellum, optic nerve and the spinal cord (Polman 2010). This leads to accumulation of plaques in the central nervous system. The demyelination is a progressive process and the myelin sheath regenerate until a point where nerve destruction occurs leading to manifestations. Osteoarthritis occurs when the cartilage preventing the bones from contact friction at the joints wear out leading to difficulty in joint movement (Zhang 2009). The main risk factor is advanced age. Miller developed the functional consequences theory to identify the influences impacting on older person and their level of function (Cotes, Chinn & Miller, 2009 & Hunters 2012). Mr. Dinh Nguyen is 83 year old widower living alone. Physiological changes accruing in old age predispose old people to many diseases. Their low immunity also contributes a lot. In this case levett-jones clinical reasoning cycle is going to be applied in the management of Mr. Dinh condition using the eight steps ( Lovett-jones 2010).

BODY PART 1

Nursing Care Priorities

Mr. Dinh experiences activity intolerance relates to the disease process. Multiple sclerosis causes effect on normal functioning of the nerves. When nerves get demyelinated the transmission of impulses is slowed thus affecting motor response. As the disease progresses damage of nerves occurs thus impairing nerve coordination. This is the result of Mr. Dinh experiencing an electric shock type of feeling when he moves his head and neck often traveling down his back and into his legs impacting his movement and gait. Also this is contributed by old age as described by miller’s functional consequence theory. As a person advance in age, there is reduction in muscle strength and function which can impair the ability to maintain activity (Blagojevic 2010). Furthermore  Mr. Dinh had an history of osteoarthritis which occurs when the protective cartilage on the ends of the bones wear out and if it progresses more it can cause difficulty in movement and carrying out day to day activities as it commonly affects knee joint, hand, hip and spine joints. This has a great impact on Mr. Dinh as he has to perform all activities on his own, go to work, and also has difficulty in climbing stairs because he lives in a story building. Also self-care deficit related to musculoskeletal disorders like arthritis and also damaged nerve due to multiple sclerosis. This has affected him so that he can’t do some activities on his own like cooking showering, dressing and bending.  This is due to impaired joint movements (Gordon 2014).

Bowel and urinary incontinence related to the multiple sclerosis is another nursing diagnosis to be prioritized. Nerves supplying the gastrointestinal tract are affected and therefore the involuntary contraction and relaxation of longitudinal and circular muscles together with spinster muscles are affected. In old age, individuals cannot respond to normal physiological cues hence they cannot respond to urge to urinate effectively. Normal aging also causes changes in the intestinal musculature and bladder muscles which may contribute to the incontinence. Micturition is a complex physiological function that relies on the proper functioning of the bladder muscles and spinsters responding to spinal nerve impulses (S2, S3 and S4) (Fry et al 2010). Urinary incontinence occurs whenever bladder, spinsters or nerves involved are diseased or damaged.  Functional bowel movement can also result if an individual cannot reach the toilet in a timely manner this may be because of immobility or impaired mobility. Incontinence brings an embarrassing problem which can lead to isolation in the society. This leads to lower self-esteem of the individuals involved a contributing factor to delayed healing process. Prolonged incontinence can also lead to poor skin integrity especially around the perineal area. The burning effect of urine destroys the skin cells especially of the epidermis and can easily lead to infections and bed sores. The main goal as a nurse is to reduce and manage incontinence and related complications. This can be done by teaching patient to have schedule to the bathroom frequently. Both external and in dwelling catheters is of great use but infection control should be performed to avoid ascending infections. Also the patient or the care giver can be taught on intermittent self-catheterization to empty bladder at specified times.  Collaborative management such as surgical procedures such as sphincterotomy may need to be done and also medications such as anticholinergic medications can help. This will greatly help avoid society stigma and isolation and also improve self-esteem (Johnson 2012).

Bowel and Urinary Incontinence

Anxiety related to advancing multiple sclerosis, decline in his health condition and worsening exacerbations of symptoms is another nursing diagnosis. His advanced disease condition has brought many limitations. As Mr. Dinh is a widower living alone with no children or close family apart from his brother who he doesn’t want to involve him in his life, he doesn’t have anyone close who can help him. He also recently lost his wife and the moments of grief and death is still fresh in his mind. He still has to go to job and do all activities of daily living with no assistance. With his deteriorating condition he fears who is going to help him as he has been independent all through. He also experiences family dysfunction. The role of a nurse is to help the patient demonstrate positive coping mechanism and reduce the level of anxiety. This can be achieved by reassuring the patient that he is in safe hands explaining all procedures to be done in an understandable language. Also patient education is very important. Tell the patient about his disease condition, the course of the disease process, treatment he has to undergo and the importance of having a close relative around. Inform him the importance of involving his brother in his condition and the expected outcome of the disease. This will help the patient relax. Also help the patient develop anxiety-reducing skills whenever they feel anxious. Skills like deep breathing, positive visualization and reassuring self-statements (Oliveira 2008).  

PART 2

Top Priority Nursing Care

The priority nursing care is activity intolerance.

GOALS

 The nursing goal is to ensure that the patient has increased level of activity in performing activities of daily living and to delay disease progress.

ACTIONS

This can be achieved through establishing guidelines and goals of activity with the patient. Patients get motivated if they participate in a goal setting. Activities should be within patient possibility depending on the seriousness of the patient’s disease. Mr. Dinh can be encouraged to do some activities such as dressing while seated and avoid activities such as bending to reduce suffering. However the nurse should not do for the patient what he can do for himself.  Also anticipating patient needs is very important. Basic things that the patient requires like tissue paper toilet and others should be of close rich. As Mr. Dinh has urinary incontinence closeness to the bathroom is important to him. Furthermore patient education on drug adherence is important. Corticosteroids such as prednisolone helps reduce inflammation and hence slowing progress.  Rest must be balanced with adequate exercise but exercise should not be tiring. Adequate rest periods especially before meals, after other activities of daily living, exercise sessions and ambulation. The patient should refrain from non-essential procedures to conserve energy. Provide emotional support while increasing activity. Promote positive attitude regarding abilities and encourage patient to choose activities that gradually build endurance. Family involvement is also important as it gives the patient sense of belonging and encouragement and can also continue with care provision at home. Collaborative management on rehabilitation, physiotherapy and psychotherapy contributes a lot to the wellbeing.  Appropriate aids can also be given as for Mr. Dinh a wheelchair can help in his movements. Mr., Dinh can experience financial difficulties as he lacks family support. The nurse can help him by introducing him to organizations such as of social worker to help with the bills (Thibault 2008).

Anxiety

Evaluation

On evaluating Mr. Dinh after two weeks he is able to perform such activities as cooking dressing with ease after physiotherapy and wheel chair use. Also he shows signs of improved self-esteem on his facial expression as he is able to manage his urine incontinence effectively and no more stigmatization. His brother also started offering support and care after his involvement with Mr. Dinh and this has boosted his esteem better and reduces isolation. He has also been adhering to medication as prescribed and this has contributed to his improvement.

Reflection

I now understand the effects of multiple sclerosis on activities of daily living and the importance of family and relatives in the management of health condition.

Conclusion

In conclusion, multiple sclerosis and osteoarthritis are disease conditions that greatly affect individual’s ability to perform activities of daily living. Symptoms such as blurred vision, sensory symptoms or numbness, motor symptoms such as paralysis of muscles extreme fatigue and decreased energy levels are contributors of impaired activity performance. Also managing osteoarthritis is possible on adherence to medication while multiple sclerosis has no specific treatment but management of symptoms is important in reducing progress. These conditions are contributed by advanced age as physiological and psychological changes occur in old age rendering them susceptible to such. The nurse plays a very crucial role in the management of individuals with multiple sclerosis and this care contributes a lot to the patient improvement. Other professionals like doctors, physiotherapists, psychotherapists, neurologists, nutritionists and others must also be involved in the management as it is a collaborative management .Family support and also support organization is also required for the success of patient care. The priority nursing care is activity intolerance and this can be achieved in many ways including involving other professionals. Anxiety is also another diagnosis and can be managed successfully in different ways such as patient education. Also urine incontinence is another diagnosis of a patient with multiple sclerosis and can be managed effectively by surgery medications and nursing involvement. Nursing practices such as scheduled urination time and catheterization is of great importance. This is the main cause of social isolation especially old people and if managed successful it will help avoid stigmatization and hence improved self-esteem.

Blagojevic, M., Jinks, C., Jeffery, A., & Jordan, 1. (2010). Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis. Osteoarthritis and cartilage, 18(1), 24-33.

Cohen, J. A., Coles, A. J., Arnold, D. L., Confavreux, C., Fox, E. J., Hartung, H. P., … & Brinar, V. V. (2012). Alemtuzumab versus interferon beta 1a as first-line treatment for patients with relapsing-remitting multiple sclerosis: a randomised controlled phase 3 trial. The Lancet, 380(9856), 1819-1828.

Cotes, J. E., Chinn, D. J., & Miller, M. R. (2009). Lung function: physiology, measurement and application in medicine. John Wiley & Sons.

Fry, C. H., Meng, E., & Young, J. S. (2010). The physiological function of lower urinary tract smooth muscle. Autonomic neuroscience, 154(1-2), 3-13.Gordon, M. (2014). Manual of nursing diagnosis. Jones & Bartlett Publishers. Oliveira, N., Chianca, T., & Rassool, G. H. (2008). A validation study of the nursing diagnosis anxiety in Brazil. International Journal of Nursing Terminologies and Classifications, 19(3), 102-110.

Hunter,S.(Ed). (2012). Miller’s nursing for wellness in older adults. Sydney: Woters Kluwer/Lippinot, Williams and Wilkins.

Johnson, M., Bulechek, G. M., Dochterman, J. M. M., Maas, M. L., Moorhead, S., Swanson, E., & Butcher, H. K. (2011). NOC and NIC Linkages to NANDA-I and Clinical Conditions-E-Book: Nursing Diagnosis, Outcomes, and Inverventions. Elsevier Health Sciences

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.

Levett-jones, T. (Ed). (2013). Clinical reasoning: Learning to think like a nurse. Frenchs Forest, NSW:Pearson.

NANDA. International. (2012). Nursing Diagnoses: definitions & classification 2012-2014. Wiley-Blackwell.

Oliveira, N., Chianca, T., & Rassool, G. H. (2008). A validation study of the nursing diagnosis anxiety in Brazil. International Journal of Nursing Terminologies and Classifications, 19(3), 102-110.

 Polman, C. H., Reingold, S. C., Banwell, B., Clanet, M., Cohen, J. A., Filippi, M., … & Lublin, F. D. (2011). Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria. Annals of neurology, 69(2), 292-302.

Thibault, P., Loisel, P., Durand, M. J., Catchlove, R., & Sullivan, M. J. (2008). Psychological predictors of pain expression and activity intolerance in chronic pain patients. Pain, 139(1), 47-54.

 Zhang, W., Nuki, G., Moskowitz, R. W., Abramson, S., Altman, R. D., Arden, N. K., … & Dougados, M. (2010). OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis and cartilage, 18(4), 476-499.