Case Study: Clinical Reasoning Cycle And Functional Consequences In Nursing Care Prioritization

Mr. Nguyen’s Condition

The following is a case study of Mr. Nyugen who is 83 years old and suffers from urinary incontinence, multiple sclerosis, osteoarthritis. The report utilizes the Functional Consequences to analyze the effect of the different conditions on the functions of the patient. Additionally, the Clinical Reasoning Cycle is used in order to identify the best strategy for intervention for one of the selected issue the patient is facing (Levett-Jones, 2013). The care priority identification is important as it allows focusing on one particular condition and developing a plan to address it and thus help the patient (Papastavrou et al., 2014; Urden et al., 2015).

This report aims to identify the care priorities of nursing, and identify which priority needs to be addressed. The clinical reasoning cycle is used to determine the care priorities, identifying the age related changes, risk factors and negative functional consequences (Dalton et al., 2015; Levett-Jones, 2013)). Cues or information is gathered next and then processed to find the relation between the challenges or issues faced by the patient to the clinical conditions (Bregagnollo et al., 2017). From this selected problems, one care priority area is selected to be focused on. Next goals are set which is specific, measurable, achievable, and realistic and time bound. Care plan is developed based on the goals. The plan is then evaluated to analyze if it was able to achieve the goals, and reflection on the key learning is discussed at the last to highlight the knowledge gained, and the best practice that can be utilized for other cases (Khokhar et al., 2017; Yang et al., 2015; Hunter, 2016)).

Age Related Changes:

The patient (Mr. Nyugen) is an 83 year old man. Due to his advanced age he is suffering from multiple sclerosis, osteoarthritis, urinary incontinence, reduced mobility and blurred vision.

Risk Factors:

The patient lives alone in a two storey home. He is facing a reduction in his income due to low returns of investment due to which he is just adequate to cover his basic expenses. He has blurring of vision and restricted mobility which can increase the risks of falling and injuring himself. He is also recently facing urinary incontinence issues.

Negative Functional Consequences:

Urinary incontinence, challenges in performing ADL, such as taking a shower, dressing him up, tying shoelaces, preparing food. Risks of social isolation and depression. Death of his wife, which is causing the patient to be isolated. Financial constraints due to reduced flow of cash (Fonareva & Oken, 2014).

Nursing Care Priorities – Clinical Reasoning Cycle

Three Nursing Care Priorities:

1. Helping the patient the Incontinence- This is the top priority since it affects patient’s ADL. Due to the age of the patient he can be experiencing incontinence issues, affecting his ADL, and therefore his quality of life.
2. Improving Gait and Balance: This is an important care priority since the condition of Multiple Sclerosis his restricted mobility is affecting the ability to perform the ADL’s and therefore can hamper the quality of life (Jerez?Roig et al., 2016).  However this is the second priority because the patient is already receiving treatment for Multiple Sclerosis.
3. Psychological Care- This is also an important nursing care priority, since the isolation of the patient from his family can increase the risks of depression and mental health issues. His psychological stress also could be aggravated due to his reduced mobility, financial constraints and the inability to go on holidays (Maruish, 2017; Hessler et al., 2018).

Cues/Information

Mr. Nguyen was diagnosed of Multiple Sclerosis 6 years ago, and with osteoarthritis 4 years go. He lives alone in his two storied house since the death of his wife a year ago. He has no children or an immediate family. Mr. Nyugen’s brother and his family lives close by, but he wants to avoid bothering his brother and his family with his problems. His reduced mobility have prevents him from going on holidays. He is also experiencing blurred vision, numbness in face and an electric shock like feeling whenever he tries to move his head. The pain travels down his neck and towards his legs impacting his movement and gait. Due to this he is facing difficulties in his Activities of Daily Living such as taking a shower, dressing himself, tying shoelaces and making food.  He is also facing trouble due to his urinary incontinence. Mr. Nyugen is constantly worried now due to his deteriorating health conditions and is worried about his future.

Process information

Urinary Incontinence: Related to multiple sclerosis or age. Neuronal damages can also cause urinary incontinence which can be caused due to Multiple Sclerosis. Also because of age, urinary incontinence can occur (Jerez?Roig et al., 2016; Hunter, 2016).

Blurred vision: Related to Multiple Sclerosis and Macular Degeneration. Blurred vision can be caused due to the damage to the optical neurons due to multiple sclerosis, as a result of which the optic neurons are not able to carry visual signals to the brain causing blurring (Balcer et al., 2014; Preziosa et al., 2016). In case of Macular Degeneration, the center of the retina can deteriorate and leaky blood vessels can develop below the retina. The effect is the loss of the center of vision and blurry vision (Wong et al., 2014).

Numbness of face: Related to multiple sclerosis. The neuronal damage can also cause numbness of face as it interferes with the signal transfer from the facial nerves to the brain. Loss of sensation or numbness can occur because of this (Xu et al., 2017).

Reduced mobility and gait: Related to osteoarthritis and multiple sclerosis. Due to multiple sclerosis, the patient is facing an electric shock like feeling every time he moves his head, and the pain travels down his neck and to the legs that affects his movement and gait (Qureshi et al., 2016). Also, because of osteoarthritis, he can have painful joints and thus have difficulties moving his hands and legs thereby affecting his movement and gait (Gill and Kim, 2018; Hunter, 2016).

Functional Consequences Theory

Problems/Issues

The main issues that can be identified from the case study includes: reduced mobility and gait, blurred vision, numbness of face and urinary incontinence. Of these problems we have chosen reduced mobility and gait as the top area of priority for the patient.

Goals:

The goals for improving incontinence can be:

1. Nyugen will have reduced episodes of incontinence within a week
2. Nyugen will be able to schedule his toilet schedules on his own in 2 weeks

Nyugen will no longer need interventions for urinary incontinence in one month

Action Plan

Goal i: Mr. Nyugen will have reduced episodes of incontinence within a week

Expected Outcomes: Mr. Nyugen will report a 50% reduction in the episodes of incontinence in the first week of the care plan implementation

Intervention:

1. Assessment to the challenges to the proper implementation of the care plan and also asses its appropriateness and side effects of medicines to be done by the nurse (Talley et al., 2017).
2. Voiding record would be maintained for the first three days completed by Mr. Nyugen (Ackley et al., 2016).
3. Educational plan for Mr. Nyugen prepared by the nurse.

4.Implementation of a voiding schedule that is tailored to Mr. Nyugen’s condition and needs and based upon the voiding record maintain in the first three days of the care plan by the nurse (Syan & Brucker, 2016).

1. Educating Mr. Nyugen on behavioral change to improve continence (Hälleberg et al., 2017).

Rationale

1.Episodes of incontinence can be caused due to inaccessibility to the bathroom or bathroom modifications, improper lighting, medications for pain and inadequate knowledge about urinary incontinence (Ackley et al., 2016).

Through the 3 day voiding program the normal pattern of voiding for Mr. Nyugen can be understood (Syan & Brucker, 201).

2.Educating Mr. Nyugen on incontinence, management of pain and guidelines on best practices can help to improve the condition and would need a multidisciplinary team (Hälleberg et al., 2017).

3.Voiding schedule that is individually prompted to suit Mr. Nyugen’s need can support him to empty his bladder on a schedule before he feels the ‘urge’ to urinate and avoid the fear of not reaching the toilet on time (Talley et al., 2017).

4.By following the practice of pelvic floor muscle exercise, re-training of the bladder, reducing the intake of caffeine are forms of non invasive interventions that can be taught to Mr. Nyugen (Hälleberg et al., 2017; Hunter, 2016)

5.This can help in better and seamless documentation as well as monitoring of Mr. Nyugen’s condition and voiding records. This can also help in the tracking of the voiding patterns and analyze the progress towards the goals (Hälleberg et al., 2017).

Involving a multi disciplinary team to evaluate the effectiveness and efficacy of the voiding program as well as any other intervention designed for Mr. Nyugen and modifying them as needed (Ackley et al., 2016; Hunter, 2016).

Goal ii. Mr. Nyugen will be able to schedule his toilet schedules on his own in 2 weeks

Expected Outcomes: Mr. Nyugen will be able to maintain his own schedule and follow them on his own.

Identified Priorities and Miller’s Functional Consequences Theory

Intervention:

i.Long term care plan would be given to Mr. Nyugen, where he can make schedules of voiding the bladder (Talley et al., 2017).

ii.Involving social support and home visits from the nurses for 2 weeks.

iii.Using electronic reminders or alarms to aid memory and help Mr. Nyugen remember his toilet schedules (Ackley et al., 2016; Hunter, 2016)

Rationale:

1.Providing the long term plan can help Mr. Nyugen to follow the schedule (Ackley et al., 2016).

2.Visits from social support can also check Mr. Nyugen’s progress and current condition and raise concerns if he needs additional help (Ackley et al., 2016).

3.Setting reminders can ensure Mr. Nyugen Does not forget the schedules to void his bladder.

Goal iii. Mr. Nyugen will no longer need interventions for urinary incontinence in one month

Expected Outcomes: After a month, Mr. Nyugen would be able to continue following his regular schedule and no longer would require incontinence care.

Intervention:

Training and educative materials given to Mr. Nyugen to follow  (Talley et al., 2017)

Rationale:

Mr. Nyugen can go through the training and educative materials to better understand his incontinence issue and maintain effective behaviors to maintain his continence (Talley et al., 2017).

Evaluation of outcome

1. Mr. Nyugen is able to control his urinary incontinence with minimal assistance. He no longer is feels encumbered due to this condition
2. Mr. Nyugen has a 50% reduction in urinary inconsistence in the first week of the action plan. He no longer is urinating outside the toilet and is able to maintain the voiding schedule.
3. Mr. Nyugen is able to understand the best practices to reduce incontinence and utilize best practice to control the incontinence problems.
4. Mr Nyugen has gained significant knowledge and understanding of his incontinence problem and knows how to manage this in the future.

Reflection

1. Next time while helping a patient with incontinence issues, I would analyze the voiding patterns of the patient using a three day voiding record that is maintained by the patient.
2. Using the voiding record I would be able to identify the voiding pattern and understand how best to help the patient.
3. I should have also assessed if the patient is experiencing any pain while urinating, which could signify an underlying condition.
4. If I had also used automated system of keeping record of the voiding of bladder, it could have prevented the patient from taking the additional pain of documenting it and prevent any confusion on his/her part.

5.Not I can understand that the best practices of helping patients with incontinence issues is to develop a voiding routine based upon the voiding records, educating the patient on the best practices to avoid incontinence issues, effect of medications and behavior and how to address such issues (Hunter, 2016).

Conclusion:

From the case study it can be concluded that the patient is suffering from several conditions that is affecting his daily life. The priority area chosen for the patient was to help with his incontinence since that can be addressed on a very short term, and can be the beginning of a long term program that is aimed to help with the other care areas for the patent. Scheduling voiding plan, educating the patient and involvement of multidisciplinary team can be vital to ensure the success of the care plan, which has been used to develop the care plan for the patient.

References:

Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2016). Nursing Diagnosis Handbook-E-Book: An Evidence-Based Guide to Planning Care. Elsevier Health Sciences.

Balcer, L. J., Miller, D. H., Reingold, S. C., & Cohen, J. A. (2014). Vision and vision-related outcome measures in multiple sclerosis. Brain, 138(1), 11-27.

Discussion – Clinical Reasoning Cycle

Bregagnollo, G. H., Lopes, D. M., Barbosa, B. M., & Stamm, A. M. N. D. F. (2017). Clinical Reasoning Among Medical Students at the End of the Basic Cycle. Revista Brasileira de Educação Médica, 41(1), 44-49.

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.

Fonareva, I., & Oken, B. S. (2014). Physiological and functional consequences of caregiving for relatives with dementia. International Psychogeriatrics, 26(5), 725-747.

Gill, S., & Kim, D. (2018). Effects of obesity and knee osteoarthritis on gait and postural stability in pre-bariatric surgery candidates. Annals of Physical and Rehabilitation Medicine, 61, e355.

Hälleberg Nyman, M., Forsman, H., Ostaszkiewicz, J., Hommel, A., & Eldh, A. C. (2017). Urinary incontinence and its management in patients aged 65 and older in orthopaedic care–what nursing and rehabilitation staff know and do. Journal of clinical nursing, 26(21-22), 3345-3353.

Hefny, A. F., Abbas, A. K., & Abu-Zidan, F. M. (2016). Geriatric fall-related injuries. African health sciences, 16(2), 554-559.

Hessler, J. B., Schäufele, M., Hendlmeier, I., Junge, M. N., Leonhardt, S., Weber, J., & Bickel, H. (2018). Behavioural and psychological symptoms in general hospital patients with dementia, distress for nursing staff and complications in care: results of the General Hospital Study. Epidemiology and psychiatric sciences, 27(3), 278-287.

Hunter, S. (Ed). (2016). Miller’s nursing for wellness in older adults (2 nd Australia and New Zealand ed.) North Ryde, NSW: Lippincott, Williams and Wilkins.

Jerez?Roig, J., Santos, M. M., Souza, D. L., Amaral, F. L. J., & Lima, K. C. (2016). Prevalence of urinary incontinence and associated factors in nursing home residents. Neurourology and urodynamics, 35(1), 102-107.

Khokhar, A., Lodhi, M. K., Yao, Y., Ansari, R., Keenan, G., & Wilkie, D. J. (2017). Framework for mining and analysis of standardized nursing care plan data. Western journal of nursing research, 39(1), 20-41.

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

Maruish, M. E. (Ed.). (2017). Handbook of psychological assessment in primary care settings. Taylor & Francis.

Papastavrou, E., Andreou, P., & Efstathiou, G. (2014). Rationing of nursing care and nurse–patient outcomes: a systematic review of quantitative studies. The International journal of health planning and management, 29(1), 3-25.

Preziosa, P., Comi, G., & Filippi, M. (2016). Optic neuritis in multiple sclerosis Looking from a patient’s eyes. Neurology, 87(3), 338-339.

Qureshi, A., Brandt-Pearce, M., & Goldman, M. D. (2016, August). Relationship between gait variables and domains of neurologic dysfunction in multiple sclerosis using six-minute walk test. In Engineering in Medicine and Biology Society (EMBC), 2016 IEEE 38th Annual International Conference of the (pp. 4959-4962). IEEE.

Syan, R., & Brucker, B. M. (2016). Guideline of guidelines: urinary incontinence. BJU international, 117(1), 20-33.

Talley, K. M., Davis, N. J., & Wyman, J. F. (2017). Determining a treatment plan for urinary incontinence in an older adult: application of the four-topic approach to ethical decision-making. Urologic Nursing, 37(4), 181.

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