Nursing Care Prioritization Using Levett-Jones’ Clinical Reasoning Cycle And Miller’s Functional Consequences Theory

Clinical Reasoning Cycle

Aging is a normal process of the time-related changes that beings with birth and continues throughout one’s life. In aging, there is intrinsic and extrinsic aging. The intrinsic is a result of the programmed aging of a species while the extrinsic is influenced by the surrounding, which hastens to age. The extracellular and the cellular changes of the old ages causes a decline in functioning and a change in the physical appearance. Changes occur in all systems; cardiovascular, respiratory, gastrointestinal, integumentary, musculoskeletal, genitourinary, reproductive, nervous system and the special senses. Majority of the chronic conditions that are commonly found in the old patients can be prevented, limited and managed (Hinkler & Cheever, 2013). In this essay, a case scenario has been provided and from it, three nursing care priorities will be identified using the Levett-Jones Clinical Cycle that includes; considering the patient, collecting information and cues, processing the information that was collected and lastly, identifying the issues/problems. In addition to this rationale will be provided for each. Secondly, out of the three problems, the one with the most crucial/most important nursing care will be identified using the Miller’s Functional Consequences theory. The nursing goals, interventions, and the evaluation of the care given will be discussed. Lastly, a conclusion to summarize the case study.

Clinical Reasoning Cycle.

Patient Dinh Nguyen is 83 years old, a widower who was diagnosed six years ago with multiple sclerosis and osteoarthritis four years ago. Mr. Dinh has been experiencing numbness of the face, blurred vision, an electric shock type of feeling that travels from the head all the way to the legs. That has greatly affected his gait and movement. Lastly, he experiences urine incontinence.

The age-related changes which are not modifiable include; the blurred vision resulting from an accumulation of cells in the lens after apoptosis as cell death is higher than cell formation. This forms a yellow plague which reduces the elasticity of the lenses affecting vision (Dendrou, Fugger & Friese, 2015).

 Secondly, the urine incontinence is as a result of the damaged nerves that controls bladder which has resulted from old age changes and made worse by multiple sclerosis, weakening of the bladder muscles as a result of the old-age changes, osteoarthritis which makes it difficult to get to the washroom in time and lastly it could be as a result of an enlarged prostate that causes an increase in urine retention and overflow incontinence (Lohmander, Thorlund & Roos, 2016).

Consider the patient

Lastly, the client has numbness of the face and has a feeling like an electric shock that runs from his head to the neck, back and then the legs. This results due to the shrinkage of the axonal length, loss of the mitochondria and the degeneration of the insulating myelin sheath. These changes are as a result of the rise of the proinflammatory mediator’s concentrations in the body (Hinkler & Cheever, 2013). The body of the aged clears this toxics very slowly which contributes to peripheral nerves damage. This causes the reduction in sensation and a problem in nerve conduction. This will explain the numbness and the electric shock feeling (Stenholm, Pulakka, Aalto, Kivimaki & Vahtera, 2015).

The risk factors (the modifiable factors) includes osteoarthritis and multiple sclerosis which can be controlled both pharmacologically and non-pharmacologically. Multiple sclerosis is an auto-immune disorder in which the antibodies attack the myelin sheath. This affects the nerve conduction worsening the paranesthesia that occurs in old age (Visser et al., 2018). In addition to this, osteoarthritis impairs his mobility further as the joints stiffen and become painful as a result of calcification of the joints cartilages. A combination of both the modifiable and the non-modifiable factors causes an impairment of the activity of daily living (Bann et al., 2015).

Mr. Dinh Nguyen is elderly, 83 years old was diagnosed with multiple sclerosis and osteoarthritis, six and four years ago respectively. The patients report that he has been experiencing blurred vision, electric shock feeling, face numbness which impacts his gait and movement severely making it hard to shower, dress cook and even bend to close his shoelaces. On top of this, he has been having episodes of urine competence which makes him perceive that his disease process has worsened and also he starts wondering how he will face his future which is full of uncertainties.

Process information

As explained above the manifestations are both as a result of modifiable and non-modifiable factors. The blurred vision is as a result of aging, whereby the cell death is higher than the cell proliferation which causes accumulation of the dead cells on the lens causing the formation of a plague and reducing its elasticity (Lublin et al., 2014). The numbness and the electric shock like feeling can be explained by the age-related changes in the nervous system. Similar to the blur vision, the nerves cells degeneration is higher than the generation and the removal of the neurotransmission is slow causing accumulation of these mediators. This causes a reduction in the propagation of a nervous impulse and also causes the destruction of the neurons affecting the sensitivity (Visser et al., 2018). This is further worsened by multiple sclerosis which is an auto-immune disease that affects the myelin sheath reducing the impulses transmission (Celius, Andersen & Fredriksen, 2017). The urine incontinence is as a result of the damaged nerves that controls bladder which has resulted from old age changes and made worse by multiple sclerosis, weakening of the bladder muscles as a result of the old-age changes, osteoarthritis which makes it difficult to get to the washroom in time (Le Quintrec et al., 2014). Lastly, it could be as a result of an enlarged prostate that causes an increase in urine retention and overflow incontinence (Ward et al., 2017).

Collect cues/information

Identification of problem/issues.

The following are the problems facing Mr. Dinh Nguyen; self-care deficit related to the immobility issues which results from the old age changes which have caused blurred vision and osteoarthritis (Johnson et al., 2016). This has been aggravated by multiple sclerosis which has further affected his mobility and the level of his daily activities. This is evidenced by the patient’s verbalization that it is impossible, to cook, shower, and tie his shoelaces (Ward et al., 2017). Secondly, urine incontinence related to old age changes that weaken the bladder muscles which include the sphincter muscles. The enlargement of the prostate causes retention and overflowing incontinence (Timby & Smith, 2013) This is made worse by multiple sclerosis which damages the nerves, therefore, no urine control by the nervous system. Lastly, ineffective coping mechanism related to the old age changes and the disease mechanisms which is evidenced by his verbalization of fear of the future (he wonders how he will face the uncertainty of his future and also he perceives that his disease has worsened) (Ackley, Ladwig & Makic, 2016).

Nursing Care Plan.

Nursing diagnosis to be prioritized is self-care deficit as it touches on the activities of the daily living. The level of the activities of daily living is a measure of one’s functioning status. These activities; personal hygiene, continence management, dressing, feeding and ambulating are important for survival. Therefore, self-care deficit should be the issue to be prioritized to ensure quality living. This has resulted from the age-related changes and multiple sclerosis which has caused a negative functioning consequence (Dalton & Levett-Jones, 2015).

Goal	Intervention/action plan	Rationale	Evaluation
Improve Mr. Dinh independence by increasing his performance of activities of daily living in seven days.	1. Establish short-term goals with Mr. Dinh.	When we set goals that are realistic with him, this will help in reducing frustration (Hinkler & Cheever, 2013).	By the end of the seven days, the patient’s performance of the activities of daily living will have increased, improving his independence.
2. Guide Mr. Dinh in accepting the needed amount of dependence.	Mr. Dinh needs help in determining the safe limits of trying to be independent in comparison to asking for assistance when necessary (Hinkler & Cheever, 2013).	By the end of the seven days, the patient’s performance of the activities of daily living will have increased, improving his independence
3. There should be positive reinforcement for all the attempted activities noting the partial achievements.	The positive reinforcement resources that are external are important as they promote the client’s ongoing efforts as they often have difficulty in seeing the progress (Hinkler & Cheever, 2013).	By the end of the seven days, the patient’s performance of the activities of daily living will have increased, improving his independence
4. Implement measures to promote independence although intervene whenever the patient cannot function.	Getting assistance in performing some level of activities is appropriate as it prevents injuries from activities without causing frustrations to the client. Nurses are key to helping clients to accept both permanent and temporary assistance (Hinkler & Cheever, 2013).	By the end of the seven days, the patient’s performance of the activities of daily living will have increased, improving his independence
5. Apply regular routines and allow adequate time for Mr. Dinh to complete the task.	When a routine has been established it allows adequate time and requires less effort. This aids the patient in carrying out self-care activities and in being organized (Hinkler & Cheever, 2013).	By the end of the seven days, the patient’s performance of the activities of daily living will have increased, improving his independence
6. Ensure that patient’s privacy is observed during dressing.	Patient’s privacy is fundamental. He may take longer to dress which may be as a result of being fearful of breaches of privacy (Hinkler & Cheever, 2013).	By the end of the seven days, the patient’s performance of the activities of daily living will have increased, improving his independence
7. Suggest use of elastic shoelaces or Velcro closures on the shoes.	This will eliminate the shoelace tying which is a source of frustration (Hinkler & Cheever, 2013).	By the end of the seven days, the patient’s performance of the activities of daily living will have increased, improving his independence
8. Give frequent encouragement and help in dressing as needed.	Aiding/assisting the patient helps in reducing the energy expenditure and the frustrations. Although the nurse should ensure that he/she does not rush through the tasks as it reflects negatively on the patient (Hinkler & Cheever, 2013).	By the end of the seven days, the patient’s performance of the activities of daily living will have increased, improving his independence
9. Aid the patient with ambulation by directing them to use ambulation devices such as the canes, crutches, and walkers.	These methods will promote patient’s safety and aid them in support and balance (Hinkler & Cheever, 2013).	By the end of the seven days, the patient’s performance of the activities of daily living will have increased, improving his independence
10. Assess the patient’s ability to verbalize the urge to void and their capacity to use urinals and bedpans. In addition to this bring the patient to a bathroom at intermittent and regular intervals.	This will eradicate urine incontinence (Hinkler & Cheever, 2013).	By the end of the seven days, the patient’s performance of the activities of daily living will have increased, improving his independence

Conclusion

Using the first four steps of the clinical reasoning, three nursing care problems were identified from the case study of patient Dinh who is elderly and has multiple sclerosis and osteoarthritis. He has a self-care deficit, urine incontinence, and ineffective coping mechanism. Using the miller’s functioning consequence theory; self-care deficit was identified as the most crucial nursing care problem as it entails an inability to perform activities of daily living which are essential for survival. A nursing care plan was discussed. It entailed setting a specific goal, coming up with action plans/interventions, rationales for the interventions and evaluations of the targeted outcomes.

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