Clinical Reasoning Cycle for Multiple Sclerosis Patient

This paper discusses the clinical reasoning cycle for a Multiple Sclerosis patient. It identifies the problems faced by the patient, establishes goals, takes action, and evaluates outcomes. The patient's condition, background, and environment are considered while providing nursing care strategies.

Introduction
Clinical reasoning cycle consists of some steps which are necessary in
identifying the proper nursing care strategies after a thorough assessment of any
patients’ health related issues (Levett-Jones, 2013). It is also helpful in making any
decision regarding the health condition and treatment procedure of the patient. The
clinical reasoning cycle is very much effective in nursing practice to provide care for
the patients (Hunter, 2016). In this paper, the case study of an elderly patient will be
considered who is suffering from Multiple Sclerosis. According the condition and
background of the patient, information will be collected. After that the paper will
describe how the information will be processed and the major problems will be
identified. Considering the identified problems, goals will be established and
according to that some actions will also be taken. The evaluation and reflection after
the action will also be illustrated in the paper. Finally, the paper will conclude with the
future requirements for the patient to improve his health condition.
Part A
Considering the patient’s case
The name of the client is Mr. Dinh Nguyen and he is 83 years old widower.
Six years ago, he was diagnosed with Multiple Sclerosis (MS). Even, four years back
he was also diagnosed with osteoarthritis which came under control following some
medication process. His wife died twelve months ago and since then Nguyen is living
alone in his two storey home with ongoing grief as well as increased isolation. For
not having any child, Nguyen has no immediate family and he is living an
independent life too. Recently he is experience some health declination and he feels
a pain similar to “electric shock” when he moves his body while doing any action and
it is affecting his movement and gait severely. Nguyen is also experiencing blurred
vision. He lives in a two storey house and if this continues then the risk of falling will
be higher and he may become the victim of serious accident. His small and
independent income only covers his required expenses. However, he tries to go out
in holidays once in a year, but due to his altered mobility, this year he could not.
Recently he is also experiencing some urinary incontinence and he wonders if these
difficulties continue to grow then how he will face all the uncertainties in future being
alone.

Collecting information
Since the death of his wife one year ago, Mr. Nguyen is living alone as they
do not have any child. However, he has a brother, Bao who lives with his own family.
Although, very close to Dinh’s house but Dinh do not want them to be bothered by
involving in his personal matter. Due to the recent death of his wife he is undergoing
some grief and he lives a completely isolated life from his extended family. However,
he was diagnosed with Multiple Sclerosis six years back but, from some days, when
he is moving his head and neck, he is experiencing an “electric shock” type of felling
which is travelling down from his back and into the legs. This is affecting his daily
activities like cooking, showering and dressing. Particularly at the time of bending
down to tie shoe laces he faces the extreme difficulty due to this feeling. Also he is
experiencing a visual disturbance in the form of blurred vision and numbness in his
face. Even, some episodes of urinary incontinence has also been found as a
symptom of MS. For his osteoarthritis, which is now under control he uses Panadol
Osteo 4/24 Oral prn, he also uses Teriflunomide 14mg Oral daily to control his
bladder function and all other symptoms of MS. During the exacerbation of the
disease, he uses Prednisolone 25mg oral BD.
Processing information
 Multiple sclerosis- It is a potentially disabling disease which affects the central
nervous system including the brain as well as the spinal cord of a human
body. In creates the communication problem between the brain and the other
parts of the body. The signs and symptoms of this disease vary according to
the amount of nerve damage (Filippi et al., 2017). In this case the patient is
having the feeling of electric sensation travelling down from the back to the
leg. This disease can increase the risk of falling and cause paralysis in long
term among the patients. Some environmental factors such as depression can
also be responsible for the extremity of the disease (Thompson et al., 2017).
 Vision disturbance- It is related to MS and this problem comes and goes
frequently. Different types of visual disturbances can come out as a symptom
of MS among the patients and in this case Nguyen is affected by blurred
vision which is termed as optic neuritis as an effect of Multiple Sclerosis

(Hauser et al., 2017). The condition stays up to two weeks and then begins to
improve gradually.
 Urinary incontinence- This happens as the brain fails to transmit the signal on
when the bladder is full due to the nervous dysfunction (Dendrou, Fugger &
Friese, 2015). A patient of bladder incontinence may experience difficulty in
holding urine in the bladder and feeling the bladder is not emptying completely
(Cotterill et al., 2016). During coughing and sneezing the urine may come out
accidentally.
Identifying the problems or issues
Synthesizing all the information that has been collected and processed, three
main problems of the patient has been identified as the major issues. Nguyen was
diagnosed with MS six years back, and it is the main problem which is creating
several issues. All the issues are vital and they are as follows.
1. Lhermitte’s sign- It is associated with MS and creates uncomfortable
sensation among the patients which affects the normal activities as well as
movements. If nerves are no longer coated with myelin as a consequence of
MS as it destroys myelin, then these damaged nerves responds all the
movements of the neck and as a result create sensation and “electric shock”
type feeling (Raza, Behzadi, Blumenfeld, Girardi & Prince, 2018). Nguyen is
experiencing the feeling while cooking, showering, dressing and mostly while
making shoe laces, bending down. This problem is highly important as the
patient lives alone in a two storey house so difficulty in movement can
increase fall risk and can ruin his independency too.
2. Optic neuritis- This is a type of visual disturbance that is occurred as a result
of MS and it blurs the vision of the patient. The symptom develops when the
MS begins to break down the coating surrounding the optic nerve of the
patient. However, this disturbance goes away within few weeks but it also
comes back again (Montalban et al., 2017). The condition worsens when the
MS grows and may lead to permanent blindness in some cases also. Almost
70% patients of MS have experience optic neuritis or blurred vision problem
(Balcer, Miller, Reingold & Cohen, 2014). In case of Nguyen, this can create
accident as he lives alone. It will affect his daily activity too.

3. Urinary incontinence- Nguyen experienced some episodes of this problem
which occurs due to Multiple Sclerosis. The nerves that transmit the signals
about when to empty the bladder is damaged in this condition and the patient
cannot control his urine as it comes out for the pressure while coughing or
sneezing (Cotterill et al., 2016). Nguyen also faced this problem and it should
be considered with high priority as in future it can lead to several problems.
Part B
Establishing goals
Considering the patients age pathological conditions as well as psychological
stresses some goals are established in order to treat the issues. While establishing
the goals the lifestyle and social network of the patient will also be considered. The
goals for managing different symptoms of multiple sclerosis will be:
 First of all an action will be taken to reduce the sensation of “electric shock”
type feeling which is Lhermitte’s sign, due to multiple sclerosis. This is most
important because it affects the daily activities of the patient (Cotterill et al.,
2016).
 His vision disturbances like Blurred vision will also be considered to reduce as
it can increase the risk of falling down and it will be reduced within two to
three days.
 Goals will also be established in order to stop the urinary incontinence of the
patient within few days.
Take action
 Deep breathing technique and stretching exercises can be helpful to lessen
the pain of the patient. Improving the posture of the patient with the
assistance of a physical therapist will also be helpful in recovering the
Lhermitte’s sign (Scaglia, Haggqvist, Lindholm & Capobianco, 2017).
 To control the vision disturbance steroid injection can help in speeding up the
recovery but it will not improve the long term vision (Vu, Bradshaw, Moses,
Sriram & Pawate, 2016). The patient will be referred to a Neurologist for
coping up with the situation.

 Self catheterization by inserting a thin and small tube into the urethra of the
patient will allow him to fully empty his bladder (de Abreu Pereira, Castiglione
& Kasawara, 2017). He will also be suggested to consult a physical therapist
to get a treatment with a pelvic floor muscles therapy, to improve the control in
urination.
Evaluate Outcomes
 Nguyen is able to cook, shower, and dress himself with minimal pain.
Stretching exercises along with deep breathing technique will help to reduce
the pain.
 His vision disturbances have also gone away. Intravenous
methylprednisolone as steroid injection will be helpful to speed up the
recovery from blurry vision (Vu, Bradshaw, Moses, Sriram & Pawate, 2016).
Further treatment of neurologist will assist in complete cure.
 Nguyen is able to control his urine. The self-catheterization technique will
reduce the incidence of leakage (Lublin et al., 2014). It is an easy process and
the patient will be able to self-catheterize four times daily. However, pelvic
floor muscle therapy will also help to control urine.
Reflection
 I am now aware of the symptoms of Multiple Sclerosis.
 If I would have some more knowledge on physical-therapy I could assist the
patient.
 Now, I also understand how emotion or depression due to any grief can
worsen the condition of MS.
Conclusion
After the assessment of the disease of Nguyen considering the environment
and mental condition nursing plan and actions have been provided. However,
Nguyen needs further assistance in recovering his problem regarding vision
disturbance and other symptoms of Multiple Sclerosis. The patient lives alone and he
has undergone a serious grief recently which has affected his health condition and
moreover, he is isolated from his family as he does not want his family members to
be bothered about him. His financial condition has also come down comparatively.

Even, his altered mobility also did not allow him to travel which he does every year.
All these affected his mental health and worsened his MS condition. He requires
further support or assistance from consultants on depression. He needs to visit
doctors regularly in order to maintain the stability of his health status.

References
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.
Cotterill, N., Wilkins, A., Copestake, C., Weir, I., Norton, C., & Drake, M. (2016).
Cross-sectional prevalence study of urinary and/or anal incontinence and its
impact on quality of life in a cohort of individuals with progressive multiple
sclerosis.
de Abreu Pereira, C. M., Castiglione, M., & Kasawara, K. T. (2017). Effects of
physiotherapy treatment for urinary incontinence in patient with multiple
sclerosis. Journal of physical therapy science, 29(7), 1259-1263.
Dendrou, C. A., Fugger, L., & Friese, M. A. (2015). Immunopathology of multiple
sclerosis. Nature Reviews Immunology, 15(9), 545.
Filippi, M., Rocca, M. A., Ciccarelli, O., De Stefano, N., Evangelou, N., Kappos, L., ...
& Gasperini, C. (2016). MRI criteria for the diagnosis of multiple sclerosis:
MAGNIMS consensus guidelines. The Lancet Neurology, 15(3), 292-303.
Hauser, S. L., Bar-Or, A., Comi, G., Giovannoni, G., Hartung, H. P., Hemmer, B., ...
& Traboulsee, A. (2017). Ocrelizumab versus interferon beta-1a in relapsing
multiple sclerosis. New England Journal of Medicine, 376(3), 221-234.
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.
Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse.
Frenchs Forest, NSW: Pearson.
Lublin, F. D., Reingold, S. C., Cohen, J. A., Cutter, G. R., Sørensen, P. S.,
Thompson, A. J., ... & Bebo, B. (2014). Defining the clinical course of multiple
sclerosis: the 2013 revisions. Neurology, 10-1212.
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.

Raza, S. I., Behzadi, A. H., Blumenfeld, J. D., Girardi, S. K., & Prince, M. R. (2018).
Bladder diverticuli following injection of onabotulinum toxin A in a patient with
multiple sclerosis and autosomal dominant polycystic kidney
disease. Radiology Case Reports.
Scaglia, M., Haggqvist, S., Lindholm, E., & Capobianco, D. I. (2017). Bowel and
Bladder Dysfunctions in Multiple Sclerosis Patients with Lower Functional
Handicap. BAOJ Neuro, 3, 032.
Thompson, A. J., Banwell, B. L., Barkhof, F., Carroll, W. M., Coetzee, T., Comi,
G., ... & Fujihara, K. (2017). Diagnosis of multiple sclerosis: 2017 revisions of
the McDonald criteria. The Lancet Neurology.
Vu, N., Bradshaw, M., Moses, H., Sriram, S., & Pawate, S. (2016, April). Efficacy and
Tolerability of Fingolimod, Dimethylfumarate, and Teriflunomide in Patients
with Multiple Sclerosis: Real World Experience from a Single Center.
In Neurology (Vol. 86). TWO COMMERCE SQ, 2001 MARKET ST,
PHILADELPHIA, PA 19103 USA: Lippincott Williams & Wilkins.