Catherine was admitted to a nursing home 6 months ago. She is 43 years old and suffers with Multiple Sclerosis. Catherine got diagnosed with MS at the age of 23. Catherines husband and two daughters were unable to cater to the growing health and wellbeing needs of Catherine at home and she now requires full time nursing care.
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Multiple Sclerosis is a disease that disrupts the information from the brain. It interrupts the information that is sent from the brain to the body. People with MS will experience trouble walking and have a loss of balance. It is a progressive disease but the cause is unknown but it is believed to be genetic and or environmental.
Symptoms of Multiple Sclerosis
- Loss of balance
- Numbness of legs
- Muscle weakness/muscle spasticity
- Vision issues
- Chronic or acute pain
- Memory or concentration problems
Members of multidisciplinary team
The MS nurse has many roles through all stages of the progressive disease. The MS nurse will provide assistance to the patient and will help the client understand their condition, how to manage day to day life whilst living with MS. An MS nurse will explore many options of treatment from the early stages to palliative care. He/she will monitor and offer ways of management to the client as the patient deals with the symptoms that come with the disease. An MS nurse will provide advice on treatments and advice to the client on how to overcome the psychological effects of suffering with MS. (mstrust.org)
When a client is diagnosed with MS, a neurologist would have made the diagnosis. A neurologist specialises in the treatment of brain disorders and the nervous system. If the neurologist suspects a problem with the brain or spinal cord, he/she will have the patient take an MRI scan. If MS has been diagnosed, the neurologist will then establish options best suited to the patient.(ms.society.ie)
An occupational therapist mentors and offers advice on how a patient with MS can manage and maintain a level of independence. The occupational therapist (OT) will assess the client's needs and work out a plan to establish independent living. The OT will look at all aspects of a client from cognitive, physical and emotional. The OT will then make a client care plan on any improvements that may be needed to help. (ms.society.ie)
Clinical Dermatology Nurse
The role of a clinical dermatology nurse is the treatment of skin integrity. The nurse deals with wounds and infections of the skin with the best treatment for said skin issue. The nurse will then monitor, offer advice and structured treatment to the client as best ways to treat the skin. (BMC Nursing)
Catherines mobility is limited due to her condition. The use of an electric wheelchair is vital for Catherine to be mobile and a sense of independence. During the course of Catherines condition a mobility wheelchair needs to cater to her mobility needs. A wheelchair specifically designed for patients with MS can tilt, recline, stand and rotate. (Redman powerchair.com) Catherines condition has been deteriorating rapidly the last 12 months and since entering full time nursing care her mood has become low, so allowing Catherine the use of an electric wheelchair will sustain her sense of independence. Certain daily exercises should be performed to maintain a level of mobility. These exercises can be done in the wheelchair along with standing exercises.
"When prescribing an electric wheelchair, it is especially important to stress the need for regular active therapy and standing exercises. Suitable models allow for a combination of the two".
- (J. Kesselring, 2016)
The use of mobility aids during Catherines condition has allowed her to stay at home to be cared for by her family. When first diagnosed, Catherine would have used aids such as a walking stick and was independently mobile. Since MS is a progressive disease and has stages of progression, Catherine needs a physiotherapist to help her do exercises that minimize muscle and bone deterioration. An exercise care plan will be developed by the physiotherapist where they will assess Catherines fluctuating condition.
"Physiotherapists often run groups for people with MS. As well as skilled support from the physiotherapist, these offer group exercise, peer support and encouragement."
- (Irish Society of Chartered Physiotherapist)
To aid Catherine during transfers a sit to stand lift will help reduce the risk injuries to both patient and care provider. A lift to stand aid can be used to get in and out of bed, in and out of wheelchairs and also be used to transfer to and from the shower. This is used in conjunction with an electrical hospital bed that raises up and down, raises and lowers the feet. Catherines may require a ceiling hoist for transfers also, these aids a most widely used for individuals with MS. (Mobilityequipmentforless.com)
Catherine requires a suprapubic catheter as an elimination aid. Catherine would have undergone a small operation, where the catheter was inserted into a small opening in the abdomen into the bladder. This catheter is usually a permanent solution for a patient with MS. The catheter needs changing every six to eight weeks. (MS-UK-ORG)
The drainage of a catheter bag needs to be done carefully to prevent infection.
- Wash hands thoroughly
- Take tube out and hold over toilet or commode
- Open valve and empty contents
- Wash hands again
When this is completed the valve needs to be cleaned with an alcohol-based wipe to prevent infection. A record of Catherines fluid intake and the liquid in the catheter bag may need to be documented. At night a much larger bag is applied to the tube and changed in the morning.
Over 50% of people who are diagnosed with MS suffer with bowel issues. People with limited mobility will suffer from either constipation or have little control emptying the bowel. (MS-UKORG) This occurs when messages to the brain from the rectum are bypassed and the messages are missed, for the messages to be received a lot of nerves and muscles need to work in coordination to empty the bowel.
Catherine requires suppositories three times a week to prevent constipation. The suppositories are inserted into the back passage to allow relief from constipation. Some laxatives increased the water content in the stool thus making the passage of the stool easier. (The National MS Society.org) Although laxatives are seen as a quick solution, most are not seen as a total alternative to constipation. Dietary and fluid intake are most effective when problems with bowel movement occurs. Plenty of high fiber fruits and vegetables such as berries, pears, melons, cabbage, broccoli and carrots along with plenty water intake can help resolve constipation. (National MS Society.org)
Pressure sores develop when damage to the skin or underlying tissue has occurred due to friction. People who are immobile and old people are more at risk of developing these lesions because of long periods of sitting and lying in beds or chairs. Poor nutrition and dehydration are also factors in skin integrity. (barrowtrainingonline)
The HSE have developed a guide (PUTZ) pressure ulcer to zero in attempt to reduce pressure sores. It has proven by evidence to be the best practice for the prevention of ulcers. The guide has 5 steps knows as the Sskin Bundle.
- Surface – is the surface supports suitable for the patient?
- Skin Integrity- what is the skins integrity and have high risk areas been monitored?
- Patent mobility- has the patient been mobile either with or without assistance?
- Incontinence- does the patient require assistance with toileting?
- Nutrition/ fluid intake- has the patient had adequate fluid and diet intake and are supplements needed?
Pressure sores are graded by the amount of damage done to the skin and underlying tissue.
- Grade one – is reddening of intact skin or discolouration of the skin.
- Grade two- skin develops a partial thickness, skin loss or both. Ulcer may be present.
- Grade three- full skin thickness or skin loss involving damage to the subcutaneous.
- Grade four- major damage to skin, muscle and bone.
Catherine has Grade one on her sacrum, elbows and heels. To prevent these sores worsening pressure relieving devices should be used. The use of electrical beds with an air mattress that minimise pressure on the skin by allowing weight distribution throughout the bed, this will decrease the chances of developing pressure sores.
To help prevent the pressure sores on Catherines elbow, it needs to be washed gently with a very mild soap and warm water, moisturiser also needs to be applied. A light dressing may also be applied to prevent more friction to the skin. (Treatment of pressure ulcers grade 1-4)
Air filled pillows under Catherines elbows will improve the pressure sore. For Catherines Grade 1 heel sore, a heel trough a splint or a pillow under the heel or leg can help the blood flow. Evalution of the pressure sore areas should be done if symptoms worsen or the patient loses weight, a new condition arises or when fluid and food intake lessen. (Treatment of pressure ulcers grade 1-4)
Catherine requires full assistance for feeding as she is unable to do so independently. It is important to familiarize yourself with the foods Catherine likes and dislikes but also to keep in mind that Catherine needs a high fiber and protein diet to prevent constipation.
Protein is a known nutrient that encourages tissue repair thus will help cure Catherines pressure sore that have developed. (Nationalmssociety.org)
Catherine is in the care of a physician who can refer Catherine to a dietitian. In doing so a planned diet can be developed to enhance Catherines well-being.
Catherines dietary needs should consist of foods high in omega 3, plenty of fruits and vegetables. It is recommended for good bowel movement, a patient with MS should consume 20-30 grams of fiber a day. A breakfast high in fiber will also make Catherine feel fuller for longer. Fiber is known to absorb water so plenty of fluids are required during the day. (Nationalmssociety.org)
People who have been diagnosed with MS, may eventually develop swallowing issues. If this is to occur to Catherine a tube will need to be inserted into the abdominal wall to allow for nutrients and fluids that are needed. (multiplesclerosisnewstoday.com)
Catherine requires full assistance with personal care. Every morning Catherine will need a body wash with particular attention paid to her pressure sore locations. This also gives time to check Catherines skin integrity on other parts of her body. She will need assistance with dressing also, allowing Catherine to pick what she wants to wear gives her a feeling of independence and control.
Catherine has struggled settling in to the nursing home. She misses her family and her home. To alleviate Catherines feeling of upset, weekly family visits could be set up. Personal pictures of her family, or pictures of special occasions during Catherines life can be placed in her room. Finding out about her hobbies and working a plan out that although she may be limited to what she can physically do, there may be a way around it.
Catherine enjoys reading, she might have a device in her home that allowed her to do. A tablet specially designed for a person with mobility issues could be used, these devices are controlled by the individual's eyes. When the person looks at a certain key, it will display on the screen.
Downloading reading apps on her device will allow Catherine to read whenever she wants recreation time. Catherine could join a book club within the nursing home, she will meet new people and gain confidence. Joining clubs has been proven to decrease stress levels and loneliness.
Dan is 84. He lives with his wife Molly. At the age of 86, Dan suffered a stroke he has since been in the care of his wife and is allocated three visits a day from a private care company. Cerebral Vascular Accident otherwise known as a stroke, occurs when the blood flow to the brain is halted by either a blockage or from a blood vessel that has burst.Dan needs assistance with all activities of living. (healthline.com)
Individuals who suffered a stroke do tend to have swallowing problems. This is due to the muscles in the tongue becoming week. Coordination of the muscles may also be weak after a stroke. (www.myclevelandclinic.org) A specially designed diet plan is needed so malnourishment does not occur. Controlling Dans food intake will help minimise the risk of another stroke.
Choosing low fat foods will keep dans blood pressure at the right level. A diet known as the DASH diet is a planned approach to help prevent strokes and keeping blood pressure low.
As Dans meals are cooked by his wife Molly, she may need to become familiar to certain foods that Dan requires to avoid becoming malnourished and lower the risk of another stroke. The DASH diet consists of a low sodium (salt) intake. The recommended portion servings of the
DASH diet are as follows; servings of grains, rice, pasta or cereal 6 to 8 serving preferably. 4 to 5 servings of vegetables such as tomatoes, carrots along with leafy green vegetables is recommended.
Dan has swallowing issues at times so to avoid a choking episode; the vegetables could be used in a soup.
To avoid choking episodes Dan should be in an upright position, very small portions on fork/spoon and make sure all food is cleared from mouth.
Dan uses a zimmer frame as a way of getting to and from rooms in the house. This allows Dan to have a level of independence within his home but Dan has had a history of falls so as a precautionary measure, Dan should have access to a wheelchair and have use of the wheelchair during transfers through the house.
Dan requires a hoist in and out of bed. When a hoist is to be used, two people trained on the use of the hoist need to be present. This can consist of a healthcare assistant and a member of his family that live nearby. A manual Handling plan is in place for care staff to follow.
Dan has a catheter bag which will need to be emptied every 3 to 4 hours. The drainage of a catheter bag needs to be done carefully to prevent infection.
- Wash hands thoroughly
- Take tube out and hold over toilet or commode
- Open valve and empty contents
- Wash hands again
As Dan has experienced incontinence of faeces, an incontinent pad may have to be applied. By doing so, this will maintain a level of dignity for Dan. It will give him the confidence knowing that he won't soil his clothes, chairs or bed. (everydayhealth.com)
Although Dan has continence issues, 85% of stroke survivors regain control over there bowel and bladder. Certain bladder and bowel training may help Dan with his incontinence. Bladder training, bladder stimulation and medication could help Dan have more control over his bladder. Bowel treatments consist of dietary modifications, medication to reduce movement of the bowel and bowel training. (stroke.org.uk)
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Dan has a venous ulcer on his left leg that gets attended to by the public health nurse twice a week. Venous leg ulcers occur where there is constant pressure in the veins thus has caused damage to the skin. These ulcers develop on the inside of the leg above the ankle.
Venous leg ulcers are treated by cleaning and dressing the wound regularly. If the wound gets infected a course of antibiotics may be needed, this will clear the infection within the ulcer but won't clear the ulcer itself. This type of ulcer could take up to 4 months to clear if done by a professional. (www.nhs.uk)
An examination known as the Doppler Study is done by the General Practitioner to distinguish the difference if any between the blood pressure in the ankles and the blood pressure in the arm. If the blood pressure in the ankle is lower than the blood pressure in the arm, the GP can diagnose the patient with peripheral arterial disease. It is imperative that this test be done as the main treatment for these ulcers is using compressions. It is not safe to use a compression stocking if the artery on the ankle is low. (www.nhs.uk)
Dan has issues with communication skills since suffering a stroke. Speech issues are a common in the aftermath of a stroke. Sixty percent of stroke victims suffer with speech impairments following a stroke. This occurs when the muscles in the mouth weaken. These muscles are in control of breathing, swallowing and speech. Difficulty with speech known as apraxia, is problems with coordination of these muscles.
Apraxia may cause speech to become slurred, strained and hoarse. A speech and language therapist may be needed for Dan. The treatment will begin with an assessment as to what Dans speech impediment is, from there a strategic plan will be put in motion by the speech and language therapist to improve Dans speech. (www.spectrumspeech.ie)
Dan requires assistance with daily activities such as dressing, care of dentures and hearing aid. In the morning Dan requires a hoist out of bed, prior to this Dan needs help dressing. Allow Dan to pick the items of clothing he would like to wear that day. Dan may be able to apply some clothing himself therefore strengthening his independence.
Denture care is required for Dan, proper denture procedures are as follows;
- Run water over dentures to remove food particles.
- Soak dentures
- Brush denture with a soft bristled toothbrush.
- Soak dentures overnight in a solution specifically designed for dentures.
- Rinse dentures every morning to wash solution residue.
Dan requires a hearing aid. Hearing aids should be cleaned every day according to manufactures instructions. These devices need to be checked at least 4 times a year to ensure the aid is working effectively. Debris and wax build up in the hearing aids and may make hearing for the client difficult.
Cleaning of a hearing aid should be done in the following ways
- Wipe with cloth to remove any debris or wax build up.
- If wax is present, a tool kit that is provided by the manufacturer should be used. This will consist of a brush and a wire pick
- When the hearing aid is cleaned, open the battery compartment and place hearing aids in the case, this will remove any moisture that may have entered.
To prolong battery life of Dans hearing aid, the aid should be turned off when not in use. It should not be left in areas of the house where condensation will occur i.e.; the bathroom. If the battery has become dead, the battery should be removed immediately. (www.hse.ie)
The best power wheelchair for multiple sclerosis, available from: https://www.redmanpowerchair.com/the-best-power-wheelchair-for-multiple-sclerosis/#:~:text=As%20symptoms%20of%20multiple%20sclerosis,the%20position%20you%2 0prefer%20automatically. accessed on 6 January 2021
Mobility equipment recyclers, assistive technology, available from: https://mobilityequipmentforless.com/blogs/mobility-equipment-recyclers-blogs/best-mobilitymedical-devices-multiple-sclerosis accessed on 7 January 2021
Department of Health Government of Western Australia, available from: https://www.healthywa.wa.gov.au/Articles/A_E/Caring-for-your- catheter#:~:text=Empty%20your%20leg%20bag%20at,half%20to%20three%2Dquarters%20full . Accessed on 7 January
The national MS society, Bowel management in multiple sclerosis available from: https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/Clini cal_Bulletin_Bowel-Management-in-MS.pdf accessed on 7 January 2021
Barrow training online, unit 4 Prevention of Pressure sores, available from: https://www.barrowtrainingonlinecourses.ie/TrainingCourse.aspx accessed on 7 January 2021
Wound-essentials-2-the-treatment-of-pressure-ulcers-from-grade-1-to-grade-4.pdf Is there an MS diet? Available from: http://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Documents/Mom entum/momentum_fall08_msdiet.pdf accessed on 8 January 2021
Multiple sclerosis news today, available from: https://multiplesclerosisnewstoday.com/news-posts/2020/02/10/survival-following-theplacement-of-gastrostomy-tube-in-patients-with-multiple-sclerosis/ accessed on 8 January 2021
Your Guide to incontinence pads, available from: https://www.everydayhealth.com/incontinence/guide-to-incontinencepads.aspx#:~:text=Incontinence%20pads%20and%20adult%20diapers,for%20solutions%20to% 20urinary%20incontinence.&text=Incontinence%20pads%20are%20designed%20specifically,sk in%20from%20wetness%20and%20rash. Accessed on January 12 2021
Continence Problems after stroke, available from: https://www.stroke.org.uk/sites/default/files/continence_problems_after_stroke.pdf accessed on 12 January 2021.
The speech hub available from: https://www.spectrumspeech.ie/stroke#:~:text=Speech%20Difficulties%20following%20a%20St roke,these%20same%20muscle%20and%20structures accessed on 12 January 2021
The speech hub available from: https://www.spectrumspeech.ie/stroke#:~:text=Speech%20Difficulties%20following%20a%20Str oke,these%20same%20muscle%20and%20structures accessed on 12 January 2021
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