NRSG366 Partnerships In Chronicity

Questions:

1.On your initial visit to Andrea in her home, you need to undertake a comprehensive history and assessment. For each of the assessments listed below provide a rationale as to why you would undertake this assessment. Include in your answer information taken from the case study to support your response.

2.Based on the information from the scenario and your assessment strategies, plan one intervention for each of the four areas assessed in question one (1). For each intervention provide your rationale and how you will evaluate its effectiveness.

3.Andrea’s illness directly effect’s her husband’s and children’s life. List three (3) areas of Daniel’s (husband) life that would be directly impacted by A n d r e a ’ s illness and provide a rationale as to why each would impact on Daniel.

4.For each of the areas identified in question three (3), list one (1) strategy or intervention a community nurse could implement to support Daniel; provide a rationale for each intervention.

5.Pain is a major component of Andrea’s disease. Identify and describe the four (4) types of pain often experienced in MS and the potential causes of the pain.

6.Identify and justify four (4) non-pharmaceutical interventions that can be used to assist Andrea with pain management.

7.Identify the class of drug and the indications for the use of Baclofen, Diazepam and Gabapentin in the pain management of multiple sclerosis.

8.Andrea and Daniel confide that they are struggling with their sense of identity and role definition. They are also concerned about the impact on their children. What multi-disciplinary services could Andrea and Daniel access to assist them? List two (2) services that they could access providing a rationale for your recommendation as to why this would be a useful service.

9.A nursing student you are working with for the day asks you as the Community Nurse “considering her MS, what is Andrea’s prognosis?” Discuss your response specific to Andrea’s Relapsing – Remitting Multiple Sclerosis

Answers:

Assessment	Rationale
Physical	Physical assessment is one necessary assessment technique for multiple sclerosis patients as relapse remitting multiple sclerosis is associated with many neuromuscular degeneration. Lhermitte’s sign, spasticity and increased reflexes, internuclear ophthalmoplegia, optic neuroritis and gait or balance disturbance are few of the key symptoms of multiple sclerosis which can be assessed by physical assessment (Learmonth et al., 2012).
Environmental	As Andrea had been suffering from extreme gait disturbance and mobility restriction, the fall risk is very high for her. Along with that as she needed assistance in most of the activities of daily living, environmental assessment had been necessary for her (Lublin et al., 2014).
Physiological	As Andrea had been suffering from many physiological manifestations of multiple sclerosis such as gait disturbance, incontinence, pain, fatigue and motor function disturbance. Hence, the physiological assessment will help in discovering the severity of her symptoms (Learmonth et al., 2012).
Psychological	Depression is often a significant aftermath of the challenges associated with relapse remitting multiple sclerosis and hence psychological assessment is extremely important for the community nurse to understand whether or not she requires counselling to cope with her condition (Lublin et al., 2014). As Andrea had been suffering from uncertainty and inadequacy worrying about her marriage and family, a psychological assessment will be necessary for her.

Assessment	Intervention	Evaluation
1. Physical (mobility deficits)	The community nurse will provide gait training, gait assistive devices, powered mobility equipment, wheelchair, and mobility assistive strategies (Coote, Hogan & Franklin, 2013).	These assistive services will help provide Andrea with the opportunity to control and manage her mobility restrictions and will aid in empowering her. The outcome efficiency of this strategy can be assessed by feedback from the patient and her family members.
2. Environmental (fall risk)	The community nurse will provide environmental modifications such as de-cluttering the physical environment and enhancing the light and visibility of her living space along with vestibular rehabilitation including the aid of supportive nonskid footwear.	The de-cluttering and other such environmental modifications will help Andrea evade the fall risk; the aid of supportive footwear and vestibular rehabilitation will help her progress effectively. This outcome can be evaluated by periodic fall assessment and one-to-one feedback session (Lublin et al., 2014).
3. Physiological (spasms in her legs)	The nurse will provide the aid of stretching exercise, cooling strategies, standing frame, positioning aid, and baclofen pump (Amatya et al., 2013).	These assistive devices and interventions will help reduce the frequency and impact of the spam and will help her feel better. This outcome can also be evaluated with feedback sessions.
4. Psychological (onset of depression)	The nurse will provide the aid of cognitive behavioral therapy, mindfulness based therapies and counselling assistance (Simpson et al., 2014).	The psychotherapies will help Andrea cope with the challenges of multiple sclerosis and improve the quality of her life.

3.Physical:

As the impact of relapse-remitting multiple sclerosis has rendered Andrea unable to take part in any of the responsibilities of the household, her husband has had to shoulder the responsibility of their three children and along with that Andrea as well. As he also had been the only earning member of the family, the additional responsibilities will undoubtedly have a toll on his time and energy rendering him fatigues and exhausted (Pakenham, Tilling & Cretchley, 2012).

Psychological:

The impact of neurodegenerative disorder often renders one person incapable of standard state of functionality, and watching a loved one suffer through the extreme challenges of relapse remitting multiple sclerosis will have a severe impact on the psychological state of Andrea’s husband.

Financial:

Both Andrea and Daniel had been working both contributed equally to their household and taking care of three growing children. Now, Andrea had to resign from her job due to the loss of functionality due to the relapse remitting multiple sclerosis. Along with that, the extensive treatment and assistance that Andrea required due to her progressing condition will also have a significant financial strain on Daniel as the only earning member (Pakenham & Samios, 2013).

4.Physical:

In this case, the nurse will require to recommend the aid of a social care worker who can take the responsibility of caring for his wife and in turn provide him reprieve. Along with that the nurse can also recommend the assistance of occupational therapists to help him with the fatigue and exhaustion

Psychological:

The community nurse can provide counselling and community engagement interventions to Daniel as preliminary psychotherapeutic assistance. However, in case Daniel needs more specialized assistance, the community nurse will need to recommend him to a psychotherapist (Uccelli, 2014).

Financial:

Although the scope of practice of a community nurse does not extend to providing financial recommendations to the patient family, although in this case, the nurse can educate Daniel about the national disability schemes and other community care benefits that the patients with neurological disabilities are applicable for under the state and national policies taking the aid of evidence based practice.

Type of pain	Cause of pain
1. Trigeminal neuralgia	This is a kind of facial pain syndrome that is very common in people with multiple sclerosis (Montano et al., 2013). This is particularly a sharp and electrical jabbing pain that generally occurs on one cheek; although the pain is very severe but only lasts for a few seconds. The cause of the pain is the damage to the myelin sheath that surrounds the trigeminal nerve due to the onset of multiple sclerosis. As the trigeminal nerve is responsible for chewing or feeling the sensation of pain in the face, the damage to this nerve causes the sharp, electric pain, which is often triggered by daily activities (Tuleasca et al., 2014).
2. Burning limb pain	The second type of the pain that is caused by this particular disease is the burning pain that is generally caused in the legs but might occur anywhere else in the body. This particular pain is also associated with sensitivity to the touch, however, researchers are of the opinion that the affected leg can also feel cold to touch as well (Foley, 2017). Exploring the cause of this particular pain, it has to be mentioned that the extensive demyelination that is associated with relapse-remitting multiple sclerosis causes significant damage to the central nervous system of the patient along with the brain tissues. As a result, the sensory signals that to the spinal cord and the brain are altered facilitating burning pain sensations.
3. Neck and back pain	Another common type of pain that patients of multiple sclerosis experiences includes an aching stiff sensation in the neck of the patient which may or may not radiate to the back of the patient as well. According to Solaro, Trabucco and Uccelli, 2013, this pain can be moderate to severe and is mainly caused by long term immobility. Furthermore, it has to be mentioned that this type of pain is basically a musculoskeletal or nociceptive pain that is caused to the muscles, tendons, ligaments and soft tissue for prolonged period of immobility.
4. Multiple sclerosis hug	This is a very common pain type that is associated with the construct of multiple sclerosis. This is a banding of girdling pain sensation in the chest that the Multiple sclerosis patients undergo. In certain cases this pain is also associated with rib pain, and tightness or being squeezed around the chest as well. The cause of this particular pain is co9llective spasms in the intercostal muscles located in the rib and surrounding muscles and the spasms in the surrounding tissue causes the sensation of the pain in the chest pain (Montano et al., 2013).

Non-pharmaceutical Intervention	Justification
1. Exercise and yoga	Exercise and yoga is one of the greatest non-pharmacological treatment opted as the complementary or alternative treatment measure taken for the pain management in severe conditions such as the relapse remitting multiple sclerosis. It helps in blood circulation which in turn has a positive impact on the impact of pain felt by the patient. Along with that, it also helps in diverting the attention of the patient from the pain to peace and contentment in turn helping in better pain management (Ambrose & Golightly, 2015).
2. Acupuncture	Acupuncture is another very common nonpharmacological treatment measure which has been found to be extremely beneficial in treating pain and the origin of this treatment has been inn ancient china as early as 8000 years ago. According to authors, it helps in unblocking or otherwise redirecting the flow of energy which helps lessen the sensation of pain and helps the patient suffering from pain focus on something other than the pain.
3. Mindfulness based therapy	Mindfulness based cognitive therapies help in chronic pain management by altering the quality and state of consciousness and paying attention on the purpose or the outcome of the therapy. This particular therapy will help Andrea focus on attaining freedom of mind and freedom from reflexive conditioning helping her overcome the pain (Uccelli, 2014).
4. Magnet therapy	This is another alternative treatment option for pain management which is gaining rapid popularity for its effectiveness. This therapeutic measure involves the utilization of static or unmoving magnets to alleviate the feeling or sensation of pain. Researchers are of the opinion that static magnets function in pain management by altering the bioenergetics fields of the person and helping them ignore the sensation of pain.

Drug	Class of Drug	Indication
Baclofen	Antispasticity agents (muscle relaxant)	This particular medication is generally used to treat the muscle spasms occurring in the multiple sclerosis for the relief of flexor spasms and concomitant pain. Is administered intrathecally (Draulans et al., 2013).
Diazepam	Benzodiazepines	Is used as adjunctive treatment of spastic muscular paresis that are caused by muscular sclerosis, administered orally
Gabapentin	Anticonnvulsant	Is used as adjunctive therapy for partial seizures for patients with neuralgia due to multiple sclerosis, taken orally (Turcotte et al., 2015).

8.The impact of a parent with a progressive neurological condition has a significant impact on the psychological health and sanity of the children. According to Parisé et al. (2013), the impact of neurological and physical disability of a parent is significantly profound on the growing children, especially on those aged five to 10. As Andrea and Daniel had three children belonging to age 11, 7 and 5, the impact of their mother’s disability could have had a significant impact on their psyche. Hence, the first assistive service that the parents can take the assistance from in ensuring optimal health of their children is a child psychiatrist.

The second assistive service that the parents can take the assistance from is a child health and welfare committee. It has to be mentioned that for the children growing up on their own with a disabled and severely sick parent can have growth dysfunction or developmental restrictions (Pakenham, Tilling & Cretchley, 2012). In such cases, the aid of a dietician, counselor and therapeutic counsellor is imperative. The child welfare centers can help both Andrea and Daniel in periodic assessment of the health of their children, both physical and psychological.

9.Prognosis of multiple sclerosis is generally dependent on the type of multiple sclerosis that the patient is going through. In this case, Andrea, the patient in the case study, has been suffering from relapse remitting multiple sclerosis which is an autoimmune disorder where the autoimmune system attacks the central nervous system of the patient. This particular neurodegenerative condition represents physical, psychological and emotional challenges and directly affects the living condition and lifestyle of the patient, imposing several restrictions, as observed in the case of Andrea as well, facilitated by the muscular spams, mobility restrictions, gait disturbance, incontinence struggle and pain (Ascherio, 2013). With respect to her condition, she is expected to experience optic disturbances and speech difficulties as her disease progresses. However, relapse remitting multiple sclerosis does not pose an immediate life threat to the patient and many patients live a long life with adequate assistance from the care professionals. Hence, with adequate treatment and assistive support, Andrea can also be expected to have a long life with better coping and symptomatic management.

References:

Amatya, B., Khan, F., La, L. M., Demetrios, M., & Wade, D. T. (2013). Non pharmacological interventions for spasticity in multiple sclerosis.

Ambrose, K. R., & Golightly, Y. M. (2015). Physical exercise as non-pharmacological treatment of chronic pain: why and when. Best Practice & Research Clinical Rheumatology, 29(1), 120-130.

Ascherio, A. (2013). Environmental factors in multiple sclerosis. Expert review of neurotherapeutics, 13(sup2), 3-9.

Coote, S., Hogan, N., & Franklin, S. (2013). Falls in people with multiple sclerosis who use a walking aid: prevalence, factors, and effect of strength and balance interventions. Archives of Physical Medicine and Rehabilitation, 94(4), 616-621.

Draulans, N., Vermeersch, K., Degraeuwe, B., Meurrens, T., Peers, K., Nuttin, B., & Kiekens, C. (2013). Intrathecal baclofen in multiple sclerosis and spinal cord injury: complications and long-term dosage evolution. Clinical rehabilitation, 27(12), 1137-1143.

Foley, P. L. (2017). Pain in multiple sclerosis (Doctoral dissertation, University of Edinburgh).

Learmonth, Y. C., Paul, L., McFadyen, A. K., Mattison, P., & Miller, L. (2012). Reliability and clinical significance of mobility and balance assessments in multiple sclerosis. International Journal of Rehabilitation Research, 35(1), 69-74.

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.

Montano, N., Papacci, F., Cioni, B., Di Bonaventura, R., & Meglio, M. (2013). What is the best treatment of drug-resistant trigeminal neuralgia in patients affected by multiple sclerosis? A literature analysis of surgical procedures. Clinical neurology and neurosurgery, 115(5), 567-572.

Pakenham, K. I., & Samios, C. (2013). Couples coping with multiple sclerosis: A dyadic perspective on the roles of mindfulness and acceptance. Journal of Behavioral Medicine, 36(4), 389-400.

Pakenham, K. I., Tilling, J., & Cretchley, J. (2012). Parenting difficulties and resources: The perspectives of parents with multiple sclerosis and their partners. Rehabilitation Psychology, 57(1), 52.

Parisé, H., Laliberté, F., Lefebvre, P., Duh, M. S., Kim, E., Agashivala, N., … & Weinstock-Guttman, B. (2013). Direct and indirect cost burden associated with multiple sclerosis relapses: excess costs of persons with MS and their spouse caregivers. Journal of the neurological sciences, 330(1-2), 71-77.

Simpson, R., Booth, J., Lawrence, M., Byrne, S., Mair, F., & Mercer, S. (2014). Mindfulness based interventions in multiple sclerosis-a systematic review. BMC neurology, 14(1), 15.

Solaro, C., Trabucco, E., & Uccelli, M. M. (2013). Pain and multiple sclerosis: pathophysiology and treatment. Current neurology and neuroscience reports, 13(1), 320.

Tuleasca, C., Carron, R., Resseguier, N., Donnet, A., Roussel, P., Gaudart, J., … & Régis, J. (2014). Multiple sclerosis-related trigeminal neuralgia: a prospective series of 43 patients treated with gamma knife surgery with more than one year of follow-up. Stereotactic and functional neurosurgery, 92(4), 203-210.

Turcotte, D., Doupe, M., Torabi, M., Gomori, A., Ethans, K., Esfahani, F., … & Namaka, M. (2015). Nabilone as an adjunctive to gabapentin for multiple sclerosis-induced neuropathic pain: a randomized controlled trial. Pain Medicine, 16(1), 149-159.

Uccelli, M. M. (2014). The impact of multiple sclerosis on family members: a review of the literature. Neurodegenerative disease management, 4(2), 177-185.

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NRSG366 Partnerships In Chronicity

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