Nursing Care Plan Multiple Scelorsis
Nursing Care Plan Multiple Scelorsis
CARE SETTING
Community or long-term care with intermittent hospitalization for disease-related complications.
RELATED CONCERNS
Extended care
Pneumonia: microbial
Psychosocial aspects of care
Sepsis/Septicemia
Patient Assessment Database
Degree of symptomatology depends on the stage and extent of disease, areas of neuronal involvement.
ACTIVITY/REST
May report:
Extreme fatigue/weakness, exaggerated intolerance to activity, needing to rest after even simple activities such as shaving/showering; increased weakness/intolerance to temperature extremes, especially heat (e.g., summer weather, hot tubs)
Limitation in usual activities, employment, hobbies
Numbness, tingling in the extremities
Sleep disturbances, may awaken early or frequently for multiple reasons (e.g., nocturia, nocturnal spasticity, pain, worry, depression)
May exhibit:
Absence of predictable pattern of symptoms
Generalized weakness, decreased muscle tone/mass (disuse), spasticity, tremors
Staggering, dragging of feet, ataxia
Intention tremors, decreased fine motor skills
CIRCULATION
May report:
Dependent edema (steroid therapy or inactivity)
May exhibit:
Blue/mottled, puffy extremities (inactivity)
Capillary fragility (especially on face)
EGO INTEGRITY
May report:
Statements of reflecting loss of self-esteem/body image
Expressions of grief
Anxiety/fear of exacerbations/progression of symptoms, pain, disability, rejection, pity
Keeping illness confidential
Feelings of helplessness, hopelessness, powerlessness (loss of control)
Personal tragedies (divorce, abandonment by SO/friends)
May exhibit:
Denial, rejection
Mood changes, irritability, restlessness, lethargy, euphoria, depression, anger
ELIMINATION
May report:
Nocturia
Incomplete bladder emptying, retention with overflow
Urinary/bowel hesitancy or urgency, incontinence of varying severity
Irregular bowel habits, constipation
Recurrent UTIs
May exhibit:
Loss of sphincter control
Kidney stone formation, kidney damage
FOOD/FLUID
May report:
Difficulty chewing, swallowing (weak throat muscles), sense of food sticking in throat, coughing after swallowing
Problems getting food to mouth (related to intentional tremors of upper extremities)
Hiccups, possibly lasting extended periods
May exhibit:
Difficulty feeding self
Weight loss
Decreased bowel sounds (slowed peristalsis)
Abdominal bloating
HYGIENE
May report:
Difficulty with/dependence in some/all ADLs
Use of assistive devices/individual caregiver
May exhibit:
Poor personal habits, disheveled appearance, signs of incontinence
NEUROSENSORY
May report:
Weakness, nonsymmetrical paralysis of muscles (may affect one, two, or three limbs, usually worse in lower extremities or may be unilateral), numbness, tingling (prickling sensations in parts of the body)
Change in visual acuity (diplopia), scotomas (holes in vision), eye pain (optic neuritis)
Moving head back and forth while watching television, difficulty driving (distorted visual field), blurred vision (difficulty focusing)
Cognitive changes, i.e., attention, comprehension, use of speech, problem solving, difficulty retrieving/recalling, sorting out information (cerebral involvement)
Difficulty making decisions
Communication difficulties, such as coining words
Seizures
May exhibit:
Mental status: Mood swings, depression, euphoria, irritability, apathy; lack of judgment; impairment of short-term memory; disorientation/confusion.
Scanning speech, slow hesitant speech, poor articulation
Partial/total loss of vision in one eye; vision disturbances
Positional/vibratory sense impaired or absent
Impaired touch/pain sensation
Facial/trigeminal nerve involvement, nystagmus, diplopia (brainstem involvement)
Loss of motor skills (major/fine), changes in muscle tone, spastic paresis/total immobility (advanced stages)
Ataxia, decreased coordination, tremors (may be originally misinterpreted as intoxication), intention tremor
Hyperreflexia, positive Babinski’s sign, ankle clonus; absent superficial reflexes (especially abdominal)
PAIN/DISCOMFORT
May report:
Painful spasms, burning pain along nerve path (some patients do not experience normal pain sensations)
Frequency varied may be sporadic/intermittent (possibly once a day) or may be constant
Duration lightning-like, repetitive, intermittent; persistent long-term painful spasms of extremity or back
Facial neuralgia
Dull back pain
May exhibit:
Distraction behaviors (restlessness, moaning), guarding
Self-focusing
SAFETY
May report:
Uneasiness around small children or moving objects, fear of falling (weakness, decreased vision, slowed reflexes, loss of position sense, decreased judgment)
History of falls/accidental injuries
Use of ambulation devices
Vision impairment
Suicidal ideation
May exhibit:
Wall/furniture walking
SEXUALITY
May report:
Relationship stresses
Enhanced or decreased sexual desire
Problems with positioning
Genital anesthesia/hyperesthesia, decreased lubrication (female)
Impotence/nocturnal erections or ejaculatory difficulties
Disturbances in sexual functioning (affected by nerve impairment, fatigue, bowel and bladder control, sense of vulnerability, and effects of medications)
SOCIAL INTERACTION
May report:
Lack of social activities/involvement
Withdrawal from interactions with others/isolation behaviors (e.g., stays at home/in room, watches TV all day)
Feelings of isolation (increased divorce rate/loss of friends)
Difficult time with employment because of excessive fatigue/cognitive dysfunction, physical limitations
May exhibit:
Speech impairment
TEACHING/LEARNING
May report:
Use of prescription/OTC medications, may forget to take regularly
Difficulty retaining information
Family history of disease (possibly due to common environmental/inherited factors)
Use of “holistic”/natural products/healthcare practices, “trying out cures,” “doctor shopping”
Discharge plan
DRG projected mean length of inpatient stay: 5.7 days.
May require assistance in any or all areas, depending on individual situation
May eventually need total care/placement in assisted living/extended care facility
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Brain MRI: Detects presence of plaques characteristic of MS that are due to nerve sheath demyelination, but is not diagnostic without supporting clinical symptoms.
CT scan: Demonstrates brain lesions, ventricular enlargement or thinning.
Evoked potentials: Visual (VER), brainstem auditory (BAER), and somatosensory (SSER) are abnormal early in a high percentage of patients with definite or suspected MS.
Lumbar puncture: CSF may show elevated levels of IgG and IgM. Protein level normal or only slightly elevated, oligoclonal bands present on electrophoresis; WBC count slightly elevated; elevated concentration of myelin basic protein may be noted during active demyelination process.
EEG: May be mildly abnormal in some cases.
NURSING PRIORITIES
Maintain optimal functioning.
Assist with/provide for maintenance of ADLs.
Support acceptance of changes in body image/self-esteem and role performance.
Provide information about disease process/prognosis, therapeutic needs, and available resources
DISCHARGE GOALS
Remain active within limits of individual situation.
ADLs are managed by patient/caregivers.
Changes in self-concept as acknowledged and being dealt with.
Disease process/prognosis, therapeutic regimen are understood and resources identified.
Plan in place to meet needs after discharge.
Source : http://nursingpedia.blogspot.com/2011/07/nursing-care-plan-multiple-scelorsis.html
CARE SETTING
Community or long-term care with intermittent hospitalization for disease-related complications.
RELATED CONCERNS
Extended care
Pneumonia: microbial
Psychosocial aspects of care
Sepsis/Septicemia
Patient Assessment Database
Degree of symptomatology depends on the stage and extent of disease, areas of neuronal involvement.
ACTIVITY/REST
May report:
Extreme fatigue/weakness, exaggerated intolerance to activity, needing to rest after even simple activities such as shaving/showering; increased weakness/intolerance to temperature extremes, especially heat (e.g., summer weather, hot tubs)
Limitation in usual activities, employment, hobbies
Numbness, tingling in the extremities
Sleep disturbances, may awaken early or frequently for multiple reasons (e.g., nocturia, nocturnal spasticity, pain, worry, depression)
May exhibit:
Absence of predictable pattern of symptoms
Generalized weakness, decreased muscle tone/mass (disuse), spasticity, tremors
Staggering, dragging of feet, ataxia
Intention tremors, decreased fine motor skills
CIRCULATION
May report:
Dependent edema (steroid therapy or inactivity)
May exhibit:
Blue/mottled, puffy extremities (inactivity)
Capillary fragility (especially on face)
EGO INTEGRITY
May report:
Statements of reflecting loss of self-esteem/body image
Expressions of grief
Anxiety/fear of exacerbations/progression of symptoms, pain, disability, rejection, pity
Keeping illness confidential
Feelings of helplessness, hopelessness, powerlessness (loss of control)
Personal tragedies (divorce, abandonment by SO/friends)
May exhibit:
Denial, rejection
Mood changes, irritability, restlessness, lethargy, euphoria, depression, anger
ELIMINATION
May report:
Nocturia
Incomplete bladder emptying, retention with overflow
Urinary/bowel hesitancy or urgency, incontinence of varying severity
Irregular bowel habits, constipation
Recurrent UTIs
May exhibit:
Loss of sphincter control
Kidney stone formation, kidney damage
FOOD/FLUID
May report:
Difficulty chewing, swallowing (weak throat muscles), sense of food sticking in throat, coughing after swallowing
Problems getting food to mouth (related to intentional tremors of upper extremities)
Hiccups, possibly lasting extended periods
May exhibit:
Difficulty feeding self
Weight loss
Decreased bowel sounds (slowed peristalsis)
Abdominal bloating
HYGIENE
May report:
Difficulty with/dependence in some/all ADLs
Use of assistive devices/individual caregiver
May exhibit:
Poor personal habits, disheveled appearance, signs of incontinence
NEUROSENSORY
May report:
Weakness, nonsymmetrical paralysis of muscles (may affect one, two, or three limbs, usually worse in lower extremities or may be unilateral), numbness, tingling (prickling sensations in parts of the body)
Change in visual acuity (diplopia), scotomas (holes in vision), eye pain (optic neuritis)
Moving head back and forth while watching television, difficulty driving (distorted visual field), blurred vision (difficulty focusing)
Cognitive changes, i.e., attention, comprehension, use of speech, problem solving, difficulty retrieving/recalling, sorting out information (cerebral involvement)
Difficulty making decisions
Communication difficulties, such as coining words
Seizures
May exhibit:
Mental status: Mood swings, depression, euphoria, irritability, apathy; lack of judgment; impairment of short-term memory; disorientation/confusion.
Scanning speech, slow hesitant speech, poor articulation
Partial/total loss of vision in one eye; vision disturbances
Positional/vibratory sense impaired or absent
Impaired touch/pain sensation
Facial/trigeminal nerve involvement, nystagmus, diplopia (brainstem involvement)
Loss of motor skills (major/fine), changes in muscle tone, spastic paresis/total immobility (advanced stages)
Ataxia, decreased coordination, tremors (may be originally misinterpreted as intoxication), intention tremor
Hyperreflexia, positive Babinski’s sign, ankle clonus; absent superficial reflexes (especially abdominal)
PAIN/DISCOMFORT
May report:
Painful spasms, burning pain along nerve path (some patients do not experience normal pain sensations)
Frequency varied may be sporadic/intermittent (possibly once a day) or may be constant
Duration lightning-like, repetitive, intermittent; persistent long-term painful spasms of extremity or back
Facial neuralgia
Dull back pain
May exhibit:
Distraction behaviors (restlessness, moaning), guarding
Self-focusing
SAFETY
May report:
Uneasiness around small children or moving objects, fear of falling (weakness, decreased vision, slowed reflexes, loss of position sense, decreased judgment)
History of falls/accidental injuries
Use of ambulation devices
Vision impairment
Suicidal ideation
May exhibit:
Wall/furniture walking
SEXUALITY
May report:
Relationship stresses
Enhanced or decreased sexual desire
Problems with positioning
Genital anesthesia/hyperesthesia, decreased lubrication (female)
Impotence/nocturnal erections or ejaculatory difficulties
Disturbances in sexual functioning (affected by nerve impairment, fatigue, bowel and bladder control, sense of vulnerability, and effects of medications)
SOCIAL INTERACTION
May report:
Lack of social activities/involvement
Withdrawal from interactions with others/isolation behaviors (e.g., stays at home/in room, watches TV all day)
Feelings of isolation (increased divorce rate/loss of friends)
Difficult time with employment because of excessive fatigue/cognitive dysfunction, physical limitations
May exhibit:
Speech impairment
TEACHING/LEARNING
May report:
Use of prescription/OTC medications, may forget to take regularly
Difficulty retaining information
Family history of disease (possibly due to common environmental/inherited factors)
Use of “holistic”/natural products/healthcare practices, “trying out cures,” “doctor shopping”
Discharge plan
DRG projected mean length of inpatient stay: 5.7 days.
May require assistance in any or all areas, depending on individual situation
May eventually need total care/placement in assisted living/extended care facility
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Brain MRI: Detects presence of plaques characteristic of MS that are due to nerve sheath demyelination, but is not diagnostic without supporting clinical symptoms.
CT scan: Demonstrates brain lesions, ventricular enlargement or thinning.
Evoked potentials: Visual (VER), brainstem auditory (BAER), and somatosensory (SSER) are abnormal early in a high percentage of patients with definite or suspected MS.
Lumbar puncture: CSF may show elevated levels of IgG and IgM. Protein level normal or only slightly elevated, oligoclonal bands present on electrophoresis; WBC count slightly elevated; elevated concentration of myelin basic protein may be noted during active demyelination process.
EEG: May be mildly abnormal in some cases.
NURSING PRIORITIES
Maintain optimal functioning.
Assist with/provide for maintenance of ADLs.
Support acceptance of changes in body image/self-esteem and role performance.
Provide information about disease process/prognosis, therapeutic needs, and available resources
DISCHARGE GOALS
Remain active within limits of individual situation.
ADLs are managed by patient/caregivers.
Changes in self-concept as acknowledged and being dealt with.
Disease process/prognosis, therapeutic regimen are understood and resources identified.
Plan in place to meet needs after discharge.
Source : http://nursingpedia.blogspot.com/2011/07/nursing-care-plan-multiple-scelorsis.html
