Nursing Care Plan Multiple Scelorsis

CARE SETTING

Community or long-term care with intermittent hospitalization for disease-related complications.

RELATED CONCERNS

1. Extended care
2. Pneumonia: microbial
3. Psychosocial aspects of care
4. Sepsis/Septicemia
5. Patient Assessment Database
6. Degree of symptomatology depends on the stage and extent of disease, areas of neuronal involvement.

ACTIVITY/REST

May report: 

1. 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)
2. Limitation in usual activities, employment, hobbies
3. Numbness, tingling in the extremities
4. Sleep disturbances, may awaken early or frequently for multiple reasons (e.g., nocturia, nocturnal spasticity, pain, worry, depression)

May exhibit: 

1. Absence of predictable pattern of symptoms
2. Generalized weakness, decreased muscle tone/mass (disuse), spasticity, tremors
3. Staggering, dragging of feet, ataxia
4. 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: 

1. Statements of reflecting loss of self-esteem/body image
2. Expressions of grief
3. Anxiety/fear of exacerbations/progression of symptoms, pain, disability, rejection, pity
4. Keeping illness confidential
5. Feelings of helplessness, hopelessness, powerlessness (loss of control)
6. Personal tragedies (divorce, abandonment by SO/friends)

May exhibit: 

1. Denial, rejection
2. Mood changes, irritability, restlessness, lethargy, euphoria, depression, anger

ELIMINATION

May report: 

1. Nocturia
2. Incomplete bladder emptying, retention with overflow
3. Urinary/bowel hesitancy or urgency, incontinence of varying severity
4. Irregular bowel habits, constipation
5. Recurrent UTIs

May exhibit: 

1. Loss of sphincter control
2. Kidney stone formation, kidney damage

FOOD/FLUID

May report: 

1. Difficulty chewing, swallowing (weak throat muscles), sense of food sticking in throat, coughing after swallowing
2. Problems getting food to mouth (related to intentional tremors of upper extremities)
3. Hiccups, possibly lasting extended periods

May exhibit: 

1. Difficulty feeding self
2. Weight loss
3. Decreased bowel sounds (slowed peristalsis)
4. Abdominal bloating

HYGIENE

May report: 

1. Difficulty with/dependence in some/all ADLs
2. Use of assistive devices/individual caregiver

May exhibit: 
Poor personal habits, disheveled appearance, signs of incontinence

NEUROSENSORY

May report: 

1. 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)
2. Change in visual acuity (diplopia), scotomas (holes in vision), eye pain (optic neuritis)
3. Moving head back and forth while watching television, difficulty driving (distorted visual field), blurred vision (difficulty focusing)
4. Cognitive changes, i.e., attention, comprehension, use of speech, problem solving, difficulty retrieving/recalling, sorting out information (cerebral involvement)
5. Difficulty making decisions
6. Communication difficulties, such as coining words
7. Seizures

May exhibit: 

1. Mental status: Mood swings, depression, euphoria, irritability, apathy; lack of judgment; impairment of short-term memory; disorientation/confusion.
2. Scanning speech, slow hesitant speech, poor articulation
3. Partial/total loss of vision in one eye; vision disturbances
4. Positional/vibratory sense impaired or absent
5. Impaired touch/pain sensation
6. Facial/trigeminal nerve involvement, nystagmus, diplopia (brainstem involvement)
7. Loss of motor skills (major/fine), changes in muscle tone, spastic paresis/total immobility (advanced stages)
8. Ataxia, decreased coordination, tremors (may be originally misinterpreted as intoxication), intention tremor
9. Hyperreflexia, positive Babinski’s sign, ankle clonus; absent superficial reflexes (especially abdominal)

PAIN/DISCOMFORT

May report: 

1. Painful spasms, burning pain along nerve path (some patients do not experience normal pain sensations)
2. Frequency varied may be sporadic/intermittent (possibly once a day) or may be constant
3. Duration lightning-like, repetitive, intermittent; persistent long-term painful spasms of extremity or back
4. Facial neuralgia
5. Dull back pain

May exhibit: 

1. Distraction behaviors (restlessness, moaning), guarding
2. Self-focusing

SAFETY

May report: 

1. Uneasiness around small children or moving objects, fear of falling (weakness, decreased vision, slowed reflexes, loss of position sense, decreased judgment)
2. History of falls/accidental injuries
3. Use of ambulation devices
4. Vision impairment
5. Suicidal ideation

May exhibit: 
Wall/furniture walking

SEXUALITY

May report: 

1. Relationship stresses
2. Enhanced or decreased sexual desire
3. Problems with positioning
4. Genital anesthesia/hyperesthesia, decreased lubrication (female)
5. Impotence/nocturnal erections or ejaculatory difficulties
6. Disturbances in sexual functioning (affected by nerve impairment, fatigue, bowel and bladder control, sense of vulnerability, and effects of medications)

SOCIAL INTERACTION

May report: 

1. Lack of social activities/involvement
2. Withdrawal from interactions with others/isolation behaviors (e.g., stays at home/in room, watches TV all day)
3. Feelings of isolation (increased divorce rate/loss of friends)
4. Difficult time with employment because of excessive fatigue/cognitive dysfunction, physical limitations

May exhibit: 
Speech impairment

TEACHING/LEARNING

May report: 

1. Use of prescription/OTC medications, may forget to take regularly
2. Difficulty retaining information
3. Family history of disease (possibly due to common environmental/inherited factors)
4. Use of “holistic”/natural products/healthcare practices, “trying out cures,” “doctor shopping”
5. Discharge plan
6. DRG projected mean length of inpatient stay: 5.7 days.
7. May require assistance in any or all areas, depending on individual situation
8. May eventually need total care/placement in assisted living/extended care facility
9. Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

1. Brain MRI: Detects presence of plaques characteristic of MS that are due to nerve sheath demyelination, but is not diagnostic without supporting clinical symptoms.
2. CT scan: Demonstrates brain lesions, ventricular enlargement or thinning.
3. Evoked potentials: Visual (VER), brainstem auditory (BAER), and somatosensory (SSER) are abnormal early in a high percentage of patients with definite or suspected MS.
4. 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.
5. EEG: May be mildly abnormal in some cases.

NURSING PRIORITIES

1. Maintain optimal functioning.
2. Assist with/provide for maintenance of ADLs.
3. Support acceptance of changes in body image/self-esteem and role performance.
4. Provide information about disease process/prognosis, therapeutic needs, and available resources

DISCHARGE GOALS

1. Remain active within limits of individual situation.
2. ADLs are managed by patient/caregivers.
3. Changes in self-concept as acknowledged and being dealt with.
4. Disease process/prognosis, therapeutic regimen are understood and resources identified.
5. Plan in place to meet needs after discharge.