Nursing Care Plan for Multiple Sclerosis

Saturday, June 25, 2011

Nursing Care Plan for Multiple Sclerosis

Multiple sclerosis (abbreviated MS, also known as disseminated sclerosis or encephalomyelitis disseminata) is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms. Disease onset usually occurs in young adults, and it is more common in women. It has a prevalence that ranges between 2 and 150 per 100,000. MS was first described in 1868 by Jean-Martin Charcot. (wikipedia)

Nursing Assessment for Multiple Sclerosis

Activity / rest
Symptoms: weakness, activity intolerance, numbness, paresthesia external
Signs: general weakness, decreased muscle tone / muscle mass, unsteady path / dragged, ataxia

Circulation
Symptoms: edema
Signs: extremity narrowed, not active, fragile capillaries

Ego integrity
Symptoms: anxiety, hopelessness, helplessness, decreased productivity

Elimination
Symptoms: nocturia, retention, incontinence, constipation, urinary tract infections
Signs: sphincter control is lost, kidney damage

Food / liquid
Symptoms: difficulty chewing / swallowing
Signs: hard to feed themselves

Hygiene
Symptoms: personal hygiene assistance
Signs: less self-care

Pain / discomfort
Symptoms: painful spasms, facial neuralgia

Security
Symptoms: a history of falls / trauma, use of assistive devices

Sexuality
Symptoms: impotent, impaired sexual function

Social Interaction
Symptoms: withdraw
Signs: speech disorders

Neuro Sensory
Symptoms: weakness, muscle paralysis, numbness, tingling, diplopia, blurred vision, memory loss, difficulty communicating, seizures
Signs: mental status (euphoria, depression, apathy, sensitive, disorientas)
Stammering, blindness in one eye, impaired sensation of touch / pain, nystagmus, diplopia
Lost motor skills, spastic paresis, ataxia, tremor, hiperfleksia, + Babinski, klonus on knee.

Nursing Diagnosis for Multiple Sclerosis

Impaired Physical Mobility related to weakness, muscle paresis, spasticity

Expected results :

Participate in a rehabilitation program
Demonstrate behaviors that maintain / increase activity

Nursing Intervention for Multiple Sclerosis

Determine the level of client activity
Assess the weaknesses
Provide regular change of position
Help fulfill the basic needs of clients according to needs
Collaboration: physical therapy / work by physiotherapists, medical treatment (steroids, baklofen, immunosuppressants)