Nursing 213

N213: Health Differences Across the Lifespan 3 Study Guide • Review laboratory and radiology reports: o Lumbar puncture: Lumbar puncture will show antibodies and gamma globulin o MRI/CT scans: Plaques will manifest on the myelin sheath and brain o Evidence based criteria: MS is most often diagnosed by meeting certain criteria for symptoms; symptoms are checked off on a chart and if a certain number of criteria are met then a diagnosis of MS cannot be excluded Nursing diagnosis for multiple sclerosis: • Pain related to muscle spasticity and contractures • Ineffective airway clearance related to weakness and paralysis • Impaired mobility related to muscle weakness and paralysis • Risk for skin breakdown related to paralysis and loss of sensory function • Risk for injury related to muscle weakness, vertigo, and vision loss • Self-concept disturbance related to chronic condition • Altered urinary pattern related to sensory deficits Nursing interventions for multiple sclerosis: • Frequently assess neurological status, muscular status, fatigue, and pain levels • Monitor respiratory abilities and encourage deep breathing andcoughing • Give medications per MD order: o Corticosteroids: Prednisone can be given either orally or via IV to decrease symptoms and inflammation. These medications have side effects including weight gain, high blood pressure, emotional changes, and risk of infections. Warn about exposure to infection. o Immune modulators: Drugs like Copaxone, Tysabri, and Novantrone can help to slow the immune systems attack on the myelin sheath. They too have side effects including risk of infection, effects on the heart, shortness of breath, and flushing. o Muscle relaxers: Baclofen and Zanaflex can help to reduce muscle spasticity, but side effects include dry mouth and increased leg weakness. o Anticholinergics: These help with spasms in the bladder and facilitate urine flow. o Cholinergics: Urecholine can help with a flaccid and weak bladder and prevent incontinence. • Monitor skin frequently for breakdown and pressureulcers • If the patient has dysphagia or respiratory concerns, sit patient upright during meals and have them point their head toward the sternum to prevent aspiration or choking • Give prompt wound care to any pressure wounds • If immobile, turn patient every two hours to prevent wounds and respiratorycomplications • Assist with range of motion exercises and stretching exercises

©2018

Achieve

Page 93

of 203