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Nursing Assessment in Multiple Sclerosis Patients

Aliza Ben-Zacharia, CRRN, ANP The Corinne Goldsmith Dickinson Center for Multiple Sclerosis Mount Sinai Medical Center. Nursing Assessment in Multiple Sclerosis Patients.

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Nursing Assessment in Multiple Sclerosis Patients

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  1. Aliza Ben-Zacharia, CRRN, ANP The Corinne Goldsmith Dickinson Center for Multiple Sclerosis Mount Sinai Medical Center Nursing Assessment in Multiple Sclerosis Patients

  2. The Nurse & The TeamKey members of MS care; Adapted from NMSS& CMS: Improving care for persons with MS, Teleconference December 1997 (Modified) Psychologist Urologist Social worker Neurologist Vocational Occupational Nurse Patient Psychiatrist Physical Physiatrist Speech Recreation Family Friends Employer

  3. The Nurse • Advocate • Caregiver • Case manager • Consultant • Collaborator • Coordinator • Educator • Facilitator • Leader • Researcher

  4. The Nurse • The Nurse is primary in building Patient’s • Adherence to therapy • Positive initial expectations • Realistic expectations • Continued education • Self confidence • Support & encouragement

  5. Nursing & Medical • Overlap between assessments • Identifying Patient’s Needs • Establishing relationship • MS related Issues • General Health considerations • Women issues • Men Issues

  6. Nursing Assessment • General Appearance • Medical History • Family History • Psych History • Social History • Review of system • MS related symptoms

  7. Nursing Assessment • General Appearance • Physical appearance • Emotional status • General attitude & mood • Cooperativeness • Mobility • Level of consciousness

  8. Nursing Assessment • Medical History • Current description of illness /MS • Chief Complaint • Onset & Diagnosis • Progression of illness / Subtype • Signs & Symptoms / PQRST

  9. P Q R S T MS related Symptoms P – Provocative / Palliative Q – Quality / Quantity R – Region / Radiation S- Severity Scale – Interfere with other activities T- Timing – Sudden or Gradual P Q R S T Nursing Assessment • P • Q • R • S • T

  10. Nursing Assessment • Multiple Sclerosis • Sudden or gradual onset assist determining the type of MS • Severity and duration of symptoms , acute exacerbation, radiation of symptoms • Multiple symptoms; motor, sensory, cerebellar, brain stem and optic. • Symptoms that affect function and interfere with daily activities

  11. Nursing Assessment • Medical History • General Health / Other diseases • Surgical History • Family History, esp. Neuro / MS • Alternative or complementary use • Medications list / ABCs / Drug interactions • Allergies – drug, food, environmental

  12. Nursing Assessment • Social History • Marital status • Residence • Children / Pregnancy / Miscarriage • Occupation / Educational background • Use of Tobacco • Use of alcohol • Use of any drug abuse

  13. Nursing Assessment • Psychological History • Support network • Coping Mechanisms • Leisure habits • Ethnic & cultural factors • Role changes • Lifestyle changes • Relationships

  14. Review of System • General – Weight loss, Sleep, Fatigue • Skin – Rash, lesions • Neurological-Dizziness, ataxia, H/A • Cardiac-Palpitations,CP, H/O MI • Pulmonary-Congestion, Recurrent Pneumonia • GU-Urgency/ Retention/ Incontinence • GI-Elimination patterns/ Constipation • Psych-Depression/Anxiety

  15. Review of System • Heat Sensitivity • Increased Body Temperature • Utoph’s Phenomenon • Exacerbate Symptoms • Stress Level • Exacerbate Symptoms • No Evidence that it makes the actual disease worse • Stress is unavoidable

  16. Nursing & Medical Assessment • MS assessment tools • EDSS = Expanded Disability Status Scale; • Based on the neurological Exam & History; • Done by MD or NP/CNS • Score 0-10

  17. Nursing Assessment • MSFC = MS Functional Composite Measure; Three Clinical dimensions: • Ambulation • Timed - 25 feet walk • Coordination-9 Peg Hole • Dominant hand • Non-dominant • PASAT - Cognition • Calculation

  18. Nursing Assessment • Discussion with Patient & Family • Assess Patient & Family • Understanding of the illness /MS • Misconceptions R/T MS • Understanding of treatment plan • Understanding of expected outcome

  19. MS Symptoms Requiring Special Nursing Assessment • Cognitive impairment • Mobility impairment • Sexual dysfunction • Bladder dysfunction • Bowel dysfunction • Swallowing impairment • Impairment in skin integrity

  20. Cognitive Dysfunction • Pre-Illness Cognitive Assessment • Medical history – thought processes • Past cognitive & Behavioral functioning • Family or friends • History of medications, Alcohol/Substance abuse • History of sleep-wake pattern

  21. Cognitive Dysfunction • Post-Illness Cognitive Assessment • General orientation • Attention span /Concentration • Intellectual functioning • Ability to FU sequence of commands • Ability to problem solve • Ability to perform daily activities • Patterns of communication/Language

  22. Cognitive Dysfunction • General neuropsychological functioning • Speed of cognitive functioning • Visuospatial & Perceptual • Academic achievement • Language & communication • Memory functioning • Problem solving, new learning • Abstraction, executive functioning

  23. Cognitive Dysfunction • MS specific effects • Sustained attention & concentration • Recent memory • Speed of cognitive processing • Abstraction & conceptual reasoning

  24. Cognitive Dysfunction • Red Flag • Large burden of disease on Brain MRI • Atrophy on MRI • Depression not responding to medications • Frustration & Irritability • Adapted from N. Bourdette

  25. Cognitive Dysfunction • Assessment Tools • Mini-Mental State Examination – Global • Neuropsychological battery tests by Neuropsychologist • Comprehensive neuropsychological assessment with multiple tests to assess cognitive function • MRI

  26. Mobility Impairment • Assessment of mobility • Posture & gait • Balance – static & dynamic • Asymmetry / Incoordination • Involuntary movements • Range of motion • Weakness during ADLs

  27. Mobility Impairment • Assessment of ADLs • Assistive Devices • Eating • Dressing • Grooming • Toileting • Homemaking • Vocational

  28. Mobility Impairment • Mobility aids • Transfers • AFOs (Ankle foot orthosis) • Crutches • Cane / Walker • Wheelchair / Scooter

  29. Mobility Impairment • Assess Need for rehabilitation • Inpatient versus Outpatient • Rehab studies show that rehab programs benefit • Disability & handicap • Quality of life • No change in EDSS (Freeman)

  30. Mobility ImpairmentGoals • Prevent complications with immobility • Increase muscle strength & mobility • Adjust & adapt to altered mobility • Prevent injury during activities • Use assistive devices correctly & consistently • Participate in social & occupational activities

  31. Sexual Assessment • Premorbid sexual function • Description of sexual activities preferred • Frequency of sexual activity • Partner who usually initiate sexual activity • Sexual preference of the client

  32. Sexual response issues Female Menstrual history Sexual interest Frequency of sexual interaction Vaginal lubrication Orgasmic capacity Sexual response issues Male Sexual interest Presence of morning erection Presence of erection with manual stimulation Process of ejaculation Sexual Assessment

  33. Specific concerns Fertility Pregnancy issues Birth control /ABC Importance of sex in the relationship Difficulty with hearing, vision, &/or oral motor control Physical issues that impact sexual function Transfers Ability to dress & undress Endurance Balance Presence of GU or GI collection devices ROM limitations Sexual Dysfunction

  34. Direct Changes in libido Genital sexual dysfunction Impotence Vaginal issues Change in orgasm Female Male Indirect Fatigue Impaired physical mobility Increased or decreased sensation Bowel / Bladder incontinence Pain, spasticity Effects of medications Sexual Dysfunction

  35. Psychological / psychiatric problems Renal insufficiency Diabetes Neurologic conditions Hypertension Endocrine disorders STDs Medications Antihypertensive Antipsychotic Antihistamines Alcohol Analgesics Narcotics Recreational drugs Sexual Dysfunction

  36. Psychosocial alterations Social isolation Self concept Body image Partnership issues Role changes Mood changes Cognitive & Behavioral alterations Decreased attention Decreased memory Impaired executive functioning Impaired communication Irritability Sexual Dysfunction

  37. Premorbid Urinary History Urgency Incontinence Dribbling after urination Retention /Initiation Incomplete emptying Obstructive symptoms R/O UTI, symptoms Onset Duration Frequency Timing Precipitating Use of pads Relevant medical history Medications Bladder Dysfunction

  38. Acute illness Neurologic disease Cardiovascular Renal Bowel disorders (Constipation, impaction) Psychological (depression, mental) Cancer, DM Medications that affect urination Diuretics Sedatives & Hypnotics Beta blockers Antidepressants Bladder Dysfunction

  39. Environmental factors Accessible bathrooms Distance to bathroom Use of toileting aids Ability to transfer Available people to assist Available equipment such as catheters Client/caregiver Interference with daily activities Expectations Previous treatment Pelvic floor exercise Tests / Neurogenic bladder Bladder Dysfunction

  40. Bladder DysfunctionGoals • Collaborate with P.T. and O.T. • Assess fine motor function for intermittent catheterization • Assess for use of mirror • Assess for use of assistive devices to facilitate intermittent catheterization • Assess transfer skills to toilet and use of commode chair

  41. Bowel Dysfunction • Past bowel routine • Dietary habits • Physical status • Cognition • Swallowing • Mobility/Activity • Medications • Future lifestyle

  42. Bowel assessment Constipation Incontinence Onset Frequency Duration Activity level Medications that may affect bowel activity Diuretics Antacids / Iron Non-steroidal & anti-inflammatory Anticholinergics Antidepressants Antibiotics Analgesic/narcotics Bowel Dysfunction

  43. Bowel Dysfunction • Assess use of Medications & effectiveness • Stool softener • Laxative • Suppositories • Enemas • Chronic use • Relevant medical history

  44. Bowel DysfunctionGoals • Achieve control • Avoid complications • Help patient with reflex neurogenic bowel to stimulate reflex activity at regular time • Help patient with flaccid neurogenic bowel to maintain firm stool consistency & keep the distal colon empty • Assist patient with uninhibited neurogenic bowel to regulate bowel elimination

  45. Swallowing Impairment • Assessment • Difficulty with solids or liquids • History of aspiration pneumonia • Presence of coughing/chocking - meals • Pain with swallowing • Modified Barium Swallow

  46. Facial asymmetry Drooling Oral mucosal sensation Cough during or after swallow Voice quality Oral muscle weakness Lips Tongue Cheek Pharynx Dentition & chewing Weight Cognition LOC Swallowing Impairment

  47. Physical assessment Head control Presence of dentures Preparing meals Accessibility issues Visual acuity Ability to eat Mobility Muscle strength Incoordination Involuntary movements Swallowing Impairment

  48. Swallowing ImpairmentGoals • Maintain adequate nutrition • Maintain adequate fluid intake • Educate client & family • Proper nutrition / Modification of diet • Use of adaptive equipment • Oral exercises • Community resources/Referral to SLP

  49. Assess Risk factors to implement Prevention Immobility Inactivity Decreased sensation Bowel or bladder incontinence Decreased nutritional status Use of steroids or immuno-suppressives Age Elevated temperature Psychosocial Tools to assess risk – Braden Scale Staging the wound Impairment of Skin Integrity

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