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A prioritized list of nursing diagnosis for a patient with multiple sclerosis. It includes scientific explanations, objectives, interventions, and rationale for each diagnosis. The document also provides short-term and long-term goals for each diagnosis. The nursing diagnoses include chronic pain, fatigue, deficient knowledge, risk for injury, risk for ineffective coping, and readiness for enhanced health management. useful for nursing students and healthcare professionals who are involved in the care of patients with multiple sclerosis.
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Prioritized List of Nursing Diagnosis
Subjective Cues:
Patient manifested: ● MRI scan revealed a multifocal white matter disease - areas of increased T signal in both cerebral hemispheres. ● Spinal tap revealed presence of oligoclonal bands in CSF. ● Pt has heat intolerance. ● Pt had significant tremors. ● Pt had arthralgia on the right and left side of her body. with MS as shown in the diagnostic findings that the patient took, such as MRI scan revealed a multifocal white matter disease - areas of increased T2 signal in both cerebral hemispheres, and spinal tap revealed presence of oligoclonal bands in CSF. The signs and symptoms of MS are varied and multiple, reflecting the location of the lesion (plaque) or combination of lesions. One common symptom of MS is pain that is caused by lesions on the sensory pathways. In addition, spasticity also occurs in 90% of patients with MS. According to NANDA, chronic pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage, sudden or slow onset of any intensity, from mild to severe, constant or recurring without an anticipated or predictable end and a duration of at initiate behavioral modifications on lifestyle and appropriate use of therapeutic interventions. initiated behavioral modifications on lifestyle and appropriate use of therapeutic interventions.
medications as prescribed. (e.g., anagelsic – acetaminophen) INTERDEPENDENT
Subjective cues: The patient verbalized:
humidity extremes. result to stumbling gait and a tendency to fall
occupational therapy for programmed daily exercises and activities. tone and to enhance the sense of well-being.
the evaluation of her long-term neurologic complaints. And two month ago, a patient was working very hard and under a lot of stress. She got sick with the flu and her neurological condition worsened. or perceptual ability and the
changes in cognitive, visual, and auditory function: verbal instruction, books, pamphlets, audiovisuals, and computer applications ● Encourage the patient to take an active role in the learning process, including the use of self-paced training if necessary.
person's sense of independence and control, which may help them stick to their treatment
● Determine which signs and symptoms require additional evaluation. ● Early management may reduce the severity of the
● Discuss the ● Allows the
importance of a daily routine that includes relaxation, exercise, activity, and eating, with an emphasis on capabilities patient to keep his or her existing level of physical independence while also reducing weariness ● Identify steps that can be performed to avoid injury, such as avoiding hot baths, inspecting skin on a frequent basis, exercising caution with transfers and wheelchair/walker mobility, forcing fluids, and eating a balanced diet. ● Assist patients in taking steps to maintain a healthy physical state and avoid complications. INTERDEPENDENT: ● Refer for vocational rehabilitation as appropriate.
● Individual restrictions and disease development may necessitate a capability evaluation and
Subjective: Patient verbalized that she had:
multifocal white matter disease
in the environment that must be easily located (e.g., stair edges, stove controls, light switches). ● Provide non-pharmacological measures to eliminate fatigue in the legs such as massage. ● Teach the client to perform active range of motion exercises ● Give nonpharmacologic action ● Perform thorough assessments regarding safety issues when planning for client care and/or preparing for discharge from care patient must get up at night. ● To reduce pain in the leg. ● Active range of motion increases mass, tone and muscle strength and improves cardiac and respiratory function. ● To relieve pain ● Failure to accurately assess and intervene or refer these issues can place the client at needless risk and creates negligence issues for the health care
● Ascertain knowledge of safety needs/injury prevention and motivation ● Assessed client’s muscle strength, gross and fine motor coordination ● Maintain bed or chair in lowest position with wheels locked practitioner ● To prevent injury in home, community, and work setting ● To identify risk for falls ● To prevent risk for fall and injuries Dependent: ● Administer medications as ordered (e.g. analgesics) Dependent: ● To relieve pain Interdependent: ● Referral to ophthalmologist ● Coordinate with a physical therapist for strengthening exercises and gait training to increase mobility. Contact Interdependent: ● To determine further procedures in treating visual acuity ● Gait training in physical therapy has been proven to effectively prevent falls.
Objective Cues: ● MRI scan showed a multifocal white matter disease - areas of increased T signal in both cerebral hemispheres. ● Spinal tap revealed presence of oligoclonal bands in CSF. Risk for ineffective coping related to multiple life changes secondary to multiple sclerosis Multiple sclerosis (MS) is a potentially devastating central nervous system illness that occurs when the immune system assaults the protective sheath called myelin that surrounds nerve fibers, causing communication issues between the brain and the rest of the body. The condition might eventually cause permanent nerve injury or degeneration. Multiple sclerosis symptoms and signs vary depending on the extent of nerve damage and which nerves are impacted. (Multiple Sclerosis - Symptoms and Causes, 2020). The patient's MRI scan revealed multifocal white matter disease - areas of elevated T signal in both cerebral hemispheres - and a spinal tap revealed the presence of oligoclonal bands in CSF, indicating
After 1-2 hours of nursing interventions, the patient will identify the link between disease process and emotional reactions, as well as changes in thinking/behavior and verbalization of personal capabilities and strengths. LONG TERM: After 2-3 days of nursing interventions, the patient will show effective problem-solving abilities and exhibit behaviors/lifestyle modifications to prevent/minimize mentation alterations and
● Determine existing functional capabilities and limitations; notice any distorted thought processes, labile emotions, or cognitive dissonance. Take note of how these factors influence the individual's ability to cope. ● Assessing existing functional capabilities and limitations, observing any distorted thought processes, and noting how these factors affect the individual's ability to cope is critical for organic or psychological effects may cause the patient to become easily distracted, have difficulty concentrating, problem-solvin g, dealing with what is happening, and being
After 1-2 hours of nursing interventions, the patient shall have identified the link between disease process and emotional reactions, as well as changes in thinking/behavior and verbalization of personal capabilities and strengths. LONG TERM: After 2-3 days of nursing interventions, the patient shall have shown effective problem-solving abilities and exhibited behaviors/lifestyle modifications to prevent/minimize
the diagnosis of MS in the scenario. The patient also described how she had been seeing some substantial alterations in neurologic functioning for several years, specifically heat intolerance, which resulted in a stumbling gait and a tendency to fall and her vision acuity seemed to fluctuate. The patient, however, became ill with the flu two months ago and her neurological condition deteriorated causing her a series of life changes. She reported that she couldn't hold anything in her hands at the time, had severe tremors, and was quite tired. She also suffered a number of bad falls and had been experiencing arthralgia on the right side of her body since then, and then on the left. After several days of work, the patient suddenly developed a right hemisensory deficit. Ineffective coping is a NANDA-accepted nursing diagnosis that is defined as an inability to create a retain reality orientation responsible for their own care. mentation alterations and retain reality orientation. ● Assess the patient's grasp of the current issue and previous approaches to dealing with challenges in life. ● Evaluating the patient's understanding of the current issue as well as previous approaches to dealing with life's obstacles provides insight into how the patient might deal with the current circumstance and assists in the identification of unique resources and needs for assistance. ● Encourage patient to express their feelings and/or anxieties by accepting what they say without ● Allowing patient to express their feelings and/or fears can help to reduce their anxiety, build