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Prioritized List of Nursing Diagnosis
- Chronic Pain related to motor and sensory nerve tract damage AEB significant tremors, arthralgia on the right and left side of the body.
- Fatigue related to environmental barriers
- Deficient knowledge related to insufficient information; insufficient knowledge of resources AEB neurological condition worsened
- Risk for injury related to sensory dysfunction and decreased muscle strength AEB abnormal visual acuity, heat intolerance, stumbling gait, and tremors.
- Risk for ineffective coping related to multiple life changes secondary to multiple sclerosis
- Readiness for Enhanced Health Management # ASSESSMENT NURSING DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBJECTIVES INTERVENTIONS RATIONALE EXPECTED
OUTCOME
Subjective Cues:
- Pt stated that she has had alteration in ability to continue previous activities. Objective Cues: Chronic Pain related to motor and sensory nerve tract damage AEB significant tremors, arthralgia on the right and left side of the body. Multiple Sclerosis is an immune-mediated, progressive demyelinating disease of the CNS (Brunner & Suddarth’s, 2018). Demyelination refers to the destruction of myelin—the fatty and protein material that surrounds certain nerve fibers in the brain and spinal cord; it results in impaired transmission of nerve impulses. The patient was diagnosed Short Term Goal
- After 1-2 hours of nursing intervention, the patient will verbalize and demonstrate relief and/or control of pain or discomfort. Long Term Goal
- After 3-4 days of nursing intervention, the patient will demonstrate and
INDEPENDENT
- Assess for signs and symptoms associated with chronic pain such as fatigue, decreased appetite, weight loss, changes in body posture, sleep pattern, disturbance, anxiety, irritability, restlessness, or depression. 1. To assess etiology/precipitati ng factors of pain. Patients with chronic pain may not exhibit the physiological changes and behaviors associated with acute pain. Short Term Goal - After 1-2 hours of nursing intervention, the patient shall have verbalized and demonstrated relief and/or control of pain or discomfort. Long Term Goal - After 3-4 days of nursing intervention, the patient shall have demonstrated and
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.
- Assess the patient’s perception of the effectiveness of methods used for pain relief in the past 2. Patients with chronic pain have a long history of using many pharmacological and nonpharmacological methods to control their pain.
- Assess the patient’s ability to accomplish activities of daily living (ADLs), instrumental activities of daily living (IADLs), and demands of daily living (DDLs). 3. Fatigue, anxiety, and depression associated with chronic pain can limit the person’s ability to complete selfcare activities and fulfill role responsibilities.
- Encourage the patient to keep a pain diary to help in identifying aggravating and relieving factors of chronic pain 4. Knowledge about factors that influence the pain experience can guide the patient in making decisions about lifestyle modifications that promote more effective pain management.
- Maintain a comfortable room temperature. 5. Heat tends to aggravate MS symptoms by increasing core body temperature
medications as prescribed. (e.g., anagelsic – acetaminophen) INTERDEPENDENT
- Refer patient to physical therapists for developing an exercise and physical therapy program. 9. Exercise and physical therapy may help to decrease spasticity and soreness of muscles.
- Identify community support groups and resources to meet individual needs.
- Proper use of resources may reduce the negative pattern of “overdoing” heavy activities and then spending several days in bed recuperating.
- Refer to counseling as needed (e.g., individual, family)
- Presence of chronic pain affects all relationships and family dynamics.
ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBJECTIVES INTERVENTIONS RATIONALE EXPECTED
OUTCOME
Subjective cues: The patient verbalized:
- substantial changes in neurologic functions, particularly heat intolerance, resulting in a stumbling gait and a tendency to fall
- She noticed “arthralgia on the right and afterwards” on the “left side of her body.”
- Suddenly development of right hemisensory deficit after several days of work. Objective cues: ∅ Fatigue related to environmental barriers Environmental barriers frequently hinder or restrict a disabled person individual in completely engaging in the community, occupational, or outdoor activities. Fatigue is an overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at the usual level. The patient is unable to continue out her daily tasks as a result of the barriers she is encountering, which has resulted in burnout and various illnesses. Short Term After a day of constant nursing intervention and proper health teachings, the patient will be able to: ● “Verbalize the causes of fatigue ● Verbalize an improvemen t in energy and enhance well being Long Term After 3-4 days of constant nursing
INDEPENDENT
- Identify the presence of physical and/or psychological conditions (connective tissue disorders [e.g., multiple sclerosis])
INDEPENDENT
- To determine important information to obtain, if fatigue is a result of an underlying condition or disease process (acute or chronic). Short Term After a day of constant nursing intervention and proper health teachings, the patient shall have: ● Verbalized the causes of fatigue ● Verbalized an improveme nt in energy and enhanced well being Long Term After 3-4 days of
- Obtain client/SO descriptions of fatigue
- To assist in evaluating the impact on the client's life.
humidity extremes. result to stumbling gait and a tendency to fall
- Assist the client to identify appropriate coping behaviors. 7. To promote a sense of control and improves self-esteem. DEPENDENT
- Administer medications, if there are any, as doctor’s order
DEPENDENT
- To alleviate the patient’s underlying condition INTERDEPENDENT
- Refer to a comprehensive rehabilitation program, physical and
INTERDEPENDENT
- To improve stamina, strength, and muscle
occupational therapy for programmed daily exercises and activities. tone and to enhance the sense of well-being.
- Teach family members and caregivers signs of overexertion.
- To have an overall observation of the patient’s vital signs and general appearance that will reveal her activity level.
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
locus of control.
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.
● Increases a
person's sense of independence and control, which may help them stick to their treatment
plan.
● Determine which signs and symptoms require additional evaluation. ● Early management may reduce the severity of the
complications.
● 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.
INTERDEPENDENT:
● Individual restrictions and disease development may necessitate a capability evaluation and
ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBJECTIVES INTERVENTIONS RATIONALE EXPECTED
OUTCOME
Subjective: Patient verbalized that she had:
- Heat intolerance
- Stumbling gait
- Poor Visual
- Significant tremors
- Severe exhaustion
- History of several bad falls
- Arthralgia on both sides of her body
- Developed right hemisensory deficit Objective:
- MRI scan revealed Risk for injury related to sensory dysfunction, decreased muscle strength as evidenced by abnormal visual acuity, heat intolerance, stumbling gait, and tremors. Multiple sclerosis (MS) is a potentially disabling disease of the brain and spinal cord (central nervous system). In MS, the immune system attacks the protective myelin sheath that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of the nerves.The patient's MRI scan revealed multifocal white matter disease - areas of increased T2 signal in both cerebral hemispheres - and a spinal tap revealed the presence of oligoclonal bands in the CSF, indicating the diagnosis of multiple sclerosis in this case. Additionally, the patient indicated how for several years she had been experiencing significant changes in neurologic functioning, notably heat intolerance, which resulted in a stumbling gait and a susceptibility to fall, and her visual acuity appeared to fluctuate. However, two Short Term: After 4 hours of nursing intervention the patient will be able to: ● Verbalize understandin g of individual factors that contribute to possibility of injury Long Term: After 8 hours of nursing intervention the patient will be able to: ● Demonstrate behaviours, lifestyle changes to reduce risk factors and protect self from injury ● Be free from injury or harm Independent: ● Assess general status of the patient ● Assess and monitor vital signs ● Assess mood coping abilities, personality style that may result in carelessness. ● Acknowledge racial/ethnic differences at the onset of care. ● Evaluate the importance of cultural beliefs, norms, and values on the patient’s Independent: ● This is to determine the patient’s condition that may cause injury. ● To determine further complications in the care process ● Mood coping abilities and style of personality aid to determine the patient’s level of cooperation. ● Discovering race/ethnicity issues will enhance communication, establish rapport, and promote treatment outcomes. ● What the patient considers risky behavior may be based on cultural perceptions. Short Term: After 4 hours of nursing intervention the patient shall be able to: ● Verbalize understandin g of individual factors that contribute to possibility of injury Long Term: After 8 hours of nursing intervention the patient shall be able to: ● Demonstrate behaviours, lifestyle changes to reduce risk factors and protect self from injury ● Be free from injury or harm
multifocal white matter disease
- areas of increased T signal in both cerebral hemispheres.
- Spinal tap revealed the presence of oligoclonal bands in CSF.
- Abnormal visual acuity months ago, the patient became ill with the flu, and her neurological condition deteriorated. She mentioned that she was unable to grasp anything in her hands at the time, suffered from significant tremors, and was quite exhausted. She had also fallen several times and had been feeling arthralgia on both sides of her body. Following several days of work, the patient experienced an unexpected right hemisensory impairment. According to NANDA, risk for injury is the state in which an individual is at risk for harm because of a perceptual or physiologic deficit, a lack of awareness of hazards, or maturational age. Therefore, the patient may be at risk for injury from above-mentioned manifestations. Reference: perceptions of risk for injury. ● Thoroughly conform the patient to the surroundings. Put call light within reach and teach how to call for assistance; respond to call light immediately. ● Ask family or significant others to be with the patient to prevent him or her from accidentally falling or pulling out tubes. ● Eliminate or drop all possible hazards in the room such as razors, medications, and matches ● Avoid extreme hot and cold around patients at risk for injury (e.g., heating pads, hot water for baths/showers) ● Place an injury-prone ● The patient must get used to the layout of the environment to avoid accidents. Items that are too far from the patient may cause hazard. ● This is to prevent the patient from accidentally falling or pulling out tubes. ● This is to prevent the patient from any unpleasant experience due to dangerous objects. ● Patients with decreased cognition or sensory deficits cannot discriminate between extremes in temperature. ● Such placement
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.
ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBJECTIVES INTERVENTIONS RATIONALE EXPECTED
OUTCOME
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
SHORT TERM:
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
INDEPENDENT
● 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
SHORT TERM:
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
