Nursing Assessment in Multiple Sclerosis Patients

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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

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

• Advocate
• Caregiver
• Case manager
• Consultant
• Collaborator
• Coordinator
• Educator
• Facilitator
• Leader
• Researcher

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The Nurse

• The Nurse is primary in building Patients
• Adherence to therapy
• Positive initial expectations
• Realistic expectations
• Continued education
• Self confidence
• Support encouragement

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Nursing Medical

• Overlap between assessments
• Identifying Patients Needs
• Establishing relationship
• MS related Issues
• General Health considerations
• Women issues
• Men Issues

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Nursing Assessment

• General Appearance
• Medical History
• Family History
• Psych History
• Social History
• Review of system
• MS related symptoms

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Nursing Assessment

• General Appearance
• Physical appearance
• Emotional status
• General attitude mood
• Cooperativeness
• Mobility
• Level of consciousness

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Nursing Assessment

• Medical History
• Current description of illness /MS
• Chief Complaint
• Onset Diagnosis
• Progression of illness / Subtype
• Signs Symptoms / PQRST

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Nursing Assessment

• P
• Q
• R
• S
• T

• P
• Q
• R
• S
• T

• 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

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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

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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

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Nursing Assessment

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

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Nursing Assessment

• Psychological History
• Support network
• Coping Mechanisms
• Leisure habits
• Ethnic cultural factors
• Role changes
• Lifestyle changes
• Relationships

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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

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Review of System

• Heat Sensitivity
• Increased Body Temperature
• Utophs Phenomenon
• Exacerbate Symptoms
• Stress Level
• Exacerbate Symptoms
• No Evidence that it makes the actual disease
  worse
  
• Stress is unavoidable

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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

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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

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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

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MS Symptoms Requiring Special Nursing Assessment

• Cognitive impairment
• Mobility impairment
• Sexual dysfunction
• Bladder dysfunction
• Bowel dysfunction
• Swallowing impairment
• Impairment in skin integrity

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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

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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

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Cognitive Dysfunction

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

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Cognitive Dysfunction

• MS specific effects
• Sustained attention concentration
• Recent memory
• Speed of cognitive processing
• Abstraction conceptual reasoning

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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

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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

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Mobility Impairment

• Assessment of mobility
• Posture gait
• Balance static dynamic
• Asymmetry / Incoordination
• Involuntary movements
• Range of motion
• Weakness during ADLs

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Mobility Impairment

• Assessment of ADLs
• Assistive Devices
• Eating
• Dressing
• Grooming
• Toileting
• Homemaking
• Vocational

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Mobility Impairment

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

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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)

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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

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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

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Sexual Assessment

• 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

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Sexual Dysfunction

• 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

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Sexual Dysfunction

• 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

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Sexual Dysfunction

• Psychological / psychiatric problems
• Renal insufficiency
• Diabetes
• Neurologic conditions
• Hypertension
• Endocrine disorders
• STDs

• Medications
• Antihypertensive
• Antipsychotic
• Antihistamines
• Alcohol
• Analgesics
• Narcotics
• Recreational drugs

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Sexual Dysfunction

• 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

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Bladder Dysfunction

• 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

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Bladder Dysfunction

• 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

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Bladder Dysfunction

• 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

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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

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Bowel Dysfunction

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

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Bowel Dysfunction

• 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

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Bowel Dysfunction

• Assess use of Medications effectiveness
• Stool softener
• Laxative
• Suppositories
• Enemas
• Chronic use
• Relevant medical history

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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

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Swallowing Impairment

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

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Swallowing Impairment

• 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

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Swallowing Impairment

• Physical assessment
• Head control
• Presence of dentures
• Preparing meals
• Accessibility issues
• Visual acuity

• Ability to eat
• Mobility
• Muscle strength
• Incoordination
• Involuntary movements

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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

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Impairment of Skin Integrity

• 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

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Impairment of Skin Integrity

• Specific History questions
• Past Present skin problems
• Changes in skin pigmentation
• Excessive dryness, moisture or odor
• Performance of daily skin inspection

• Individual practices of skin care
• Bath and skin care products used
• Sitting time, Pressure relief measures
• Pressure reducing or relieving devices

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Impairment of Skin Integrity

• MS specific assessment issues
• Emphasis on Prevention
• Decreased sensation Risk of burns
• Injection sites assessment
• Skin changes
• Inspect injection sites
• Rotation

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Impairment of Skin Integrity

• Documentation
• Description of anatomic location of the wound
• Wound size depth
• Staging of wound
• Presence or absence of necrotic tissue
• Absence or presence of exudate
• Description of granulation tissue

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Impairment of Skin Integrity

• Goals
• Maintain restore skin integrity
• Prevent damage to the skin
• Understand the cause prevention
  of pressure ulcers
• Recognize intervene on warning
  signs of skin impairment
• Establish a management plan

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Nursing Assessment Documentation

• Accurate documentation
• Documentation of phone-calls
  day-to-day communication with patient,
  family or caregiver
• Importance of follow-up

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The End