Sunday, October 27, 2013

Risk for Injury - Multiple Sclerosis Care Plan


Multiple Sclerosis (MS) is a progressive and chronic disease that attacks the central nervous system.

More than 2.5 million people around the world are said to be affected by multiple sclerosis. Disease onset is usually seen more in young adults, and it is more common in women. Almost 98% of the MS population is Caucasian. MS is generally more common in people living in temperate zones.

MS can be difficult to diagnose since its signs and symptoms may be similar to other conditions. A number of specialized tests may be necessary for accurate diagnosis. Medical organizations have set diagnostic criteria to standardize the process. Currently diagnosis is based on The McDonald criteria which focus on a demonstration with clinical, laboratory and radiological data.

Nursing Diagnosis for Multiple Sclerosis : Risk for Injury
related to :
  • sensory impairment and vision,
  • effects of prolonged bed rest and spastic weakness.

Goal :
Risk for Injury did not occur

Outcomes:
  1. Clients want to participate to the prevention of trauma.
  2. Decubitus : no.
  3. Joint contractures : no.
  4. Clients do not fall out of bed.

Intervention and Rational :
1. Maintain bed rest and immobilization as indicated.
Rational : Minimize the pain caused by stimulation of grit between the bone fragments with the surrounding soft tissue.

2. Give goggles that fit with the client.
Rational : Eye shields or goggles cover implus can be used to block vision in one eye when a client is experiencing diplopia or double vision.

3. Minimize the effects of immobility.
Rational: Because physical activity and immobilization often occur in multiple sclerosis, the complications which connect with immobilization and rare covers to prevent pressure sores.

4. Modification of injury prevention.
Rational: Injury prevention is done on the client if the motor dysfunction of multiple sclerosis causes no problems in coordination and any stiffness or if there's ataxia, the risk of falling.

5. Environmental modifications.
Rational: the inability to cope, to encourage clients with empty legs on a vast space to provide a broad base and to improve the ability to walk steadily.

6. Teach walking technique.
Rational: if the loss of sensation to the body position, encourage clients to see the foot while walking.

7. Provide occupational therapy.
Rational: Occupational therapy is a resource that helps individuals to provide advice and assistance to ensure increased independence.

8. Minimize the risk of decubitus.
Rational: Because of sensory loss can lead to increased loss of motoric move. Continue to be addressed to inegritas decubitus skin. Wheelchair use increases the risk.

9. Distal section of skin inspection, every day (monitor skin and mucous membranes to irritation, redness, or blisters).
Rational : early detection of circulatory disorders and loss of sensation of the high risk of damage to skin integrity possible complications of immobilization.

10. Minimize spasticity and contractures .
Rational : Muscle spasticity is common and occurs at an advanced stage , which is visible in the form of heavy addukor on hips, with a spasm of the hip and knee flexors.

11. Teach exercise techniques.
Rational: Exercise every day to strengthen the muscles supplied to minimize joint contractures. Special attention is given to the thigh muscles, the gastrocnemius muscle, adductor, biceps and wrists, and fingers flexors.

12. Maintain a 90-degree joints of the foot board.
Rational: The soles of the feet in position 90 degrees to prevent footdrop.

13. Evaluation of signs / symptoms of the expansion of tissue injury (inflammation of local / systemic, just as increased pain, edema and fever).
Rational: Assessing the development of the client's problem.

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