Aliza Ben-Zacharia, CRRN, ANP
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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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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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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


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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 Patient’s

    • Adherence to therapy

    • Positive initial expectations

    • Realistic expectations

    • Continued education

    • Self confidence

    • Support & encouragement


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Nursing & Medical

  • Overlap between assessments

  • Identifying Patient’s 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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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


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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

    • Utoph’s 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 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


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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


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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


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Psychological / psychiatric problems

Renal insufficiency

Diabetes

Neurologic conditions

Hypertension

Endocrine disorders

STDs

Medications

Antihypertensive

Antipsychotic

Antihistamines

Alcohol

Analgesics

Narcotics

Recreational drugs

Sexual Dysfunction


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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


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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


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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


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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


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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 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


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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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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


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Physical assessment

Head control

Presence of dentures

Preparing meals

Accessibility issues

Visual acuity

Ability to eat

Mobility

Muscle strength

Incoordination

Involuntary movements

Swallowing Impairment


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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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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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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

Impairment of Skin Integrity


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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