Multiple Sclerosis – A long-term debilitating type of disease that affects the nervous system. The demyelination process on the myelin sheath disables the capability of the axons to receive electrical impulses thus the body could not perform or move the way it should be.
There is a period of remyelination however the bodily movements may not that be fine as the way it was. Physical therapy is needed in order to preserve functioning. Multiple sclerosis can be manifested with complaints of extreme tiredness, visual disruption, and uncoordinated movements of the extremities, and loss of sense of position. Episodes of attack can be termed as relapse and the absence of symptoms is called remission.
1. Provide a safe environment for the client.
2. Provide assistance in activities of daily living.
3. Promote the maximum capability of the client to move.
1. There will be a safe environment for the client.
2. Proper assistance to the client is being instituted.
3. The client will be able to gain the maximum capability to function and move.
Nursing Diagnosis: Impaired physical mobility
May be related to:
- Motor weakness
- Jerky movements
- Muscle Spasms
As evidenced by:
- Subjective complaints of loss of coordination and movement
- Limited range of motion
- Unsteady gait
- Uncoordinated movements
- The client will be able to adjust to the current situation as evidenced by taking steps in order to maximize the capability to move.
- The client will be able to use the assistive devices available properly.
- The client will be able to adhere to the limitations of his or her movements in the episode of multiple sclerosis.
Multiple Sclerosis Nursing Care Plan – Impaired Physical Mobility
|1. Introduce yourself to the client and significant others.||A therapeutic way to build trust in the working relationship.|
|2. Take baseline vital signs.||The vital signs are pertinent information in order to know if the client has a difficulty in movement or has a difficulty in maintaining the present position.|
|3. Assess the girth, muscle strength, weakness and coordination.||Period of remission in the early part of the disease is present. Determining the degree of immobility can be used as a good scale in knowing the ability of the patient.|
|4. Encourage ambulation with observance of proper gait and assistance.||This will help the patient know that he has still in control of the situation.|
|5. Provide safety measures all the time.||This may mean securing the side rails up when the patient is on his bed. Clear out the path where the patient usually ambulates. Use pillows in order to prevent straining.|
|6. Provide occasional rest periods in between ambulation or movement.||Rest periods are essential in order to regain energy and prevent fatigue.|
|7. Place the personal belongings near the bedside or within the cabinet.||This prevents the patient to exert more effort in moving around.|
|8. Encourage significant others to join in the care of the patient.||Provides a way to communicate with the significant others and being participative may make the patient feel that he or she is being supported by his or her loved ones.|