Multiple Sclerosis
These three areas are commonly affected early in MS and should be a focus of the nurse’s assessment.
What are vision, mobility, and sensory perception?
As this disease progresses, which body system becomes the nurse’s greatest priority to assess?
What is the respiratory system?
Weakness beginning in the legs and progressively moving upward is known as this characteristic pattern.
What is ascending weakness/paralysis?
A patient reports that their muscle strength is better after resting but becomes progressively weaker with activity. What pattern is the nurse recognizing?
What is fatigable muscle weakness?
Severe, sudden, unilateral electric-shock-like facial pain triggered by touching the face, chewing, brushing the teeth, or cold air is characteristic of this disorder.
What is trigeminal neuralgia (CN V)?
A patient with MS reports that their weakness and vision problems became noticeably worse after taking a hot shower. What should the nurse recognize as the likely trigger?
What is increased body temperature/heat?
A patient has progressively worsening muscle weakness but can still feel touch, pain, and temperature normally. Which type of function is being preserved?
What is sensory function?
As weakness continues to move upward, this assessment becomes the nurse’s highest priority.
What is respiratory status/respiratory function?
Weakness of this muscle places a patient with MG at greatest risk for respiratory failure.
What is the diaphragm?
A patient with Bell's palsy cannot completely close one eye. What is the nurse's priority intervention?
What is protect the affected eye?
This is the key diagnostic test used to identify plaques in multiple areas of the CNS.
What is an MRI?
Increasing difficulty swallowing in a patient with ALS places the patient at greatest risk for this complication.
What is aspiration?
This finding in the cerebrospinal fluid supports the diagnosis of GBS.
What is increased CSF protein?
This blood test looks for the antibodies commonly responsible for MG.
What is an acetylcholine receptor (AChR) antibody test?
A patient has severe vertigo, dizziness, nausea, and difficulty walking due to CN VIII dysfunction. What is the nurse's priority?
What is safety/fall prevention?
A patient with MS has painful muscle stiffness and spasticity that is interfering with mobility. Which medication may the nurse anticipate?
What is baclofen or tizanidine?
A patient with ALS develops increasing respiratory muscle weakness but is still breathing spontaneously. Which type of respiratory support may be used?
What is BiPAP/noninvasive ventilation?
This treatment removes harmful circulating antibodies from the blood of a patient with GBS.
What is plasmapheresis?
A patient taking this medication for MG should be taught to take every dose at the prescribed time.
What is pyridostigmine?
A patient with trigeminal neuralgia has severe facial pain when eating and has begun skipping meals. Which additional assessment becomes especially important for the nurse?
What is nutrition and hydration status?
A patient with MS is experiencing diplopia. Which nursing intervention can help manage this visual disturbance?
What is an eye patch?
An ALS patient has a weak cough, increasing secretions, and declining respiratory muscle strength. What should be the nurse’s priority focus?
What is maintaining airway clearance and adequate ventilation?
A patient with GBS develops increasing weakness of the diaphragm. What life-threatening complication should the nurse prepare to manage?
What is respiratory failure?
A patient with MG develops rapidly worsening neuromuscular weakness and can no longer maintain adequate ventilation. What emergency should the nurse recognize?
What is a myasthenic crisis?
A patient with CN IX and X impairment has questionable swallowing ability. What should the nurse do first?
What is stop/hold oral intake? Then anticipate a swallow evaluation and aspiration precautions.