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PROBLEM ORIENTED NURSING CARE PLANS
By Margaret McDonnell / Jan Hentgen / Naiicy Holland / Phyllis Weisel Loevison
At the time these nursing care plans were prepared, the plan was the result. The inservice staff found that it
Multiple Sclerosis Center was an integral part of the improved care and provided a consistent format for assess-
Department of Neurology at St. Barnabas Hospital. As ment both for in- and outpatients. The MS Center nursing
patients from the outpatient MS Center used the inpatient staff also found that the care plan aided communication
services, the nursing staff requested assistance in their with nursing personnel in other areas. The MS Center is
overall management of these patients. This standard care now a division of the Albert Einstein College of Medicine.
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Patient Problem Expected Outcomes Nursing Orders
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Informational Is able to identify situa- 1. Interview patient/family to assess level of understanding of
needs: tions and changes in MS in general and specific areas relevant to the patient, such
Disease process physical condition re- as prevention and early detection of urinary tract infection in
Treatment quiring physician con- susceptible individuals.
Drug therapy tact. 2. Provide relevant literature, access to community resources,
Follow-up care. Verbalizes understanding such as local MS chapter, Visiting Nurse Service. Allow for
of and willingness to fol- questions and classification.
low prescribed regi- 3. Discuss specific treatment plan, including implications of
men. medications. exercise program, use of adaptive equipment.
Verbalizes under-standing 4. Discuss fad or "quack" remedies. Explore vulnerability of
of medication regimen. the person resulting from the unknown features of MS and the
Verbalizes appropriate exploitation that may be encountered.
plans for coping with 5. Assure that specific follow-up plans have been made,
stressful situations. including appointment with the physician for a specified time
following discharge.
6. Patient evaluation should be ongoing within the clinic,
office, or hospital selling.
Changes in pa- Verbalizes concerns and 1. Assess patient's current status daily if in hospital, or at out-
tient's level of asks relevant questions. patient visit.
function. Verbalizes an understand- a. Change in already existing symptoms.
ing of how to follow the b. Development of new symptoms.
prescribed regimen. c. Evaluation of all body systems.
Verbalizes an understand- 2. Encourage patient and family to verbalize concerns about
ing of the disease pro- level of functioning.
cess and significant im- 3. Problem-solve with patient and family to deal with the
plications. patient's current needs.
4. Notify doctor of patient's current status.
5. Make appropriate referrals.
6. Review prescribed regimen with patient and family.
Visual-
Diplopia Maintains maximal Visual Check visual activity each outpatient visit or hospital admis-
Nystagmus functioning. sion. Notify the neurologist or primary physician of changes in
Blurred vision. Has satisfactory use of visual functions. Refer to opthamologist if visual acuity is
compensatory measures decreased. Primary physician order may be required.
when needed. For diplopia: Instruct patient to use eye patch or occluder.
Alternate patch to other eye q.4h. Notify physician Of any
change in visual function. Follow medical regimen and
instruct patient in precautions for effects of medications. For
example, prednisone may be ordered if exacerbation is occur-
ring. Instruct patient to rest eyes when fatigue is noticed.
Advise patient Of dvdildbility Of large-type materials and "talk-
ing books." Alleviate fear by informing patient that blindness
is unusual in MS, and visual symptoms frequently remit.
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Patient Problems Expected Outcomes Nursing Orders
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Sensory:
Diminished tem- Injury is prevented and 1. Identify the sensory impairment by patient interview, physi-
perature per- maximal level of func- cian's examination, and direct observation.
ception tion maintained. 2. Instruct patient in such safety measures as testing bath
Decreased touch water with unaffected extremity, using pot holder when cook-
sensation ing, using heating pad with caution, wearing gloves in cold
Diminished posi- weather.
tion sense 3. Educate patient regarding means of overcoming decreased
Pain touch and position sense. Visual clues will be extremely help-
Paresthesia. ful. Have the patient watch his hands perform various tasks.
4. Medication as ordered may be prescribed for pain control
(although pain is an infrequent symptom). Instruct patient and
family regarding precautions and effects of prescribed medi-
cations, such as carbamdzepine (Tegretol).
5. Reassure patient that although effective treatment is not
available for paresthesia, this symptom is usually transient.
6. Check for changes in sensory levels every other day if in
the hospital, or at each outpatient visit.
Impaired
mobility:
Paraparesis Demonstrates safety in 1. Check patient's mobility level weekly or at each outpatient
Ataxia mobility. visit.
Spasticity. Relates that falls occur less 2. Observe pdtient's mobility and teach or reinforce:
than once weekly. a. Correct use of assistive ambulatory dids.
Verbalizes understanding b. Wheelchair safety, such as locking brakes.
of effect of medication 3. Interview patient and/or family regarding safety and fre-
and its specific relation- quency of falls, including home environment. Make appropri-
ship to mobility, such as ate recommendations.
baclofen (Lioresal)- 4. Determine patient and or family's understanding of medi-
What does it do? cations and implications for mobility.
Recognizes need for ap- 5. Make appropriate referrals to physidtrist, physical therapist
propriate assistive de- (gait training), or occupational therapist (equipment needs).
vices in dmbulation, 6. Discuss individual needs for varying mobility dids in differ-
such as wall walking in ent situations.
house vs. cane or walk-
er outdoors.
Intention tremor:
Tremors of one or Attains Maximal level of 1. Interview patient to identify difficulties in independent per-
both upper ex- function in ADL. formance of ADL.
tremities causing 2. Refer to physician for possible medical management (pro-
interference with pranolol or surgical intervention, such as thalamic surgery).
independent man- Remember that pulse must be closely monitored with propran-
agement of activi- olol (Inderal) so that rate does not drop below 60/min.
ties of daily living Patient/family member/surrogate must be instructed regard-
(ADL). ing this. Thalamic surgery is usually considered only with d
persistent disability (1 to 2 years) and when tremor significantly
interferes with function.
3. Refer to occupational therapist for adaptive techniques and
equipment. Recommendations may include:
a. Wrist weights.
b. Using proximal rather than distat muscles of upper
extremities.
c. Adaptive equipment, such as stabilized plates and non-
spill cups.
d. Stabilization of extremity and trdining in use of trunk and
head to compensate for impaired function.
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Patient Problem Expected Outcomes Nursing Orders
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Bowel
dysfunction:
Incontinence Has normal bowel move. 1. Collect data on patient's dietary habits and home remedies
Constipation. menls at least every 2 to for constipation.
3 days. 2. Initiate bowel training program.
Has soft abdomen. 3. Educate the patient on need for fluid intake and foods high
Demonstrates satisfactory in roughage.
dietary intake by order. a. Prune juice at the same time each day helps establish
ing and consuming regularity.
foods high in rough- b. Roughage prevents hard stools and stimulates peristal-
age. sis.
Has no fecal impactions. c. Give an overview of diet.
d. Identify types of foods and liquids needed.
e. Cl@ misconceptions.
4. Obtain a doctor's order for suppository, laxative, or stool
softener.
5. Provide bedside commode if needed.
6. Correlate bowel and bladder dysfunction, since overall
treatment plan will encompass both areas.
7. Evaluate bowel management daily or at outpatient visit.
Urinary
dysfunction:
Frequency Verbalizes that he/she is 1. Inter-view the patient regarding bladder function and iden-
Urgency maintaining bladder tify symptoms that either interfere with daily functioning or
Incontinence function that does not pose a threat to the individual's health.
Retention impede social, occupa- 2. With M.D. approval, determine basic parameters of blad-
Recurrent urinary tional, or ADL func- der function by obtaining volumes of void and residual urine.
tract infection. tions. Communicates this information to M.D. so that appropriate
a. Voids every three medical regimen may be instituted.
hours or less often. 3. For those with high residual urine or history of UTIS, recom-
b. Maintains conti- mend vitamin C, 1 Gm. q.i.d., and liberal intake of cranberry
nence. juice.
c. Nocturia absent. a. Acidifies urine and decreases bacterial growth.
Maintains residual urine 4. Explain the need for fluid intake of at least 2000 to 3000
volume below 100 to c.c./day.
150cc. a. Minimizes precipitation of urinary crystals and stone for-
Identifies symptoms of UTI mation.
and reports promptly to b. Flushes bacteria from the unnary tract, decreasing inci-
M.D. or other primary dence of UTI.
care practitioner. c. Dilutes urine. which reduces irritation of bladder muco.
Reduces frequency and sa, thereby diminishing reflex bladder contraction and
severity of UTIs. resultant sensation of urgency.
5. Advise fluid intake and output record when this will help
further delineate the problem or evaluate the effect of inter-
veniion.
6. Recommend distribution of fluid intake to help correct
problem areas, for example, eliminate fluids after dinner if
enuresis is a problem.
7. Institute bladder training program, with appropriate addi-
tion of mechanical assistance such as Crede's or Valsalva's
maneuvers, urethral stimulation, suprapubic topping, @omi-
ndi binder, or intermittent cathetenzation.
8. Teach details of catheter use when indicated. This includes
intermittent catheterization, Foley, and cystostomy.
9. Teach symptoms of urinary tract infection, with emphasis on
early medical intervention.
10. Evaluate urinary function daily or at each outpatient visit.
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Patient Problems Expected Outcomes Nursing Orders
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Skin breakdown: Has no breakdown of skin 1. Interview patient regarding his/her perceptions of what to
surface especially over observe and how to care for skin surfaces:
bony prominences. d. Care of skin.
When already present, b. Preventive measures.
decubitus continually c. Contact M.D. if skin breakdown is present.
decreases in size and 2. Clarify realistic plans for personal care.
depth. 3. Evaluate skin condition daily or at each outpdtient visit.
4. Relieve pressure:
a. Digital circular Massage for five minutes over identified
problem areas every two to four hours while awake.
b. Shift body weight while in chair.
c. Turning schedule while in bed.
d. Lubricate skin with protective ointment, such as A & D.
e. Wash with mild soap, especially if bowel and/or bladder
incontinence is present. Recommend types of clothing that
deter skin breakdown, such as cotton pads rather than rub-
berized prints.
5. Avoid direct contact of skin with Chux; for example, place
folded sheet over Chux.
6. Use sheepskin, Water mattress, heel pads, and so forth.
d. Teach patient/family to inspect pressure areas (bony
prominences) for evidence of redness or heat.
b. Avoid skin trauma, heat, cold. and pressure.
c. Give careful attention to sacrdrand perinedl hygiene.
d. Avoid placing patient on poorly ventilated Mattress cov-
ered with plastic or impermeable material.
e. Maintain high protein intake.
f. Turn patient q.2h. while in bed.
g. Instruct appropriate patients in technique of wheelchair
pushups.
7. Check condition of skin q.8h.
Speech:
Dysarthrid Is able to communicate ef- 1. Observe communication patterns and determine if current
Scanning speech. fectively. measures are acceptable, including use of awistive devices,
such dS language board.
2. Appropriate referral to speech pathologist, with follow-up
on compliance with recommendations.
Gastrostomy Achieves adequate fluid, 1. Place patient in high Fowler's position unie'ss contraindi-
feedings: electrolyte, and nutri- cated,
tional balance. 2. Tube should be clamped except during feeding period.
Has no diarrhea. 3. Feedings should be at room temperature.
Has clear, nonirritated 4. Remove the clamp after feeding is poured into the
skin surface around gas- syringe.
trostomy opening. 5. Administer feeding by gravity flow.
6. Irrigate tube after feeding with 30 c.c. room temperature
Water.
7. Check potency of gastrostomy tube daily. Change as
needed.
8. Check condition of skin around gastrostomy opening dai-
ly, since leakage of gastric juices on feeding may cause skin
maceration.
9. Provide daily skin care around gdstrostomy: d. Wash with
mild soap and water; b. Rinse well with Water; c. Pat dry;
d.. Apply dry dressing if skin is clear; and e. Rotate the site of
adhesive tape on the abdomen.
10. Educate the patient dnd/or family about: a. Feeding;
b. Skin care; c. Changing the tube; and d. Dietary needs.
Nutritional:
Swallowing Verbalizes understanding See "Aspiration pneumonid."
problems of diet management. Instruct in reducing diet. Discuss implications of obesity:
Obesity a. Impaired circulation with increased susceptibility to phle.
bitis and emboti.
b. Strain on weak muscles with impairment of mobility.
c. Check Patient's weight weekly or at outpatient visit.
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Patient Problem Expected Outcome Nursing Orders
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Respiratory:
Aspiration pneu- Has no obvious conges- 1. Deep breathing and coughing q.4 h. while awake.
monia in suscepti- tion. 2. Turning schedule planned for patient's needs.
ble patients Has normal respiration 3. Have patient out of bed as tolerated.
a. Pseudobulbar pattern for the patient. 4. Feed patient small portions of blenderized food if difficulty
symptoms Is afebrile (99.6F. or in swallowing is present. Semisolids may be easier.
b. Bedridden. less). 5. Position patient upright when feeding.
Sexual: Expresses satisfaction of Obtain sexual history from patient. Discuss with patient's part-
sexual needs by self ner when appropriate.
Impotence in male and partner.
Diminished sensation 1. Discuss alternate methods, for example, vibrator. Reflex
in genital area erection may be stimulated in some cases.
Presence of Foley 2. Encourage patient to identify other erotic areas.
. catheter 3. Instruct patient to:
Diminished urinary Male: Fold catheter back over shaft of penis and cover with
sphincter control. well-lubricated condom. Obtain physician's permission before
discussing with patient.
Female: Instruct patient to use rear entry position to prevent
damage to the urethra. Obtain physician's permission before
discussing with patient.
a. Instruct patient to empty bladder/bowel prior to sexual
activities.
b. Encourage verbalization regarding attitudes toward var-
ous sexual practices.
c. Suggest visual aids for additional stimulation.
d. Emphasize the importance of maintaining an open and
loving relationship.
Emotional:
Denial Verbalizes adjustment to 1. Interview patient/family to determine current emotional
Depression the illness and realistic status. Identify mechanisms of emotional response to the illness
Euphoria. plans for maintaining and patterns of dealing with stressful situations. Be aware that
maximal function-so- denial and depression are fr@ent responses to MS, while
cial, vocational, ADL. true euphoria is uncommon and usually indicates advanced
Verbalizes successful organic disease.
problem-solving ap- 2. Discuss findings with physician, since emotional status will.
proaches in a variety of influence adherence and response to medical regimen.
existing and potential 3. Consider referrals to:
situations. a. Social worker for additional services.
Communicat:Lis positive b. Psychologist for testing to determine possible organic
experiences and satis- brain involvement.
fying interpersonal rela- c. Psychiatrist when serious maladaptive behavior or abnor-
tionships. mal thought patterns are identified. Psychological and psy-
chiatric involvement require physician's orders in most clin-
ical settings.
4. Identify strengths in the patient/family and maximize these
to increase self-esteem. Positive reinforcement must be valid
and communicated in a supportive Mdnner.
5. Discuss plan of care and goals with patient/family within a
framework that emphasizes and maximizes those elements
over which personal control can be exerted. The nature of MS
may engender an overwhelming sense of helplessness. The
individual's sense of control over important decisions and
management of his or her physical, personal, and social needs
is essential to combat denial and depression.
6. Recognize limitations of patient involvement in decision
making if there is Organic brain damage or denial or depres-
sion require psychiatric intervention.
7. Ongoing evaluation and at each outpatient visit.
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Patient Problems Expected Outcomes Nursing Orders
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Premature disabil- Builds self-esteem and re- 1. Allow patient to grieve for his or her changes of life-style.
ity due to despair establishes a positive 2. Assist patient in exploring future goals with regard to future
and resignation to self-image. Capabilities.
the disease. 3. Avoid activities that tend to decrease or disturb petient's
concept of self.
4. Increase activities that foster development of a stable, con-
structive self-concept and maintain self-esteem.
5. Provide time to sit and talk with patient.
Social:
Actual or potential fi- Verbdlizes concerns by 1. Initiate conversation with patient and family members to
nancial problems asking questions. identify problems.
from chronic dis- Discusses "What to do" 2. Get background information and feeling regarding pa-
ease expenses. with nurse and/or social tient's problem.
Potential worry over worker. 3. Clarify concerns and assist with solving problems.
children at home. Has family involvment in 4. Refer to social worker or rehabilitation counselor.
Potential worry over problem-solving discus- 5. Provide support while emphasizing areas of pdtient's con-
family adjustment sions. trol when crisis develops. Help identify and reinforce alterna-
to chronic disease Has addressed economic tives available.
process and its ef- needs with resolution of
fects. current problems and
Altered life-style. projected plan for fu-
ture financial manage-
ment.
Vocational:
Actual or potential Achieves maximal voca- 1. Interview patient to identify current level of vocational
difficulties related to tional functioning: function and adjustment, projected problems and needs,
current or potential a. Employment utilizing including the homemaker role.
vocational status, in- full potential and capa- 2. Refer to the rehabilitation counselor when available, to
cluding homemak- bilities of the individu- Office of Vocational Rehabilitation directly when necessary.
ing. al. Independent homemaker functioning often requires interven-
b. Participation in d Vo- tion by the occupational therapist, and these services May be
cational rehabilitation facilitated by the sponsorship of OVR.
program to develop 3. Contribute to increase of self-esteem of the disabled person
maximal occupational by encouraging the pursuit of vocational goals and supporting
potential, the individual in a current occupation when applicable.
c. Homemaker achiev- 4.'Refer to the Social worker or advise patient of availability of
ing independent status, benefits such as Medicaid or Social Security Insurance or Dis-
or in an ADL program ability Benefits to support the individual while vocational goals
to attain this goal. are pursued.
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MARGARET MACDONNELL RN., M.A., is the nursing inservice education NANCY HOLLAND, RN., M.A., Is the coordinator of the clinical services
director and JAN HENTGEN, RN, M.A. is an inservice instructor at St. and PHYLLIS WEISEL LEVISON. RN., B.S.. is a nurse specialist in neurolo-
Barnabas Hospital, Bronx, N.Y. They assist nursing staff in develop- gy at the Multiple Sclerosis Comiprehensive Care Center at Albert
ing care plans for MS patients. Einstein College of Medicine, Bronx, N.Y.
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This information provided by the Center for Neurologic Study. Please visit us at http://www.cnsonline.org