Med Surge Multiple Sclerosis & Spinal Cord injury

Tegretol (carbamazepine)

Anticonvulsant. It works by decreasing nerve impulses that cause seizures and pain (and dysesthesia in PTs with MS).

Lab tests to look out for with MS

CSF with elevated protein (IgG) and increased WBCs

Diagnostic test for MS

MRI

ASIA impairment Scale: E

Normal; motor and sensory function are normal

The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following? 1. paralysis 2. spinal shock 3. high cervical injury 4. temporary hypovolemia

2

The client with a spinal cord injury arrives in the ER. What assessments and actions will the nurse take at this time and put them in order? a. Maintain airway and provide resp. support b. Insert intravenous line c. Bring patient to radiology for a CT Scan to confirm SCI d. Monitor neurologic status e. Assess for bleeding f. Administer vasopressors to maintain BP g. Administer IV fluids and blood replacement as needed

A, E, B, G, F, D, C

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. Fluctuations in blood pressure B. Loss of cognitive function C. Ineffective cough D. Drooping eye lids

B

The nurse is planning care for a client with multiple sclerosis. Which intervention would address the nursing diagnosis of Fatigue? A) Encourage increased activity. B) Schedule physical therapy three times a day. C) Plan activities with sufficient rest periods. D) Group activities together so care will not be interrupted.

C Balance of activity and rest! -Dr. Flaherty

Three pathophysiological process characterize MS

Chronic Inflammation Demyelination Gliosis (Scarring) in the CNS

relapse-remitting

Clear defined relapses w/ full recovery or residual deficit unpredictable flare-ups Most common type of MS

McDonald Diagnostic Criteria for MS

Clinical Presentation MRI - detected lesions Positive CSF (presence of oligoclonal banding and elevated IgG) Number of attacks

ASIA Impairment Scale: A

Complete; No motor or sensory function is preserved in S4 or S5

An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care will be followed? Select all that apply. 1. Immobilize the neck using rolled towels or a cervical collar. 2. The patient will be placed in a supine position 3. The patient will be placed on a ventilator. 4. The head of the bed will be elevated. 5. The patient's head will be secured with a belt or tape secured to the stretcher.

Correct Answer: 1,2,5 Rationale: In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious should be treated as though they have a spinal cord injury. Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent movement are all basic guidelines of emergency care. Placement on the ventilator and raising the head of the bed will be considered after admittance to the hospital.

Which spinal cord injury results in loss of respiratory control and death if not recognized immediately? a. A concussion located in the cervical spine b. A contusion located in the cervical spine c. A thoracic cord laceration between T1 and T2 d. A cervical cord transection above C4

D

A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? A. "This medication will help you with your tremors." B. "This medication will help you with your bladder function." C."This medication may cause your skin to bruise easily." D."This medication may cause your skin to appear yellow in color."

D Dantrolene and tizanidine are antispasmodic medications that are given to clients who have MS to treat muscle spasms. An adverse effect of this medication is a yellow appearance of the skin, also known as jaundice. The nurse should instruct the client to monitor for this finding, as this can be an indication of impaired liver function.

progressive relapsing

From onset it's progressing Clear acute relapse w/ or w/o full recovery B/n relapses have continued progression

Medication management for treatment of acute exacerbation

IV methylprednisolone

secondary progressive

Initially relapse-remitting then Progression w/ or w/o relapse/remission/ & plateaus Most develop this within 10 years of having MS

Interventions for parasthesias ("pins & needles")

Neurontin or tegretol

What time of day should a patient take interferon beta 1-a and why?

Patients should take interferon beta 1-a at bedtime because a common side effect of the med are flu-like symptoms. Taking the med at bedtime, and taking acetaminophen or ibuprofen immediately prior and during the first 24hrs on the med can aid in relieving those symptoms.

What time of day should a patient take interferon beta 1-b and why?

Patients should take interferon beta 1-b at bedtime because a common side effect of the med are flu-like symptoms. Taking the med at bedtime, and taking acetaminophen or ibuprofen immediately prior and during the first 24hrs on the med can aid in relieving those symptoms. (same as with interferon beta 1-a)

The most common form of MS

Relapse and Remitting

Spinal Shock

State of transient physiologic reflex depression of cord function below the level of injury. Includes flaccid paralysis and loss of bowel and bladder function. Lasts hours to days until reflex arcs below the level of injury begin to function again (heralded by the return of the bulbocavernosus reflex)

Intervention for decreased peripheral vision

safety is a priority, use scanning technique where PT scans their environment by moving their head side to side

interferon beta 1-b administration

subQ every other day (q.a.d) rotate injection sites to avoid infection

Interventions for dysesthetic itching

tegretol or adaracts steriod creams won't help

MS occurs twice as often in

women

Iterferon beta 1-a (avonex) administration

1x week IM (thigh, upper arm or hip)

normal range for IgG

620-1400mg/dl

Which of the following symptoms you as the nurse expect to see in the patient with primary progressive multiple sclerosis? (Select All that Apply): A) Unilateral Vision Loss B) Fatigue C) Diarrhea D) Intention tremors E) Paralytic ileus

A B D

Risk for Aspiration

Assess gag reflex Swallowing techniques: small bites no talking during meals Suction equipment at bedside Food consistencies: most difficult to swallow are liquids Calorie count Enteral feeding: pt with no gag reflex

Neurogenic shock occurs with spinal cord injuries above T6 which causes autonomic system dysfunction. What are the symptoms of neurogenic shock? Tachycardia Decreased blood pressure Flaccid paralysis below the level of injury Sensation loss below the level of lesion Warm, dry skin

decreased BP & warm dry skin

During an outpatient clinic follow-up appointment, a 46-year-old client with multiple sclerosis (MS) has lab tests completed. The results show elevated levels of aspartate aminotransferase (AST), serum glutamic-oxaloacetic transaminase (SGOT), alanine aminotransferase (ALT), serum glutamic-pyruvic transaminase (SGPT), and alkaline phosphatase (ALP). What is the priority concern for the nurse?? Select all that apply. A) Adverse response to Avonex B) Adverse response to Aubagio C) Flare-up due to demyelination D) Adverse response to bisacodyl E) Damage from viral infection

A B AST, SGOT, ALT, SGPT and ALP are liver enzymes that are monitored to detect adverse response to the medications Avonex and Aubagio. Flare-ups due to de-myelination do not cause liver enzymes to increase. Bisacodyl is a stool softener used for constipation in MS and does not cause liver enzymes to elevate. Incomplete evidence links viral infection to the risk of MS. There is no reason to attribute elevated liver enzymes to viral exposure.

A client with relapsing-remitting multiple sclerosis tells the nurse that even though the primary symptoms of exacerbation are leg spasms and blurred vision, the hardest part is trying to get through the day because of being so tired. Which diagnosis should the nurse identify as a priority for this client? A) Fatigue B) Disturbed Sensory Perception C) Impaired Physical Mobility D) Self-Care Deficit

Answer: A The client states that the worst part of the disease exacerbation is being tired even though leg spasms and blurred vision are present. The nurse should identify the diagnosis of Fatigue as being a priority for this client. The diagnoses of Impaired Physical Mobility because of the leg spasms and Disturbed Sensory Perception because of the blurred vision are additional nursing diagnoses applicable for this client, but they are not the priority based on the client's statement. The client may or may not have a Self-Care Deficit.

Your patient has been diagnosed with MS. You are teaching her about how to reduce muscle spasticity. Which of the following statements, if made by the patient would indicate the need for further teaching? A) Daily exercise, including weight bearing can help relieve spasticity B) My stretching routine can help with the spasms C) Taking Baclofen may help relieve these painful spasms in my legs D) At the end of a day, taking a nice hot bath may relieve the muscle spasms

Answer: D. The patient with MS should never use hot water for a bath due to sensory deficits. All other answers can help with muscle spasms. Warm compresses can be used to relieve muscle spasms.

You are the first to arrive at the scene of an automobile accident. The driver of the car is unconscious. Which actions will you take and place them in order? Select All that Apply a. Attempt to wake the client up by shaking him. b. Assess the client's pupils for reaction. c. Assess the scene of the accident for any safety issues. d. Stabilize the client's cervical spine. e. Carefully remove the driver from the car. f. Call the paramedics.

C, D, F, B

ASIA impairment scale: D

Incomplete; motor function is preserved below the neurological level and at least half of key muscles below neurological level have a muscle grade of 3 or more.

ASIA impairment Scale: C

Incomplete; motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade less than 3.

Your client with a SCI at Cervical 6 level has spinal shock for 24 hours post-injury. How will the nurse determine that the spinal shock has resolved? There will be: Select All that Apply systemic hypotension and tachycardia a return of sacral reflex activity a loss of bladder tone airway stabilization spasticity and hypertonicity

a return of sacral reflex activity airway stabilization spasticity and hypertonicity Note: spinal shock is temporary and will resolve

The onset on MS is typically between ___ & ___ yrs of age

20 & 40

A client with a history of relapsing-remitting multiple sclerosis is expecting her first child. What would be indicated for this client? A) Suggest reproductive counseling, as multiple sclerosis can be genetic. B) Instruct to expect a period of remission after delivery of the baby. C) Instruct to expect an exacerbation of symptoms while pregnant. D) Discuss pain control during labor, as contractions will be severe.

A A definite genetic factor has not been established; however, studies suggest that genetic factors make some individuals more susceptible to the disorder than others. Reproductive counseling would be recommended for this client. Pregnancy often brings about remission of multiple sclerosis, but with a slightly increased relapse rate postpartum. The strength of uterine contractions in a client with multiple sclerosis is not severe, and because clients often have lessened sensation, labor may be almost painless.

A client with multiple sclerosis is prescribed diazepam (Valium). What assessment finding indicates that the medication is effective for the client? A) Muscle spasticity is reduced. B) Blood glucose level is within normal limits. C) The client states that muscles are weak. D) Ophthalmologic examination shows no evidence of cataracts.

A Diazepam (Valium) is a muscle relaxant commonly used for clients with multiple sclerosis. Diazepam (Valium) does not cause muscle weakness. Evidence of medication effectiveness would be an observed reduction in muscle spasticity. Glucose intolerance would be assessed if the client were prescribed an adrenal corticosteroid. Cataract development is also a side effect of adrenal corticosteroids.

A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly? 1. autonomic dysreflexia 2. autonomic crisis 3. autonomic shutdown 4. autonomic failure

Correct Answer: 1 Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia (sudden high BP). Track urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic shutdown, and autonomic failure are not terms used to describe common complications of spinal injury associated with bladder distension.

Which of the following is the priority nursing diagnosis for a patient diagnosed with a spinal cord injury? 1. Fluid Volume Deficit 2. Impaired Physical Mobility 3. Ineffective Airway Clearance 4. Altered Tissue Perfusion

Correct Answer: 3 Rationale: Ineffective Airway Clearance is the priority nursing diagnosis for this patient. The nurse utilizes the ABCs (airway, breathing, circulation) to determine priority. With Ineffective Airway Clearance, the patient is at risk for aspiration and therefore, impaired gas exchange. Fluid Volume Deficit is the nurse's next priority (circulation), and then Altered Tissue Perfusion. If the patient does not have enough volume to circulate, then tissue perfusion cannot be adequately addressed. The last priority for this patient is Impaired Physical Mobility.

primary progressive

From onset its slow worsening neuro fxn No distinct relapse/remission (e.g no flare ups)

The HIGHER the injury on the spinal cord the:

GREATER the loss of function

Bowel alterations in PTs with MS

constipation and urinary incontinence

ASIA impairment Scale: B

Incomplete; sensory but NOT motor function is preserved below the neurological level and includes sacral segments S4-S5

A 32-year-old client recently diagnosed with multiple sclerosis is a full-time aerobics exercise instructor at a local fitness center. Which statements contain the correct information to give the client when answering her specific questions about lifestyle? Select all that apply. A) "Hyperbaric oxygen treatment is recommended prior to vigorous physical exercise." B) "You will tolerate exercise better in an air-conditioned room." C) "Acupuncture may benefit some of your symptoms." D) "Drinking cold water is recommended during exercise." E) "You will be able to maintain your exercise teaching schedule."

B C D Symptoms of MS are exacerbated by increased body temperature. Exercising in a cold room and drinking cold beverages keep body temperature down. Acupuncture has low risk and may be beneficial for some symptoms. Hyperbaric oxygen therapy carries more risk than benefit. It is unlikely that a newly diagnosed client with MS will be able to tolerate a full-time exercise instructor role.

When establishing a diagnosis of MS, the nurse should teach the patient about what diagnostic studies (select all that apply)? EEG CT scan Carotid duplex scan Evoked response testing Cerebrospinal fluid analysis

B D E There is no definitive diagnostic test for MS. CT scan, evoked response testing, cerebrospinal fluid analysis, and MRI along with history and physical examination are used to establish a diagnosis for MS. EEG and carotid duplex scan are not used for diagnosing MS.

Which measure should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)? Vigilant infection control and adherence to standard precautions Careful monitoring of neurologic assessment and frequent reorientation Maintenance of a calorie count and hourly assessment of intake and output Assessment of blood pressure and monitoring for signs of orthostatic hypotension

A Infection control is a priority in the care of patients with MS, since infection is the most common cause of an exacerbation of the disease. Decreases in cognitive function are less likely, and MS does not typically result in malnutrition, hypotension, or fluid volume excess or deficit.

A client admitted with an exacerbation of multiple sclerosis is demonstrating frustration with eating because hand and arm spasms prevent the proper use of utensils. What should the nurse do to assist this client? A) Consult with Occupational Therapy regarding assistive devices for meals. B) Counsel the client to select finger foods for meals. C) Plan time to feed the client. D) Consult with Physical Therapy regarding hand and arm exercises.

Answer: A Since the ability to feed oneself is essential to positive self-concept and self-esteem, the nurse should consult with Occupational Therapy for devices that the client can use to maintain independence at meal times. The nurse should not counsel the client to select finger foods for meals, or feed the client. This would not support the client's self-concept and self-esteem needs. Physical Therapy might be consulted for hand splints, but hand and arm exercises might not be beneficial for this client.

The nurse is teaching the client with MS about the use of corticosteroids for treatment. Which of the following statements, if made by the patient indicates correct understanding? A) I should watch for side effects such as euphoria and insomnia while taking this medication B) This medication will need to be administered for at least 2 weeks before I begin to see improvements in my condition C) The corticosteroids will reduce my chances of relapsing in the future D) I could see flu-like symptoms while taking this medication

Answer: A. Some side effects of corticosteroid use include euphoria, mood changes, and insomnia. This medication should only be used for short periods of time (3-5 days) and is often tapered off. This medication is for use in shortening the duration of a relapse, not preventing relapse. Flu-like medications are often seen in Interferon beta-1a or 1b medications (Betaseron, avonex) which are used to for long-term treatment of MS.

A young adult client complains of blurred vision and muscle spasms that come and go over the past several months. On what information from the client's history should the nurse focus to help identify this help problem? A) Family history of Parkinson disease B) Family history of epilepsy C) Is an immigrant from Germany D) Has been depressed

Answer: C Explanation: A) Multiple sclerosis is primarily a disease of people of northern European ancestry. The onset of multiple sclerosis is usually between the ages of 20 and 50, with the peak at age 30. Family history of epilepsy, Parkinson disease, and depression are important items of the client's history but do not support a diagnosis of MS.

A client diagnosed with multiple sclerosis has an acute onset of visual changes, fatigue, and leg weakness. The client says that the last time this happened, recovery occurred in a few weeks. Which classification of multiple sclerosis is the client experiencing? A) Progressive-relapsing B) Secondary-progressive C) Relapsing-remitting D) Primary-progressive

Answer: C Explanation: A) There are four classifications of multiple sclerosis. The client has an exacerbation of symptoms and has a history of full recovery. This is classified as relapsing-remitting and is the most common type. Primary-progressive is a steady worsening of the disease with occasional minor recovery. Secondary-progressive begins as relapsing-remitting but the disease becomes worse between exacerbations. Progressive-relapsing is rare, with the disease progressing from the onset with periods of exacerbation.

The nurse is caring for a patient with Multiple Sclerosis (MS) and appropriately plans to: A) Teach the patient to avoid all forms of weight bearing exercise B) Avoid the use of an eyepatch as this could cause further damage to vision C) Encourage the patient to consume a low-residue diet D) Teach the patient how to inject medications as all MS medications are administered via SQ or IM injection

Answer: D. It is important for the patient to understand how to inject medication as all MS medication is required to be injected. Weight bearing exercise should be done in moderation and may help with muscle spasticity and prevention of joint contractures. An eyepatch may be beneficial the patient experiencing diplopia. A low-residue diet is low in fiber - patients with MS should consume adequate amounts of fiber to prevent constipation.

A patient with multiple sclerosis states "After I started taking my medication, I feel nauseous and feel fatigued. I also am also running a fever". After looking in the patient's chart you note that she is taking Interferon beta 1b (Betaseron). What is the nurses' best response? A) "We are going to stop your medication immediately. This is a sign of an adverse reaction" B) "It would probably be best to admit you to the hospital. Your MS is relapsing and we will need to begin you on a corticosteroid regimen" C) "This is only a side effect of your medication. It will just eventually go away" D) "Taking your medication at bedtime with a Tylenol my help reduce these symptoms"

Answer: D. Taking the medication at bedtime and managing symptoms with ibuprofen or acetaminophen can help reduce the side-effects of this medication. While option C is true, it is not the most therapeutic response. It offers no suggestion for management. A and B are incorrect because the symptoms are not a sign of adverse reaction or relapsing MS.

The nurse is presenting a talk for the monthly Nursing Case Study education group at her facility. Which client would be a good choice for a case study on multiple sclerosis (MS)? A) Brazilian with chronic parasitic infestation B) Italian with colonized methicillin resistant staphylococcus aureus (MRSA) C) Northern Canadian who has smoked for 25 years D) African-American man in his 20s with a vitamin D deficiency

C The client with the greatest risk lives the farthest from the equator and smokes. Smokers are at increased risk of MS. Brazilians and Italians live close to the equator, which lowers the risk of MS. Chronic parasitic infestation lowers the immune response, which lowers the risk of MS. African-Americans and men are at lower risk of developing MS. It is theorized that vitamin D deficiency may increase risk of MS because it is seen less in locales near the equator.

treatment for diploplia

eye patch

9 factors that trigger the disease

viruses/infection (UTI & URI) cold climates physical injury stress pregnancy fatigue overexertion temp. extremes hot shower/bath