CRITICAL THINKING

Reverend Wilson's wife asks what ALS is. How do you describe it to her?

Amyotrophic lateral sclerosis (ALS) is a nerve disease in which the nerves that stimulate the muscles to make them contract degenerate and form scar tissue. This makes it difficult for muscles to contract.

Reverend Wilson is concerned about continuing in his job and asks if his mind is going to be affected. How do you respond?

He should know that ALS does not affect thinking. If his job is not physically demanding he should be able to continue.

He develops painful muscle spasms. What medications might be ordered to help relieve them?

Muscle spasms can be relieved with medications such as baclofen (Lioresal) or a benzodiazepine such as diazepam (Valium).

Reverend Wilson returns to the physician's office several months after his diagnosis because he fell walking to the podium to preach. What is happening? What can he do about it?

Nerves that control the muscles in his legs are becoming more affected. A referral for physical therapy and a cane or other walking aid might help Reverend Wilson continue to function for as long as possible.

Reverend Wilson's condition deteriorates, and he has to retire. He becomes confined to a wheelchair. He has a gastrostomy tube inserted because he is no longer able to swallow. What additional nursing diagnoses are now appropriate?

Possible nursing diagnoses include Disturbed Body Image, Risk for Imbalanced Nutrition: Less Than Body Requirements, Impaired Oral Mucous Membrane Integrity, Impaired Physical Mobility, and Risk for Impaired Skin Integrity. Note that these are only possible ideas and would need to be verified with a thorough assessment.

Reverend Wilson stabilizes for a while. A year later, he is admitted to the hospital with aspiration pneumonia. What probably happened? What nursing diagnosis is appropriate in this situation? List an appropriate goal and two or three interventions.

Reverend Wilson's muscles that control swallowing may be affected now. An appropriate nursing diagnosis is Impaired Swallowing related to muscle weakness. Because his swallowing is unlikely to improve dramatically, a good goal might be that he will not aspirate. Talk to the physician about ordering a swallowing evaluation by a speech therapist, who can recommend interventions to help prevent aspiration. Additional interventions include making sure he is sitting up straight to eat, staying with him during meals in case he has difficulty, having him swallow each bite twice, and having him avoid thin liquids. Eventually he and his wife may need to decide if they want to consider tube feedings.