- Impaired Physical Mobility related to Neuromuscular impairment Pain As evidenced by decreased fine and gross motor skills and Movement-induced tremor
- Impaired Urinary Elimination related to Involuntary sphincter relaxation and weakened bladder muscles as evidenced by Urinary urgency and Urinary retention
- Ineffective Protection related to Impaired mobility and Physical deconditioning as evidenced by Maladaptive stress response and Vision problems
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Expression of pain and discomfort with movement -Refusal to move Objective data: -Uncoordinated movements -Poor balance -Inability to turn in bed, transfer, or ambulate -Postural instability -Gait disturbances -Reliance on assistive devices -Decreased muscle strength | Impaired Physical Mobility related to Neuromuscular impairment Pain As evidenced by decreased fine and gross motor skills and Movement-induced tremor | Patient will verbalize increased strength and demonstrate an increased ability to move. Patient will utilize mobility aids to improve physical mobility and ambulation. | 1. Encourage the use of mobility aids as needed. Mobility aids like walkers and wheelchairs can help decrease fatigue and enhance comfort, safety, and independence. Overhead trapeze bars, slide boards, and braces can support mobility. 2. Perform passive range of motion exercises. Range of motion exercises can help strengthen muscles and bones to improve mobility. 3. Encourage exercise. Patients with MS often struggle with fatigue, but exercise is shown to improve symptoms. Patients should participate in moderate aerobic exercise while staying cool and hydrated. 4. Administer medications as ordered. Baclofen can help relieve muscle spasms and rigidity in patients diagnosed with multiple sclerosis. 5. Refer the patient to a PT/OT. Patients with MS can have problems with functional abilities like vision, coordination, movement, and sensations. An occupational or physical therapist can help assess the patient’s functional abilities and formulate an appropriate plan of care. | Patient verbalized increased strength and demonstrated an increased ability to move. Patient utilized mobility aids to improve physical mobility and ambulation. |
| Subjective data: -Urgency -Hesitancy -Dysuria -Nocturia Objective data: -Bladder distention -Retention as detected through bladder scanning -Incontinence -Use of catheterization -Frequency | Impaired Urinary Elimination related to Involuntary sphincter relaxation and weakened bladder muscles as evidenced by Urinary urgency and Urinary retention | Patient will demonstrate elimination patterns within normal limits. Patient will remain free from urinary complications, including infection, overactive bladder, and retention. Patient will verbalize strategies to prevent impaired urinary elimination problems. | 1. Encourage adequate fluid intake. Adequate hydration promotes urinary output and prevents urinary stasis. Ensure daily water intake, limiting intake several hours before bedtime to prevent nocturia. 2. Initiate a bladder training program. Bladder training involves scheduling voiding at set times, whether the urge is felt or not, gradually increasing the time between bathroom trips, and training the bladder to hold more urine. This can help restore adequate bladder functioning and reduce the occurrence of incontinence, frequency, and urgency. 3. Instruct the patient to avoid bladder irritants like caffeine and alcohol. Bladder irritants can cause the bladder to become overstimulated and irritated, leading to urinary frequency, urgency, spasms, and pain. 4. Demonstrate intermittent catheterization. Patients who exhibit incomplete emptying and experience frequent UTIs may require intermittent catheterization. The nurse can demonstrate how to perform this skill to prevent the introduction of bacteria. 5. Administer medications. For patients with an overactive bladder, antispasmodics like oxybutynin can be taken to decrease bladder spasms and symptoms of urgency. | Patient demonstrated elimination patterns within normal limits. Patient remained free from urinary complications, including infection, overactive bladder, and retention. Patient verbalized strategies to prevent impaired urinary elimination problems. |
| Subjective data: Verbalizes fear from falls Objective data: -Fatigue -Weakness -Impaired physical mobility -Maladaptive stress response -Vision problems -Speech and swallowing difficulties -Neurogenic bladder | Ineffective Protection related to Impaired mobility and Physical deconditioning as evidenced by Maladaptive stress response and Vision problems | Patient will remain free from infection, falls, and injury. Patient will demonstrate interventions that improve physical endurance. | 1. Aggressively treat infections. Educate patients that infections and illness are triggers of MS exacerbations. Fevers must be controlled as increases in temperature can worsen symptoms and affect disease progression. Administer antibiotics and antipyretics as prescribed. 2. Instruct on strategies to prevent urinary tract infections. Urinary tract infections commonly affect patients with MS as bladder dysfunction prevents effective emptying, and stagnant urine allows bacteria to thrive. The nurse should educate on these measures to reduce UTIs: Drink plenty of water to flush out the kidneys and bladder Prevent constipation, as this can further obstruct urine flow Always wipe from front to back after urinating and defecating If self-catheterizing, practice clean techniques to prevent introducing bacteria 3. Refer the patient to rehabilitation and physical therapy. PT can help patients with MS with stretching and strengthening exercises that will make it easier to perform daily tasks and promote effective protection against injury and falls. 4. Refer the patient to a speech-language pathologist. SLPs can help patients with MS overcome speech and swallowing difficulties and reduce the risk of aspiration. 5. Educate on strategies to prevent infection. Patients with MS must take extra care to prevent infections and illnesses that can exacerbate MS, such as: Avoiding sick people and large crowds Practicing proper hand hygiene Receiving recommended vaccinations Monitoring for signs of infection (fever, chills, cough, skin breakdown, etc.) | Patient remained free from infection, falls, and injury. Patient demonstrated interventions that improve physical endurance. |