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Technical College

295 Major acute alteration clinical, January 18, 2018

Lisa Zerby MN, RN, CNOR










A 59 years old
male presented to the emergency department on 01/04/18 with overall        weakness and found to have exacerbation
multiple sclerosis. He noticed a decline in strength over the last 3 weeks with
acceleration of symptoms in the last several days. Magnetic resonance imaging
(MRI) and lab screening were obtained. MRI of brain showed many scattered white
matter plaques along with new lesions in the right cerebellum. Lab screening result
showed hyperkalemia and dehydration. The patient complains of frequent nocturia
and had been on oxybutynin for several months. He has a history of acute
cystitis with out hematuria, neurogenic bladder, neurogenic bowel, ataxia,
weakness, seizure, spasticity, hypopituitarism, central hypothyroidism, hypogonadotropic,
hypogonadism, and sexual dysfunction. He has no known allergy. His lower extremities
are weak, has difficulty walking, and uses two front wheel walker. While the
patient is getting treatment in the hospital, the patient developed confusion.
Urinalysis was done and was grossly positive and suggestive of urinary tract

vital signs BP 94/60, HR 87, RR 18, Temp 98.6, Spo2 98%. Admitted weight 168lb
and current weight also has not significant change 168lb. Alert and oriented X4.
This patient has alteration in central nervous system (CNS) and that can affect
different body part. Symptoms of include loss of mobility, sensory disorder,
sexual dysfunction, pain, weakness, fatigue, and impaired coordination, spasticity,
bladder and bowel dysfunction and confusion.

The mechanism of demyelination in multiple sclerosis may be
activation of myelin-reactive T-cells in the periphery, which then express
adhesion molecules, allowing their entry through the blood-brain barrier (BBB).
T-cells are activated following antigen presentation by antigen-presenting.
Perivascular T-cells can secrete pro-inflammatory cytokines. Ongoing
inflammation leads to epitope spread and recruitment of other inflammatory cells
then they make antibodies for the myelin for further degradation and the
cytokines can be toxic to the myelin as well. The white matter tract of central
nervous system is the most commonly affected by the demyelination process.
However, grey matter tract can also be involved there is a predilection for the
optic nerve. Both sensory and motor neuron are affected. At times the
inflammatory phase can resolve area of demyelination can heal. Allowing the
disease to go in to remission and the periods between relapses are
characterized by a lack of new symptoms, although the underlying disease
process may be continuing.

Most of the symptom which stated on our
textbook or any reliable website are quite similar with this patient symptom.
For example, seizure, trouble walking, fatigue, muscle weakness, seizure, impaired
coordination, blurred or double vision, sexual problems, and bladder
dysfunction symptoms which
is also listed in our text book. However, the patient also has diagnosis
of pituitary tumor which is not stated in the pathophysiology text book, but
current studies do not completely associate multiple sclerosis and brain
tumors, and it is difficult to define. However, diagnosis of brain tumor multiple
sclerosis patients may seem more frequent than in the general population due to
frequent neuroimaging scans performed in these patients. On the other hand, patient’s
symptom of sexual dysfunction could also be related to prolactinoma which is a
tumor in pituitary that secret excessive amount of prolactin that decrease the
testosterone level in the body and lead to low libido or sexual dysfunction.
Moreover, the patient also has hypothyroidism. As stated in the above, the
cause of this problem might arise from hypopituitarism or may associate with
the main diagnosis. Studies stated there is a significant cooccurrence of thyroid
disease in a patient with multiple sclerosis compared to the general

is no single test or set of tests that can establish a diagnosis of multiple
sclerosis however, his laboratory panel, clean catch urine analysis is done
result shows >100,000 cfu/ml non-lactose terminating cram negative rods are
found, in addition, WBC (urine) >50, BUN is high 33, BUN/creatinine ratio is
high 27, cortisol is high 49.7, neutrophil is high 91.3, lymphocyte low 7.5,
testosterone is low 224, pituitary prolactin is high 22.2ng/ml. In addition to
lab results the patient also has MRI that is done on 1/5/2018 thoracic spine
with and without contrast. The result showed multiple T2 hyperintense lesion in
the thoracic cord than compared to 2014 result. Findings are compatible with
demyelination from multiple sclerosis, it also showed multilevel degenerative
cervical spondylosis progressive when compared to 2010 result. Sometimes cerebral
spinal fluid (CSF) studies can be done which is not found in this patient.
Elevated levels of IgG and other immune system proteins found in the CSF but
not in the blood indicate the kind of abnormal immune response seen in multiple
sclerosis S but it might not be accurate in all patients. According to studies,
CSF analysis is normal in 10% to 20% of people with MS and O-bands are also
present with other diseases, thus results from CSF analysis cannot be used
alone to diagnose MS. we can also use a patient symptom to diagnoses this
All the above values and finding are significant and there is no lab value and
findings that surprised me. They indicate the patient is having multiple
sclerosis and other complication which arise from it.

                        Because MS suspected to be an
autoimmune disease directed against the CNS available treatment involve
preventing inflammatory cells from crossing the blood brain barrier. Immunomodulating
agents reduce clinical attack of new MS lesion they may have an impact on
disability progression. Immunosuppressive agents can also be used to suppress T
Cell immune reaction. Although none of the treatment can cure this disorder,
they may reduce the number of days that person suffers from those symptoms.
They may also help in reducing the lesion in CNS. Corticosteroid also another
treatment option used to reduce acute inflammation fast recovery from
exacerbation MS. In this patient, since he is diagnosed on Exacerbation MS, he
took a high dose of prednisone and also taking other medication for related
problems. I believe that the patient is getting standard treatment based on his

                        At present, there is no
cure for multiple sclerosis and full recovery is not expected but effective
management can improve the patient’s quality of life. The goal of medical
management is vary based on the disease progresses and symptoms of the patient.
In this patient, stopping the disease process, reduce the number of relapse and
steroid use, maintain hormone level through supplement; symptom management such
as such as paint, fatigue, spasticity, and use of physical and occupational
therapist to prevent complications and secondary disabilities, prevent seizure
and other complication are the next best outcomes. Beside all the medical
treatment the patient showed improvement he is gaining back his strength and
helped us in transferring him bed to chair; he denied any pain; his appetite
was good.

of bone density is a common complication of persons with MS. It correlates with
a loss in the ability to ambulate and bear weight, but occurs to a greater
extent even in individuals still able to walk. With decreased ability to walk
comes a greatly increased risk of falling, and as bone mineral density
decreases, so does the risk of fractures. In addition to the risks of a
decreased ability to bear weight, many MS patients require either multiple
short-term or long-term courses of corticosteroids. These drugs can also
decrease bone mineral density. Multiple treatments can be initiated, depending
on the severity of the bone density loss and the potential for recovery. Measures
to reduce or prevent osteoporosis in those with MS include education regarding
adequate calcium and vitamin D intake, avoidance of smoking and excessive
alcohol intake, and regular exercise, particularly weight-bearing exercise. Treatment of Decreased
Bone Mineral Density is Encourage patients weight bearing prolonged walking and
running and standing as much as possible. If independent standing is not
possible, use a standing frame to allow weight bearing at least once per day,
as long as tolerated and use calcium citrate and vitamin D supplement.

              Another common complication of
multiple sclerosis is impairment of bladder function. These significantly
increases the risk of urinary tract infections (UTIs), Bladder sensation is
often impaired, leading to infrequent voiding and inability to feel the
discomforts of a UTI. Patients may choose to dehydrate themselves to avoid
urinary frequency and loss of control. the use of steroids, which may decrease
the individual’s ability to fight the infection. To prevent this problem drinking
plenty of water around 6-8 glasses a day is recommended to dilute your urine
and help flush out bacteria. If the classic symptoms of a UTI are
present—increased urinary frequency and urgency, altered urine color and odor,
dysuria, and lower abdominal pain—the diagnosis can easily be made. All too
often, however, because of decreased bladder sensations, these symptoms are
lacking, and other manifestations are present. Most commonly these include
worsening of lower extremity spasticity and weakness, increased fatigue,
increased numbness and tingling or tremors, or increased imbalance. In other
words, either existing neurologic symptoms are worsened, or previous
neuro-logic symptoms reappear. A person being evaluated for an MS relapse
should first have a screening, by history, examination, and if appropriate
laboratory studies, for

 infection, especially a UTI and need to be
treated with antibiotic. Birnbaum, G. (2009).

 Multiple Sclerosis. Oxford: Oxford University



Side effect

Nursing precaution

Reason for

Medication is
working or not


Potentiates the
action ofdopamine in the CNS. Prevents penetration of influenza A virus
host cell.

dizziness insomnia anxiety confusion, depression, seizures nausea
anorexia, constipation

amantadine in divided doses may decrease CNS side effects.
not administer last dose of medication near bedtime;
Dividing doses decrease
CNS side effect

Treatment of
weakness in multiple sclerosis patients

patient weakness gain strength





Thyroid supplementation
In hypothyroidism. Treatment or
suppression of euthyroid
Adjunctive treatment for thyrotropin-dependent thyroid cancer.



              The biggest safety risk of my
patient is fall risk. My patient has weakness, history of seizure, difficulty
of walking and unsteady gait. He is Bed alarms also notify and alert nursing
staff to respond to the alarm whenever he tries to stand up. Furthermore, seizures
can happen without warning, therefore as a nurse, we must ensure safety. Use
and pad side rails with bed in lowest position and administer medication as directed
may minimize injury Seizure. Patient is treated with respect by accommodating
all his needs (bath, giving time to visit with his wife and low stimuli
environment). The patient is stable in overall condition and discharged to
short term rehabilitation center to improve his strength and mobility.

            The first goal is to maintain safety
throughout the day. Since he is in fall and seizure preauction, we put the bed
in lowest position; side rails up and a pad on it while he is in bed. The other
goal is to help his stand, walk at least 1 feet and transfer to chair before
discharge with observance of proper gait and assistance. At 11;00AM after we
gave him bath, we assisted him to stand and walk about 3 feet with his front
wheel walker and help him to sit on a chair that has firm seat and arms on both
side. This will help the patient to support in case of weakness and ambulation
helps to increase his mobility. The last goal is encouraging the families to
join in the care of the patient through the day. His wife was with the patient
the whole time and participated to his care me and the nurse were helping them
until the patient is discharged. This Provides a way to communicate with the
significant others and being participative may make the patient feel that he or
she is being supported by his or her loved ones.

     One of the interdisciplinary
team that is important to the client is physical therapy. The role of physical
therapy depends on the patient needs, disability and disease progress due to
relapse. However, the goals of physical therapy will remain the same, to help to
achieve quality of life, safety, independence. and maintain physical
functioning by doing range of motion, gait training, functional transfer
training and bladder retraining there along with another rehab goal. In this
particular case the report shows the patient improving strength of bilateral
extremities, leading to display balance impairment. The role of occupational
therapy is helping the patient in plan of care by teaching skills such as
Endurance training, activities of daily living, Fatigue management, Activity modification,
use of adaptive equipment and technologies and Strategies to Compensate for
Impaired body function. As nursing student, we can also help our patients by
doing range of motion, give massages and relaxing baths, ambulate the patient
as needed, teach Fatigue management and energy conservation techniques learned
from nurses and the occupational therapist.

  Patient teaching

Exercise may improve your strength. A
physical therapist can help you determine which exercises are safe for you.

Get plenty of rest. Extreme tiredness is a
common symptom of MS.

Plan your activities in advance.

Avoid excessive heat and cold or
infectious agents.

Use walker or other aid to help you get
around and conserve energy, if needed.

Stretching can be useful with medicines to
help symptoms of stiff muscles.

Eat a diet that is high in fiber to
promote health and good bowel elimination.

Do not skip doses and stop medications

some medications may accentuate weakness
such as some antibiotics, muscle relaxants, antiarrhythmics, antipsychotics,
check with health care provider or pharmacist before taking any new

See your provider
if you have one of the following symptoms

Blurry, foggy, or hazy vision, eyeball
pain, loss of vision, or double vision.

A feeling of heaviness or worthening of

Tingling or a pins-and-needles sensation;
numbness; tightness in a band around the trunk, arms, or legs; or electric
shock sensations moving down the back, arms, or legs.

Problems with memory, attention span, finding
the right words for what you mean, and daily problem-solving.

If you have any mood change or feel sad.




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