Question

4

Ms. Suzy McCue

Date of birth: 02/14/1964

Allergies: NKDA

Ms. McCue has a history of (H/O) Multiple Sclerosis (MS), diagnosed one year ago. She uses a walker at baseline. She was in her usual state of health yesterday when she had difficulty gripping her walker due to “the long sleeve sweater” she was wearing. She started to fall and was unable to catch herself. She reports she did not lose consciousness and was able to return herself to a standing position and continue her activities of daily living (ADLs). She remained at home overnight “thinking the pain was not too severe.” However, by this morning her pain was 9/10, and she decided to call a transport service to take her to the Emergency Department (ED).

After a medical history, physical, and x-ray, Ms. McCue was diagnosed with a right femoral neck fracture. She is otherwise in good health, denies any H/O Myocardial Infarction (MI), Congestive Heart Failure (CHF), stroke, or lung disease. She has not had any chest pain, shortness of breath, orthopnea, or peripheral nerve disease (PND). She has no history of surgery or anesthesia and currently has no known history of deep vein thrombosis (DVT) or pulmonary embolism (PE).

Provider Orders for Medication

0800                            Lioresal 10 mg                                     Oral                 Three times a day

0800                            Naproxen Sodium 220 mg                  Oral                 Every 12 hours

Clinical Reasoning Questions: Suzy McCue

Directions: Reflect on the individual case study and formulate a short detailed written response to each question based on the case study information. To demonstrate your “nurse think,” be prepared to verbally support your response to each question during your check-off with rationale from the skills sections of the Potter and Perry Lab Textbook.

What is the primary problem and what is its underlying pathophysiology?

What clinical data needs to be trended because it is clinically significant to the primary problem?

What three assessments are a priority and will be the baselines that guide a plan of care?

What nursing interventions will you initiate based on each priority?

What is the most likely complication to anticipate based on the primary problem you identified?

What nursing assessment(s) will identify the complication EARLY if it develops?

What nursing intervention(s) will you initiate if the complication does develop?

What education principles have you identified for the patient?

Answer 1

1. The primary problem is Multiple sclerosis (MS),which is an immune-mediated demyelimating disease of the central nervous system

Underlying pathology: exact cause is unknown, thought to be because of autoimmune mediated demyelination. Genetic predisposition is indicated by the presence of specific cluster (halotype) of human lecukocyte antigens (HLA) on the cell wall. This may promote susceptibility to factors such as viruses that may trigger autoimmune response activated in MS

Three pathologic process charcterize multiple sclerosis:

• Chronic inflammation
• Demyeliantion
• Gliosis

The primary neuropathologic condition is an autoimmune process accelerated by a viral infection by activated T cells. Subsequently, these activated T cells migrate to the CNS and damages the blood brain barrier. Eventually, an antigen-antibody response activates the inflammatory process leading to the demyelination of the axons. Intially, these changes may occur in the myelin sheath of neurons of brain and spinal cord result in damage to the myelin sheath without afecting the nerve fibers . Therefore, impulse transmission is not affected only problem is there is slowness in the conduction. Hence, patient may reports compliants of weakness .However, myelin has the capacity to regenerate , during this phase the symptoms disappear and client may have remissions

Eventually, the ongoing inflammation may cause damage to the oligodendrocytes and thus myelin loses its ability to regenerate. As a result further damge to the axon occurs, which may affect nerve impulse transmission, resulting in permanent loss of nerve function. Consequently, glial scar tissue replaces the damged tissue leading to the formation of sclerotic plaques in the white matter

2. One of the possible precipating factor for excacerbation of multiple sclerosis is physical injury, which may predisposes the client to occurence of symptoms. She remained at the home overnight thinking that pain is not severe, this may be due to slowness in impulse conduction which is one of the characteristic feature of multiple sclerosis. Sensation of decreased pain is due to demyelination

3.Assessment includes

Assess an extremitiy's color (pink, pale, cyanotic) and temperature (hot, warm, cold) in the area of the injury

Assess for deformity, tenderness and pain, edema at the injured site, loss of muscle function, paraesthesia or tingling and numbness

Check neurovascular status distal to injury before and after splinting

Monitor for symptoms of fat embolism such as dyspnea , elevated body temperature and chest pain

4. Compartment syndrome is the usual complication associated with fractures of the long bones of the leg.Paresthesia (abnormal sensation) patients usually complaints of tingling and numbness sensation sometimes report hypersensation or hyperhtesia occurs as a result of peripheral neurovascular dysfucntion due to vascular insufficiency and nerve compression which may precipitate multiple sclerosis. Partial or full loss of sensation is a late complication of neurovascular compromise

Six Ps are characteristic feature of compartment syndrome

• Pain distal to the injury not relieved by opiod analgesic
• Pressure- increased pressure experienced in the compartment
• Paresthesia - characterized by tingling and numbness sensation
• Pallor
• paralysis
• pulselssness

5. A thorough neurovascular assessment should be conducted by the nurse in these types of patients

• A warm cyanotic extermity indicates poor venous return
• Capillary refilling time of nail beds should be noted, if it is greater than 3 seconds, it should be notified immediately
• Compare pulses on both affected and unaffected extremity. A diminished or absent pulse distal to the injured site may indicate vascular dysfunction and insufficency
• Assess the dorsi flexion and plantar function of the the affected extremity which indicates the functioning of peroneal and tibial nerves

6.Perform and document prompt nuerovascular assessment

Carefully assess location, intensity, duration and radiation of pain

Notify the health care provider immediatley, if the client complaints of severe excruciating pain unrelieved by opioid analgesics

Do not elevate the extremity above the heart level, as it may increase venous return and slow aterial perfusion