3B Group 1C

A CASE STUDY ON P.A., A 40-YEAR-OLD

FEMALE WITH MULTIPLE SCLEROSIS
Key Issue

Fatigue related to decreased energy production secondary to Multiple

Sclerosis as evidenced by inability to maintain usual routines such as her
schoolworks and her household chores. 

Scientific Basis: Almost everyone with MS will have some loss of mobility,
which may take the form of impaired (lessened) motor control, muscle
weakness, impaired balance, and spasticity. Spasticity is one of the
primary symptoms of MS and is characterized by weakness, loss of
dexterity, and the inability to control specific movements. It's usually more
severe in the legs and torso.
Desired Outcomes

After 3 days of student nurse-patient interaction, the patient will:

• Identify individual areas of weakness, needs.
• Demonstrate techniques and lifestyle changes to meet self-care
needs.
• Perform self-care activities within level of own ability.
• Identify personal and community resources that provide
assistance.
Independent Nursing Interventions
1.Identify and review factors affecting the ability of the patient to be active: temperature
extremes, inadequate food intake, insomnia, use of medications, time of day.
• Rationale: Provides an opportunity to problem-solve to maintain or improve mobility.
2.Determine the need for walking aids. Review safety considerations.
• Rationale: Mobility aids can decrease fatigue, enhancing independence and comfort, as
well as safety.
3.Schedule ADLs in the morning if appropriate.   
• Rationale: Fatigue commonly worsens in the late afternoon (when body temperature
rises).
Key Issue

Fatigue related to decreased energy production secondary to Multiple

Sclerosis as evidenced by inability to maintain usual routines such as her
schoolworks and her household chores. 

Scientific Basis: Almost everyone with MS will have some loss of mobility,
which may take the form of impaired (lessened) motor control, muscle
weakness, impaired balance, and spasticity. Spasticity is one of the
primary symptoms of MS and is characterized by weakness, loss of
dexterity, and the inability to control specific movements. It's usually more
severe in the legs and torso.
Desired Outcomes

After 3 days of student nurse-patient interaction, the patient will:

• Identify individual areas of weakness, needs.
• Demonstrate techniques and lifestyle changes to meet self-care
needs.
• Perform self-care activities within level of own ability.
• Identify personal and community resources that provide
assistance.
Independent Nursing Interventions
1.Identify and review factors affecting the ability of the patient to be active: temperature
extremes, inadequate food intake, insomnia, use of medications, time of day.
• Rationale: Provides an opportunity to problem-solve to maintain or improve mobility.
2.Determine the need for walking aids. Review safety considerations.
• Rationale: Mobility aids can decrease fatigue, enhancing independence and comfort, as
well as safety.
3.Schedule ADLs in the morning if appropriate.   
• Rationale: Fatigue commonly worsens in the late afternoon (when body temperature
rises).
Independent Nursing Interventions
4. Note when the patient is unable to do activities. 
• Rationale: Ability can vary from moment to moment. Nonjudgmental acceptance of
a patient's evaluation of day-to-day variations in capabilities provides the opportunity
to promote independence while supporting fluctuations in the level of required care.
5. Plan care consistent rest periods between activities. Encourage afternoon naps.
• Rationale: Reduces fatigue, aggravation of muscle weakness.
Dependent Nursing Interventions
1. Administer medication (carbamazepine) to the patient as prescribed by the physician. 
• Rationale: Used to treat neurogenic pain and sudden intermittent spasms related to
spinal cord irritation. 
2. Administer medication (Rebif - interferon beta-1A) to the patient as prescribed by the
physician. 
• Rationale: May be used to treat acute relapses, reduce the frequency of relapse, and
promote remission.
Collaborative Nursing Interventions
1. Assist with physical therapy. Increase patient comfort with massages and relaxing baths. 
• Rationale: Reduces fatigue and promotes a sense of wellness.
2. Recommend participation in groups involved in fitness or exercise and/or the
Multiple Sclerosis Society.
• Rationale: Can help the patient to stay motivated to remain active within the limits of the
disability or condition. Group activities need to be selected carefully to meet the patient’s
needs and prevent discouragement or anxiety.
Skin
After onset of disease, patient complains of numbness in
the skin and having sensations of sharp pain all over
the body. Paresthesia was also noted, 
Scalp
Black, thick, long, well-distributed, smooth, shiny and
well-kept; scalp is warm to the touch, no presence of
dandruff noted. No lesions and discharges noted.
Head and Face
Head is normocephalic, held upright, erect at midline with symmetrical facial
features. Temporal artery is elastic and not tender, the mouth is able to
open with a distance of approximately 3 cm between upper and lower lip.
Lower jaw moves laterally 2 cm in each direction. Hard and smooth with few
lesions noted, no lumps noted; hair is black, thick; scalp had no presence of
dandruff; no abnormal facial movements noted; temporomandibular joint is
free from swelling, tenderness, or crepitation upon movement; mouth opens
& closes fully.
Nails

Client has an oval nail shape with a 160 degrees nail base,
transparent with pinkish nail bed, smooth, firm, and hard; nail
plate firmly attached to nail bed; trimmed nails; no nail clubbing
noted; CRT < 2 seconds.
Eyes and Vision

After onset of disease, client complains of blurring of vision, pain

in the eyes and having episodes of double vision.
Ears and Hearing
After onset of disease, patient reports of burning pains behind
her ear, with a pain score of 7/10. Patient also complained that
she sometimes feels dizzy.
Nose and Sinuses
Nose is in midline without lesion with presence of short black
hair. Color of the external portion of the nose is consistent with
the rest of the face, smooth, and symmetrical; both nostrils
patent, nasal mucosa is dark pink, dry, presence of dried and
hardened mucus, nasal septum intact, at midline, and free of
ulcers or perforations; clear frontal & maxillary sinuses on
transillumination & are non-tender during palpation.
Mouth and Pharynx
Lips are dark pink without lesions or swelling; tongue is moist, pinkish, at midline, without
lesions, nodules, or fasciculations; papillae present on dorsal surface, frenulum in midline
with visible Wharton’s ducts on each side; throat is pink and moist, free of patches or
obvious signs of swelling; tonsils 1+, pink, symmetric without exudate, swelling or lesions;
uvula hangs freely in midline with no exudate and swelling noted; moist oral and buccal
mucosa; color and consistency of tissues along cheeks and gums are even; gums are
pink, moist and firm with tight margins to the tooth; no lesions noted; Stensen ducts are
visible with flow of saliva; no redness, swelling or pain noted;  hard palate is pale, firm
with transverse rugae without perforations; soft palate  is intact, pinkish, movable, spongy,
and smooth; throat is pink without exudate or lesions; whitish yellow teeth, no plaque
accumulation or dental carries noted, total of 32 teeth, 16 teeth in the upper and 16 teeth
in the lower, gag reflex intact; no unusual or foul odor noted. 
Neck
After onset of disease, client reports difficulty in
swallowing especially harder foods.
Chest and Lungs
After onset of disease, client reports difficulty breathing,
RR is 22 cpm with noted shallow breathing.
Heart and Peripheral Vasculature
Pink colorations return within 2 seconds in both sides of ulnar and radial arteries upon doing the Allen Test. No
varicosities noted. Peripheral pulses are: temporal pulse on both sides was 85 bpm; carotid pulse on the right
side was 87 bpm while on the left side was 88 bpm; brachial pulse on the right side was 85 bpm while on the left
side was 84 bpm; radial pulse on both arms were 85 bpm; femoral pulse on both sides were 86 bpm; popliteal
pulse on the right side was 85 bpm while on the left side was 83 bpm; posterior tibialis pulse on the right side
was 84 bpm while on the left side was 83 bpm; dorsalis pedis pulse on both sides were 84 bpm. All pulses have
normal strength and aptitude; no bruits noted upon auscultation and no thrills noted upon palpation of the
carotid arteries. No pulsations or vibrations are palpated in the areas of the apex, left sternal border or base.
Apical impulse palpated over 5th ICS of the midclavicular line with an amplitude of 1+. Patient’s S1 was distinct
and louder at the apex (mitral and tricuspid areas) while S2 was distinct and louder at the base (aortic and
pulmonic areas). S1 and S2 heard equally loud at Erb’s point. No extra heart sounds, murmurs, and bruits were
heard. A normal jugular vein pressure of +5 mmHg was taken. No jugular vein distention and arm/leg edema
observed. Radial pulses are bilaterally strong (+2). In Allen’s test, pink coloration returns to the palm within 3-5
seconds in checking for ulnar patency. Hair covers the skin on the legs. Toes, feet, and legs are equally warm
bilaterally but cooler compared to the upper extremities. CRT of upper and lower extremities <2 seconds
bilaterally with (-) Homan’s sign.
Abdomen

After onset of disease, patient exhibits absent superficial

abdominal reflexes.
Rectum
After onset of disease, patient exhibits episodes
of constipation.
Female Genitalia
Pubic hair evenly distributed with no signs of infestation; superficial and deep inguinal
lymph nodes nonpalpable; labia majora are equal in size and free of lesions, swelling,
and excoriation; healed episiotomy noted on the perineum; labia minora appear
symmetric, dark pink, and moist; Bartholin’s glands are soft, nontender, and drainage-
free; urethral meatus is soft, nontender, and free from drainage; the vaginal opening
is moist and client is able to squeeze around examiner’s finger; surface of the cervix
projects midline, is firm, smooth, pink, and even; cervical secretion are clear and non-
odorous; vaginal canal is pink, moist, smooth, and free of lesions and irritation without
colored or malodorous discharge noted; fundus is round, firm, and smooth; uterus
moves freely and is nontender; ovaries are firm, smooth, and mobile; rectovaginal
septum is smooth, thin, movable, and firm.
Musculoskeletal
 After onset of disease, patient exhibits exaggerated patellar
reflexes (+3) and bilateral extensor plantar responses. Client
also reports numbness of her hands and from the waist down,
tingling of the hands and feet, and clumsiness of her hands.
Client also reports a band of numbness from her umbilicus to
her axillae. Patient also exhibits difficulty in balance and
coordination. Shaking of hands was also observed.
Musculoskeletal

Muscle Strength

L R
3/5 4/5
4/5 4/5
Neurologic: Mental Status
Client is alert and oriented to current situation. In the Glasgow
Coma Scale, client scores 15 observed by as follows: eye
opening response is spontaneous (rated 4); oriented verbal
response (rated 5); obeys verbal commands (rated 6).
Motor/ Cerebral
 Client is able to touch the finger pads using both thumbs in
moderate speed. The client is able to tandem walk with little
difficulty. Client stands erect with minimal swaying with both
eyes open and close. The client is able to balance and hop on
one foot. Client touches finger to nose with smooth movement
and with little hesitation and is able to touch the examiner’s
finger at various locations correctly. Client is able to run each
heel smoothly down each shin.
Sensory
After onset of disease, patient exhibits absent abdominal
reflexes, exaggerated patellar reflexes (+3), and bilateral
extensor plantar responses.
Cranial Nerve Testing
CN I (Olfactory) - identifies scent presented to each nostril.
CN II (Optic) – was able to read the student's nameplate at 2 feet with
reading glasses.
CN III, IV, VI (Oculomotor, Trochlear, Abducens) – (+) PERRLA, (+) Cardinal
gaze in all quadrants
CN V (Trigeminal) – can open and close mouth, can clench teeth, light
reflects at same point on both eyes. She is also able to identify sharp and
dull stimuli and light touch to the forehead, cheeks, and chin with the use
of a paper clip. Eyelids blink bilaterally.
Cranial Nerve Testing
CN VII (Facial) – able to smile, shows teeth, frowns, wrinkles forehead, purses lips, raises
eyebrows; movements are symmetric
CN VIII (Vestibulocochlear) – Able to balance during Romberg’s test with either open or
closed eyes with minimal swaying; able to hear 3 whispered words during whisper test;
able to hear watch tick on both ears at 1.5 inches
CN IX & X (Glossopharyngeal and Vagus) - presence of the bilateral and symmetrical rising
of the uvula and soft palate; gag reflex intact.
CN XI (Accessory) – symmetric contraction of trapezius muscles and able to shrug
shoulders against moderate resistance.
CN XII (Hypoglossal) – able to move tongue symmetrically and smooth; bilateral strength is
apparent. Eyelids blink bilaterally.
Diagnostic and Laboratory Examinations:
1. Complete Blood Count (CBC)
Description: The complete blood count (CBC) is a group of tests that evaluate the cells that circulate in
blood, including red blood cells (RBCs), white blood cells (WBCs), and platelets (PLTs). The CBC can
evaluate your overall health and detect a variety of diseases and conditions, such as infections, anemia
and leukemia. 

Purpose: Blood tests are often an effective way to eliminate or confirm other diagnoses. Blood tests can
help your doctor rule out conditions that cause symptoms similar to those of MS, including lupus
erythematosus, Sjogren's, vitamin and mineral deficiencies, some infections, and rare hereditary
diseases. This puts your doctor one step closer to making an accurate diagnosis.
 Results Units Limit set Analysis

WBC  6.0 ( µl/mm3) 3.5 - 9.6 No deviation from normal

NEU  55.1 (%) 37.2 - 70.0 No deviation from normal

LYM  46.0 (%) 21.9 - 52.6 No deviation from normal

MONO 4.2 (%) 3.9 - 10.0 No deviation from normal

EOS  0.5 (%) 0.4 - 7.5 No deviation from normal

BASO 0.3 (%) 0.1 - 1.2 No deviation from normal Complete blood
Count lab
RBC 4.1 (1012/L) 3.7 - 4.9 No deviation from normal

Hemoglobin  112 (g/L) 111 - 148 No deviation from normal

Hematocrit 

Mean Corpuscular Volume 

37.0

90.2
(%)

(fL)
33.0 - 44.0

83.3 - 98.0
No deviation from normal

No deviation from normal

results: 
Mean Corpuscular Hemoglobin  27.3 (pg/cell) 27.7 - 33.2 No deviation from normal
1
Mean Corpuscular Hemoglobin 302.7 (g/L) 317 - 351 No deviation from normal
Concentration 

PLT  160 (109/L) 159.0 - 367.0  No deviation from normal

MPV  9.0 (%) 8.9 - 11.8 No deviation from normal

ESR 22 (mm/hr) 0-30 No deviation from normal

Vitamin B12 130 (ng/mL) 200-90 No deviation from normal

Folate 432 (ng/mL) 140-960 No deviation from normal

Complete Blood Count:
Normal Findings: 
All components of the complete blood count should be within their respective normal ranges. 

Significant Findings:
No significant findings.

Implication of Significant Findings:

No significant findings were determined in this test. This implies that there are no significant changes with regards to the blood
components of the patient.

Nursing Care:
Before:
•Assess if the patients is taking any blood-thinning medications, over-the-counter medications or supplements
•Assess the patient’s level of comfort.
•Educate the patient about the procedure.
•Address the patient’s concerns regarding the procedure.
•Provide a compassionate, reassuring environment.
Complete Blood Count:
During:
•Clean the puncture site with alcohol and allow it to dry.
•Observe proper hand hygiene and avoid using soiled gloves.
•Minimize patient discomfort at all times.

After:
•Secure a band-aid or clean cotton gauze over the puncture site.
•Ensure that the specimen container is labelled correctly and completely.
•Fill out the laboratory request form completely and send the specimen to the
laboratory immediately
Serology:
Description: 
Serology is the scientific study of serum and other body fluids. In practice, the term usually refers to the diagnostic
identification of antibodies in the serum. Such antibodies are typically formed in response to an infection, against
other foreign proteins, or to one's own proteins. 

Purpose: 
This test identifies antibodies (proteins made by a type of white blood cell in response to an antigen, a foreign
substance, in the body), investigate problems with the immune system, such as autoimmune diseases (when the body's
immune system turns on its own tissues) and immunodeficiency disorders (when a body's immune system is
underactive), and determining organ, tissue, and fluid compatibility for transplantation. Many infections affecting the
CNS (central nervous system) may present signs and symptoms that mimic MS. The manifestations of Treponema
pallidum infection of the CNS are not uniform, but follow a typical pattern. Gait disorders, cognitive dysfunction,
visual and auditory deficits, paresis and paresthesia are all symptoms that may confound the diagnosis of syphilis and
MS.
Serology:
Normal Findings: 
A negative test is normal.
Significant Findings:
No antibodies to syphilis were found in the blood sample.

Implication of Significant Findings:

A negative test result indicates that there are no antibodies for syphilis was found in the blood sample therefore ruling out the
possibility of the patient having syphilis.

Nursing Care:
Before
•Assess the patient’s level of comfort.
•Educate the patient about the procedure.
•Address the patient’s concerns regarding the procedure.
•Provide a compassionate, reassuring environment.
Serology:

During
•Clean the puncture site with alcohol and allow it to dry.
•Observe proper hand hygiene and avoid using soiled gloves.
•Minimize patient discomfort at all times.
After
•Secure a band-aid or clean cotton gauze over the puncture site.
•Ensure that the specimen container is labelled correctly and completely.
•Fill out the laboratory request form completely and send the specimen to the
laboratory immediately.
CSF Analysis: 

Description: Cerebrospinal fluid (CSF) analysis is a way of looking for conditions that affect your brain and
spine. It’s a series of laboratory tests performed on a sample of CSF. CSF is the clear fluid that cushions and
delivers nutrients to your central nervous system (CNS). 

Purpose: Cerebrospinal fluid studies can confirm demyelinating disease of the nervous system. They show an
increase in immunoglobulin concentrations in more than 90% of patients with MS. IgG index (a comparison
between IgG levels in the CSF and in the serum) is elevated in many MS patients. Oligoclonal
Immunoglobulin Bands can be identified in the CSF of MS patients via electrophoresis. The overall protein
level is also slightly elevated - up to 0.1 g/L. Protein level can be higher if the patient is going through a
marked relapse (i.e.,. severe optic neuritis).

.
 CSF Analysis: 

CSF ANALYSIS FOR MULTIPLE SCLEROSIS

COMPONENTS RESULTS

Appearance N

Red blood cells N

Lymphocytes 3 x 106/l (NR <5 x 106/l)

IgG Concentration 123mg/l (NR <60mg/l)

Albumin Concentration 470mg/l (NR <400mg/l)

IgG/albumin Ratio 26% (NR 4-22%)

IgG Index 1.07 (NR <0.7)

Isoelectric Focusing Oligoclonal bands present

CSF Analysis: 

Normal Findings:
All components of CSF analysis should be labeled as N or normal.

Significant Findings:
Elevated lymphocytes and CSF protein is high. 

Implication of Significant Findings:

Oligoclonal IgG bands are not normally found in the CSF, but 90% of patients with MS have
oligoclonal bodies present in the CSF.

.
CSF Analysis: 

Normal Findings:
All variations of CSF analysis should be within their respective normal values.

Significant Findings:
CSF IgG/OB is elevated, while Serum IgG/OB is very low.  CSF cells are slightly decreased and CSF protein is
elevated. 

Implication of Significant Findings:

CSF IgG/OB is higher than normal because of multiple sclerosis and Serum IgG/OB is low due to the immune
system being weak because of the condition. High CSF protein level suggests a problem in the nervous system.

.
CSF Analysis: 

Nursing Care:
Before:
•Assess the patient’s level of comfort.
•Ask the patient if he/she is taking blood thinners.
•Assess patient if there is history of back or spinal problems.
•Assess patient for any neurological illnesses or conditions.
•Assess the patient if there is an infection or rashes on his/her back.
•Educate patient about the procedure.
•Address the patient’s concerns regarding the procedure.
•Provide a compassionate, reassuring environment.

.
Magnetic Resonance Imaging: 

Description: An MRI is painless, noninvasive, and can produce detailed images. Performed both with and without contrast dye, an
MRI can identify lesions on the brain and spinal cord. The images can show if the lesions are old, new, or currently active. In
addition to diagnosis, an MRI can help monitor disease progression.

Purpose: These scans are used to help diagnose MS and to track its progression over time. Improvements in MRI technology have
significantly improved the ability to accurately diagnose MS at an early stage. Early diagnosis and treatment is key to minimizing
the effects of the disease.

.
Magnetic Resonance Imaging: 

.
Magnetic Resonance Imaging: 

Observations:

Axial T-2 weighted image shows ovoid hyperintense lesions in both hemispheres. Hyperintense lesions, a
feature of inflammatory disease activity.

Sagittal, T2-weighted image of the cervical spinal cord shows a fusiform area of hyperintense lesions.

Conclusion: 
Examination reveals presence of white hyperintense plaque in the brain and spinal cord

.
 Magnetic Resonance Imaging: 

Normal Findings: 
Appearance and intensity of brain parenchyma are normal. Ventricular system and cisternal spaces appear normal. No evidence of intracranial
space occupying lesion or obvious vascular anomaly is detected. The visualized orbits, paranasal sinuses and calvarium appear unremarkable.

Significant Findings:
Multifocal hyperintense white matter lesions, also known as “Dawson’s fingers”, in both hemispheres of the brain and in the spinal cord.

Implication of Significant Findings:

Hyperintensities refer to areas of high intensity on types of magnetic resonance imaging (MRI) scans of the brain and spine of a human reflect
lesions produced largely by demyelination and axonal loss

.
 Magnetic Resonance Imaging: 

Before: 
•Patient may be asked not to eat or drink anything for 4-6 hours before the scan.
•Ask the patient if she is afraid of close spaces (claustrophobic) and inform the doctor. Patient may be given medication to help her feel sleepy
and less anxious.
•Ask the patient if she has a pacemaker, hearing aid, or aneurysm clips.
•Ask patient to remove the following:
• Items such as jewelry, watches, credit cards, and hearing aids may be damaged.
• PIns, hairpins, metal zippers and similar metallic items can distort the images.
• Removal of dental work should be taken out before the scan.
• Because MRI contains strong magnets, metal objects are not allowed into the room with the MRI scanner.
•Ask the patient if she is pregnant or suspects that she is pregnant and inform the health care provider prior to the procedure.

.
 Magnetic Resonance Imaging: 

During:
•Patient will be asked to remain perfectly still during the time the imaging takes place, but between sequences some minor movement may be allowed. The MRI
technologist will advise accordingly.
•When the MRI procedure begins, patient may breathe normally, however, for certain examinations it may be necessary to hold breath for a short period of time.
•Monitoring is indicated to patients who have great potential for change in physiologic status (respiratory rate, oxygen saturation, temperature, heart rate and blood
pressure) during the procedure or whenever a patient requires observations of vital physiologic parameters due to an underlying health problem.
•Monitoring is imperative to patient who are using sedative or anesthesia to ensure safety.
After:
•Prior to allowing the patient to leave the MRI facility, the patient should be alert, oriented, and have stable vital signs. A responsible adult should accompany the
patient. Written instructions that include an emergency telephone number should be provided to the patient.