Student Nurses Community

ASSESSMEN
T

DIAGNOSIS

INFERENCE

SUBJECTIVE:

Fatigue
related to
decreased
energy
production,
increased
energy
requirements
to perform
activities.

Multiple
sclerosis is
characterized by
an inflammatory
response that
results in random
or patchy areas
of plague in the
white matter of
the central
nervous system.
The myelin
sheath is
damaged and its
thickness is
reduced. Myelin
is responsible for
the
electrochemical
transmission of
impulse between
the brain and the
spinal cord and
the rest of the
body. Impulses
are still

Bigla akong
nanghina at
parang pagod
na pagod (I
feel weak and
very tired) as
verbalized by
the patient.
OBJECTIVE:
Decreased fine
motor skills
Decreased
muscle tone
and mass
Restlessness
V/S taken as
follows:
T: 36.9 C
P: 80
R: 17

NURSING CARE PLAN Multiple Sclerosis

PLANNING

INTERVENTIO
N

After 8 hours
Independent
of Nursing
Interventions, Note and accept
the patient will
presence of
identify risks
fatigue
factors and
Identify or review
individual
factors
actions
affecting ability
affecting
to be active,
fatigue;
such as
identify
temperature
alternatives to
extremes,
help maintain
inadequate
desired
food intake,
activity level;
insomnia, use
participate in
of medications,
recommended
or time of day.
treatment
program and
report
Accept when a
improved
client is unable
sense of
to do activities.
energy.
Determine need
for mobility
aids such as

RATIONALE

Persistent
fatigue is the
most
commonly
reported
symptom.
Knowledge of
these factors
provides an
opportunity to
develop
effective
measures to
maintain or
improve
mobility.
Activity
intolerance
can vary from
moment to
moment.
Mobility ads
can decrease
fatigue,
enhance
independence

EVALUATIO
N
After 8 hours
of Nursing
Interventions,
the patient
was able to
identify risk
factors and
individual
actions
affecting
fatigue;
identify
alternatives to
help maintain
desired
activity level;
participate in
recommended
treatment and
program and
report
improved
sense of
energy.

Student Nurses Community

BP: 110/80

transmitted but
are not as
effective as
before; overtime,
they may be
completely
blocked. The
areas particularly
affected include
optic nerves,
pyramidal tracts.

canes, walker,
wheelchair,
etc.
Schedule activity
of daily living
and outside
activities in the
morning or
overtime
throughout the
course of the
day.
Plan care with
consistent rest
periods
between
activitities.

and comfort,
and promotes
safety.
Fatigue
commonly
worsens when
exposed to
high
temperature
due to
weather.
Consistent
rest and
activity
reduces
fatigue.