multiple sclerosis - Nursing Case Study

Pathophysiology

• Primary mechanism: Multiple sclerosis (MS) is primarily characterized by immune-mediated demyelination in the central nervous system. The immune system mistakenly attacks myelin, the fatty substance that insulates nerve fibers, disrupting communication between the brain and the body.

• Secondary mechanism: Neurodegeneration or loss of neurons follows demyelination. Due to chronic inflammation and demyelination, axons (nerve fibers) deteriorate, leading to irreversible damage, and neurologic symptoms.

• Key complication: Severe complications arise from the widespread neurodegeneration in MS, leading to disability. This includes difficulty walking or complete loss of mobility, severe fatigue, difficulty with hand-eye coordination, and cognitive changes such as problems with memory, attention, and problem-solving skills.

Patient Profile

Demographics:

56-year-old female, former school teacher

History:

• Key past medical history: Diagnosed with Multiple Sclerosis (MS) 15 years ago, recurrent urinary tract infections, depression

• Current medications: Interferon beta-1a, Baclofen, Escitalopram, Oxybutynin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe fatigue, difficulty in walking, worsening cognitive function, and frequent urination

• Key symptoms: Intense fatigue, muscle weakness, balance issues, difficulty in concentration, memory problems, difficulty finding words, frequent urination, muscle spasms

• Vital signs: Blood pressure 90/60 mmHg, heart rate 110 bpm, oxygen saturation 92%, respiratory rate 22 breaths per minute, temperature 37.8°C (100.04°F)

Section 1

Change in Patient Status:

Over the next 24 hours, the patient's symptoms progressively worsened. She became increasingly lethargic and her fatigue intensified to the point where she was unable to participate in any physical therapy. Her cognitive function also declined, with increased difficulty in finding words and severe problems with attention and memory. Overnight, her oxygen saturation dropped to 88%, necessitating the use of supplemental oxygen. Her blood pressure also dropped to 80/50 mmHg and her heart rate increased to 120 bpm, indicating possible shock.

New Complications:

During a routine check, the nursing staff noticed signs of a developing pressure ulcer on the patient's sacral region, likely due to her increased immobility and decreased perfusion related to her lower blood pressure. Additionally, her urinalysis results came back positive for nitrites and leukocyte esterase, indicating another urinary tract infection (UTI). This was concerning, as recurrent UTIs could further exacerbate her MS symptoms and contribute to her worsening condition. Her sepsis screen also returned positive, indicating that the UTI might have led to urosepsis, a severe complication that could explain her hypotension and tachycardia.

Section 2

Change in Patient Status:

The patient's condition continued to deteriorate over the next few hours. Her blood pressure further dropped to 70/40 mmHg and her heart rate escalated to 130 bpm. She also began experiencing episodes of dyspnea and her oxygen saturation fluctuated between 85-88% despite the supplemental oxygen, indicating possible respiratory failure. She became increasingly less responsive and her Glasgow Coma Scale (GCS) score decreased to 10 from an initial 15, indicative of a significant decrease in her level of consciousness.

New Diagnostic Results:

Laboratory findings came back with alarming results. Her blood cultures showed the presence of Escherichia coli, the common causative agent of UTIs. Furthermore, her white blood cell count had risen to 18,000 cells/mm3, suggestive of an ongoing infection. Her C-reactive protein (CRP) level, a marker of inflammation, was also significantly elevated at 120 mg/L. In addition, her arterial blood gas analysis showed a pH of 7.25, PaO2 of 60mmHg, and PaCO2 of 50mmHg, indicating type II respiratory failure. Her chest X-ray displayed signs of pulmonary edema, further complicating her already complex clinical picture.

Section 3

Response to Interventions:

Despite aggressive fluid resuscitation and administration of broad-spectrum antibiotics, the patient's vital signs remained unstable. Her blood pressure only minimally improved to 80/50 mmHg, heart rate continued to oscillate between 125-135 bpm, and her oxygen saturation levels remained at 85-88%. The patient was also started on non-invasive ventilation (NIV) to correct her hypoxemia and hypercapnia, but her respiratory status showed little improvement, and she was increasingly becoming more difficult to rouse.

New Complications:

As the patient's condition continued to deteriorate, the medical team noted the onset of new complications. The patient developed a fever of 39.5°C, further confirming the suspicion of an ongoing infection. She also started exhibiting signs of neurological deterioration, such as increased muscle weakness and loss of coordination, likely related to her underlying multiple sclerosis. Furthermore, her urine output decreased to less than 20 ml/hr, raising concerns about acute renal failure. Her latest bloodwork showed a rise in her serum creatinine to 1.8 mg/dl from a baseline of 0.8 mg/dl, and her potassium levels were elevated at 5.8 mEq/L, suggesting that the patient was also dealing with metabolic complications. This deterioration called for urgent reassessment of her management plan and further diagnostic investigation to identify any hidden sources of infection or other contributing factors to her declining health status.

Section 4

Change in Patient Status:

Further into the night, the patient's condition took a sharp turn for the worse. Her blood pressure dropped to 70/40 mmHg, heart rate escalated to 145 bpm, and her oxygen saturation hovered around 80%, despite maximum oxygen support via NIV. Her level of consciousness deteriorated further, and she became unresponsive to verbal commands. On a neurological exam, she exhibited increased bilateral lower limb weakness and heightened dysmetria on finger-to-nose testing. This suggested worsening of her multiple sclerosis, possibly exacerbated by the sepsis.

New Diagnostic Results:

In response to the patient's deteriorating condition, the medical team ordered a series of new diagnostic tests. A repeat blood culture was sent to further investigate the suspected infection. An urgent CT scan of the brain was also performed to rule out any neurological complications such as cerebral edema or an abscess, which could explain her worsening neurological status. Results from the CT scan showed no acute intracranial abnormality, but there was evidence of extensive demyelination consistent with her known history of multiple sclerosis. The urinalysis report indicated the presence of leukocytes and nitrites, suggesting a urinary tract infection could be contributing to her sepsis. A renal ultrasound was also ordered to evaluate the possibility of obstruction as a cause for her low urine output. The ultrasound results showed no evidence of obstruction, but there was increased echogenicity in the renal cortex, suggestive of acute kidney injury.

Section 5

New Complications:

As the night progressed, the patient's condition continued to deteriorate. She developed a fever of 39.2°C and her respiratory rate increased to 35 breaths per minute, suggesting a worsening of the sepsis. Furthermore, her urine output progressively decreased, indicating a deterioration in her renal function. Lab results showed an increased creatinine level of 3.5 mg/dL from a baseline of 0.8 mg/dL, which further confirmed the suspicion of acute kidney injury. Additionally, her arterial blood gas analysis showed a pH of 7.25, PaCO2 of 55 mmHg, and HCO3 of 20 mmol/L, indicative of a respiratory acidosis, likely secondary to her worsening sepsis and reduced level of consciousness.

Response to Interventions:

In response to the patient's worsening condition, the medical team initiated aggressive fluid resuscitation and started her on broad-spectrum antibiotics, in line with sepsis management guidelines. Despite this, the patient's hypotension persisted, and her mental status did not improve. Given the worsening acidosis and concerning decline in her oxygen saturation, the team decided to proceed with endotracheal intubation and mechanical ventilation, aiming for a PaO2 of at least 60 mmHg and a saturation of more than 90%. Meanwhile, the nephrology team was consulted regarding the acute kidney injury, and they recommended closely monitoring her urine output and renal function, as well as considering the possibility of renal replacement therapy if her condition did not improve.