Medical Surgical ALS #1

Question

The nurse is caring for a client diagnosed with amyotrophic lateral sclerosis (ALS). The client’s family consists of two children ages 8 years of age and 16 years of age and a spouse. Which of the following nursing diagnoses will have priority?

Answers

  1. Self-care deficit related to paralysis
    • Rationale:

      This answer is not correct because although self-care deficit is a nursing diagnosis due to the client’s inability for self-care because of muscle wasting and paralysis, it is not priority. Due to the nature of the disease, with the young ages of the client’s children, the nursing diagnosis of “Anticipatory grieving related to inevitable deathâ€ is priority for this client.

  2. Altered nutrition: less than body requirements related to inability to feed self
    • Rationale:

      This answer is not correct because in clients with advanced disease, enteral nutrition is indicated due to the potential of aspiration pneumonia from swallowing difficulties. Thus, the ALS client will most likely have a feeding tube to provide adequate nutrition and hydration, therefore, making altered nutrition not the first priority. Due to the nature of the disease, with the young ages of the client’s children, the nursing diagnosis of “Anticipatory grieving related to inevitable deathâ€ is priority for this client.

  3. Impaired physical mobility related to decreased motor function and loss of muscle tone
    • Rationale:

      This answer is not correct because although impaired physical mobility related to decreased motor function and loss of muscle tone is an obvious nursing diagnosis, it is not the priority nursing diagnosis. Dealing with the inevitability of death personally and involving the children is priority so “Anticipatory grieving related to inevitable death” is priority.

  4. Anticipatory grieving related to inevitable death
    • Rationale:

      This answer is correct because since diagnosis represents a change from life to end result of death, the anticipatory grieving associated with the disease will be a dominant theme among family, the client, and the interdisciplinary healthcare team. Anticipatory grief is a series of intense emotions one experiences when expecting the death of a loved one. The nurse will promote trust by showing empathy and active listening.

Overview

ALS also known as Lou Gehring’s disease is a neurodegenerative disease that destroys the nerves that serve that control voluntary muscle movement. This disease is progressive and worsens over time, until the client dies from respiratory failure due to paralysis of the muscles that control breathing.

Explanation

Learning Outcomes

ALS is a fatal neurological disease manifested by loss of motor neurons that affects muscle function. This includes respiratory function. Most deaths occur as a result of respiratory failure that progresses slowly. ALS clients experience no cognitive deficits and retain their mental faculties which can make the loss of muscle function and respiratory function even more difficult on the client and family. Nursing interventions include moisturizing of skin to promote skin integrity, compression stockings to prevent thrombosis, a bowel program due to lack of movements, and diversional activities. The family should be preparing for the inevitable death of the client. Hospice may need to be utilized for the care of the client and the family members. Due to the nature of the disease with the young ages of the client’s children, the nursing diagnosis of “Anticipatory grieving related to inevitable death” is priority for this client.

Test Taking Tip

Note the question mentions the client’s family demographic. This is a clue within the question as to the nurse’s first priority for this client.

Video Rationale