Medical Surgical ALS #2

Question

A nurse is preparing to care for a client with ALS. Which nursing intervention is priority?

Answers

  1. Consulting respiratory therapy for chest physiotherapy.
    • Rationale:

      This answer is not correct because though it is important, it is not the priority intervention. Chest physiotherapy can help prevent pneumonia due to the immobility associated with ALS, as well as postural drainage positioning.

  2. Provide a calm environment to decrease stimuli
    • Rationale:

      This answer is not correct because ALS causes no cognitive deficits and the client retains mental abilities. The nurse would provide intellectually stimulating activities for the client since the client will experience long-term immobility.

  3. Consult social services to promote family coping.
    • Rationale:

      This answer is not correct because although this is an important intervention to consider, providing the family with support is not priority. There is no cure for ALS and assisting the client’s family with the grieving process and understanding the poor prognosis for the disease is in the family’s and client’s best interest.

  4. Have airway management materials at bedside.
    • Rationale:

      This answer is correct because maintaining airway patency is first priority. The ALS client presents with an ineffective breathing pattern. Death is usually from respiratory muscle involvement. Monitoring respiratory status and preparing to initiate respiratory support is most important.

Overview

Amyotrophic lateral sclerosis (ALS) is an accelerating neurogenic disease that negatively affects the nerve cells that control voluntary muscles. It causes weakness in many muscles of the body, including the respiratory muscles. Therefore, airway management materials should be at the bedside.

Explanation

Learning Outcomes

Amyotrophic lateral sclerosis (ALS) is also known as Lou Geherig’s disease. It is an accelerating neurogenic disease that negatively affects the nerve cells that control voluntary muscles. It causes weakness in many muscles of the body, including the muscles responsible for breathing. Due to the ALS client’s muscle weakness and atrophy, they may be unable to effectively breath in and out to properly ventilate the lungs. They are also at higher risk for aspiration which causes respiratory infections. Hypercapnic respiratory failure and aspiration pneumonia are common in the ALS client. Having airway management equipment at bedside is the number one priority for the nurse caring for a client with ALS.

Test Taking Tip

Remember ABCs of triage. Airway patency will always be a first priority.

Video Rationale