The nurse is administering muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention is the most important for the nurse to implement?
A.
Advise the client to move slowly and cautiously when rising and walking.
B.
Evaluate muscle strength every 4 hours.
C.
Monitor intake and output every 8 hours.
D.
Ensure the client knows to stop baclofen before using other antispasmodics.
The correct answer and Explanation is :
The most important intervention for the nurse to implement when administering baclofen to a client with multiple sclerosis is:
A. Advise the client to move slowly and cautiously when rising and walking.
Explanation:
Baclofen is a muscle relaxant commonly used to manage spasticity in conditions like multiple sclerosis. It works by acting on the central nervous system to reduce muscle tone and spasticity. While baclofen can be effective in improving mobility and reducing muscle stiffness, it can also have side effects that impact the client’s safety and functional abilities.
Reason for Advising Caution:
- Risk of Dizziness and Drowsiness: Baclofen can cause dizziness, drowsiness, and a general decrease in muscle control. These side effects can impair the client’s ability to maintain balance and coordination. Advising the client to move slowly and cautiously helps mitigate the risk of falls and injuries.
- Orthostatic Hypotension: The medication can sometimes cause a drop in blood pressure when changing positions, known as orthostatic hypotension. This can make the client feel lightheaded or faint when rising from a sitting or lying position. Moving slowly helps the body adjust to these changes in posture more gradually, reducing the risk of falls.
Other Options:
- B. Evaluate muscle strength every 4 hours: While monitoring muscle strength is important, it is not the most immediate safety concern. Baclofen’s primary risk involves its side effects rather than the direct impact on muscle strength at such frequent intervals.
- C. Monitor intake and output every 8 hours: Baclofen does not typically affect fluid balance directly. Monitoring intake and output is important for other conditions but not directly related to the immediate effects of baclofen.
- D. Ensure the client knows to stop baclofen before using other antispasmodics: This is a good practice to prevent potential drug interactions but is not as crucial as ensuring the client’s immediate safety when moving, which directly addresses the most common side effects of baclofen.
In summary, advising the client to move slowly and cautiously is critical to prevent falls and other accidents related to the medication’s side effects.