1. Adrenalectomy: surgical removal of adrenal glands because of tumors or uncontrolled overactivity; also bilateral adrenalectomy may be performed to control metastatic breast or prostate cancer.
    1. Risk factors:
      1. Pheochromocytoma.
      2. Adrenal hyperplasia.
      3. Cushing’s syndrome.
      4. Metastasis of prostate or breast cancer.
      5. Adrenal cortex or medulla tumors.
    2. Assessment:
      1. Objective data: validated evidence of:
        1. Benign lesion (unilateral adrenalectomy) or malignant tumor (bilateral adrenalectomy).
        2. Adrenal hyperfunction that cannot be managed medically.
        3. Bilateral excision for metastasis of breast and sometimes metastasis of prostate cancer.
    3. Analysis/nursing diagnosis:
      1. Knowledge deficit related to planned surgery.
      2. Risk for physical injury related to hormone imbalance.
      3. Risk for decreased cardiac output related to possible hypotensive state resulting from surgery.
      4. Risk for infection related to decreased normal resistance.
      5. Altered health maintenance related to need for self-administration of steroid medications, orally or by injection.
    4. Nursing care plan/implementation:
      1. Goal: preoperative: reduce risk of postoperative complications.
        1. Prescribed steroid therapy, given 1 week before surgery, is gradually decreased; will be given again postoperatively.
        2. Antihypertensive drugs are discontinued because surgery may result in severe hypotension.
        3. Sedation as ordered.
        4. General preoperative measures.
      2. Goal: postoperative: promote hormonal balance.
        1. Administer hydrocortisone parenteral therapy as ordered; rate indicated by fluid and electrolyte balance, blood sugar, and blood pressure.
        2. Monitor for signs of Addisonian (adrenal) Crisis.
      3. Goal: prevent postoperative complications.
        1. Monitor vital signs until stability is regained; if on vasopressor drugs such as metaraminol (Aramine):
          1. Maintain flow rate as ordered.
          2. Monitor BP q5-15 minutes, notify physician of significant elevations in BP (dose needs to be decreased) or drop in BP (dose needs to be increased). Note: readings that are normotensive for some may be hypotensive for patients who have been hypertensive.
        2. NPO - attach nasogastric tube to intermittent suction; abdominal distention is common side effect of this surgery.
        3. Respiratory care:
          1. Turn, cough, and deep breathe.
          2. Splint flank incision when coughing.
          3. Administer narcotics to reduce pain and allow patient to cough; flank incision is close to diaphragm, making coughing very painful.
          4. Auscultate breath sounds q2h; decreased or absent sounds could indicate pneumothorax.
          5. Sudden chest pain and dyspnea should be reported immediately (spontaneous pneumothorax).
        4. Position: flat or semi-Fowler’s.
        5. Mouth care
        6. Monitor dressings for bleeding; reinforce prn.
        7. Ambulation, as ordered.
          1. Check BP ql5min when ambulation is first attempte
          2. Place elastic stockings on lower extremities to enhance stability of vascular system.
        8. Diet - once NG tube removed, diet as tolerated.
      4. Goal: health teaching.
        1. Signs and symptoms of adrenal crisis:
          1. Pulse: rapid, weak, or thready.
          2. Temperature: elevated.
          3. Severe weakness and hypotension.
          4. Headache.
          5. Convulsions, coma.
        2. Importance of maintaining steroid therapy schedule to ensure therapeutic serum level.
        3. Weigh daily.
        4. Monitor blood-glucose levels daily.
        5. Report undesirable side effects of steroid therapy or adrenal crisis to physician.
        6. Avoid persons with infections, due to decreased resistance.
        7. Daily schedule: include adequate rest, moderate exercise, good nutrition.
    5. Evaluation/outcome criteria:
      1. Adrenal crisis avoided.
        1. Vitals within normal limits.
        2. No neurological deficits noted.
      2. Healing progresses: no signs of infection or wound complications.
      3. Adjusts to alterations in physical status.
        1. Complies with medication regimen.
        2. Avoids infections.
        3. Incorporates good nutrition, periods of rest and activity into daily schedule.

  2. Addison’s disease: chronic primary adrenal corticotropic insufficiency. A hormonal (endocrine) disorder involving destruction of the adrenal glands, which then are unable to produce sufficient adrenal hormones (cortisol) necessary for the normal body functions.
    1. Pathophysiology:
      1. Atrophy of adrenal gland is most common cause of adrenal insufficiency; manifested by decreased adrenal cortical secretions.
        1. Deficiency in mineralocorticoid secretion (aldosterone) - increased sodium excretion —> dehydration —> hypotension —> decreased cardiac output and resulting decrease in heart size.
        2. Deficiency in glucocorticoid secretion (cortisol) —> decrease in gluconeogenesis —> hypoglycemia and liver glycogen deficiency, emotional disturbances, diminished resistance to stress. Cortisol deficiency —> failure to inhibit anterior pituitary secretion of ACTH and melanocyte-stimulating hormone —> increased levels of ACTH and hyperpigmentation.
        3. Deficiency in androgen hormone —> less axillary and pubic hair in women (testes supply adequate sex hormone in men, so no symptoms are produced).
    2. Risk factors:
      1. Autoimmune processes.
      2. Infection.
      3. Malignancy.
      4. Vascular obstruction.
      5. Bleeding.
      6. Environmental hazards.
      7. Congenital defects.
      8. Bilateral adrenalectomy.
      9. Tuberculosis.
    3. Assessment:
      1. Subjective data:
        1. Muscle weakness, fatigue, lethargy.
        2. Dizziness, fainting.
        3. Nausea, food idiosyncrasies, anorexia.
        4. Abdominal pain/cramps.
      2. Objective data:
        1. Vital signs: decreased BP, orthostatic hypotension, widened pulse pressure.
        2. Pulse - increased, collapsing, irregular.
        3. Temperature - subnormal.
        4. Vomiting, diarrhea, and weight loss.
        5. Tremors.
        6. Skin: poor turgor, excessive pigmentation (bronze tone).
        7. Lab data:
          1. Blood:
            1. Decreased: sodium (<135 mEq/L); glucose (<60 mg/dL), chloride (<98 mEq/L), bicarbonate (<23 mEq/L).
            2. Increased: hematocrit, potassium (>5 mEq/L).
          2. Urine: decreased (or absent) 17-ketosteroids, 17-hydroxycorticosteroids (<5 mg/24 hours).
        8. Diagnostic tests:
          1. CT scan, MRI
          2. ACTH stimulation test (cortisol levels are measured before and after administration of synthetic ACTH).
    4. Analysis/nursing diagnosis:
      1. Fluid volume deficit related to decreased sodium.
      2. Altered renal tissue perfusion related to hypotension.
      3. Decreased cardiac output related to aldosterone deficiency.
      4. Risk for infection related to cortisol deficiency.
      5. Activity intolerance related to muscle weakness and fatigu
      6. Altered nutrition, less than body requirements, related to nausea, anorexia, and vomiting.
    5. Nursing care pian/implementation:
      1. Goal: decrease stress.
        1. Environment: quiet, nondemanding schedule.
        2. Anticipate events for which extra resources will be necessary.
      2. Goal: promote adequate nutrition.
        1. Diet: acute phase - high sodium, low potassium; nonacute phase - increase carbohydrates and protein.
        2. Fluids: force, to balance fluid losses; monitor I&O, daily weights.
        3. Administer lifelong exogenous replacement therapy as ordered:
          1. Glucocorticoids - prednisone, hydrocortison
          2. Mineralocorticoids - fludrocortisone (Florinef).
      3. Goal: health teaching.
        1. Take medications with food or milk.
        2. May need antacid therapy to prevent GI disturbances.
        3. Side effects of steroid therapy.
        4. Avoid stress; may need adjustment in medication dosage when stress is increased.
        5. Signs and symptoms of addisonian (adrenal) crisis: very serious condition characterized by severe hypotension, shock, coma, and vasomotor collapse related to strenuous activity, infection, stress, omission of prescribed medications. If untreated, could quickly lead to death.
      4. Goal: prevent serious complications if Addisonian Crisis evident.
        1. Complete bed rest; avoid stimuli.
        2. High dose of hydrocortisone IV or cortisone IM.
        3. Treat shock - IV saline.
        4. I&O, vital signs ql5min to 1 hr or prn until crisis passes.
    6. Evaluation/outcome criteria:
      1. No complications occur.
      2. Medication regimen followed, is adequate for patient’s needs.
      3. Adequate nutrition and fluid balance obtained.

  3. Multiple sclerosis: progressive neurological disease, common in northern climates, characterized by demyelination of brain and spinal cord leading to degenerative neurological function; chronic remitting and relapsing disease; cause unknow Visual problems are often the first indication of multiple sclerosis. Classifications of multiple sclerosis: relapsing-remitting, primary-progressive, secondaryprogressive, and progressive-relapsin Exacerbations aggravated by fatigue, chilling, and emotional distress.
    1. Pathophysiology: multiple foci (patches) of nerve degeneration throughout brain, spinal cord, optic nerve, and cerebrum cause nerve impulses to be interrupted (blocked) or distorted (slowed). Researchers suggest that in genetically susceptible people, the disease results from an abnormal autoimmune response to some agent, perhaps a virus or environmental trigger.
    2. Risk factors:
      1. Northern climate.
      2. Onset age: 20-40 years.
      3. Two to three times more common in women than men.
    3. Assessment:
      1. Subjective data:
        1. Extremities: weak, numb, decreased sensation.
        2. Emotional instability, apathy, irritability, mood swings, fatigue.
        3. Eyes: diplopia (double vision), spots before eyes (scotomas), potential blindness.
        4. Difficulty in swallowing.
        5. Pain.
      2. Objective data:
        1. Nystagmus (involuntary rhythmic movements of eyeball) and decreased visual acuity.
        2. Inappropriate outbursts of laughing or crying (sometimes related to ingestion of hot food).
        3. Disorders of speech.
        4. Susceptible to infections.
        5. Tremors to severe muscle spasms and contractures.
        6. Changes in muscular coordination; gait: ataxic, spastic.
        7. Changes in bowel habits, e.g., constipation.
        8. Urinary frequency and urgency
        9. Incontinence (urine and feces).
        10. Sexual dysfunction.
        11. Cognitive changes/depression.
        12. Lab tests: cerebrospinal fluid has presence of gamma globulin IgG.
        13. Diagnostic tests:
          1. Neurological examination.
          2. Positive Lhermitte’s sign (electric shock-like sensation along spine on flexion of the head).
          3. Positive Babinski reflex.
          4. MRI detects plaques.
    4. Analysis/nursing diagnosis:
      1. Impaired physical mobility related to changes in muscular coordination.
      2. Self-esteem disturbance related to chronic, debilitating disease.
      3. Altered health maintenance related to spasms and contractures.
      4. Risk for impaired skin integrity related to contractures.
      5. Constipation related to immobility.
      6. Impaired swallowing related to tremors.
      7. Visual sensory/perceptual alteration related to nystagmus and decreased visual acuity.
    5. Nursing care plan/implementation:
      1. Goal: maintain normal routine as long as possible.
        1. Maintain mobility - encourage walking as tolerated; active and passive ROM; splints to decrease spasticity.
        2. Avoid fatigue, infections.
        3. Frequent position changes to prevent skin breakdown and contractures; position at night: prone to minimize flexor spasms of knees and hips.
        4. Bowel/bladder training program to minimize incontinence.
        5. Avoid stressful situations.
      2. Goal: decrease symptoms - medications as ordered:
        1. Methylprednisolone (high dose, IV) plus sodium succinate, followed by gradual tapering of steroids to treat at initial diagnosis.
        2. Methylprednisolone (Solu-Medrol), prednisone (Deltasone), and dexamethasone (Decadron) used to treat acute relapses.
        3. Methotrexate (Rheumatrex) (low dose) used to delay progression of impairment.
        4. Interferon (3-lb (Betaseron) reduces number of lesions and frequency of relapses.
        5. Glatiramer (Copaxone) to reduce number of relapses.
        6. Baclofen (Lioresal) for alleviating spasticity 5 mg three times daily, increased by 5 mg every three days; not to exceed 80 mg/day (20 mg four times daily). Optimal effect between 40 and 80 mg; sudden withdrawal of medication may cause hallucinations and rebound spasticity.
        7. Diazepam (Valium), dantrolene (Dantrium) to relieve muscle spasm.
        8. Carbamazepine (Tegretol) or amitriptyline HC1 (Elavil) for dysesthesias or neuralgia.
        9. Ciprofloxacin (Cipro) to treat bladder dysfunction.
        10. Psyllium hydrophilic mucilloid (Metamucil) to treat bowel dysfunction.
        11. Phenytoin (Dilantin) to treat sensory symptoms.
        12. Analgesics to treat pain.
      3. Goal: health teaching to prevent complications.
        1. Signs and symptoms of disease; measures to prevent exacerbations.
        2. Teach to monitor respiratory status to prevent infections.
        3. Importance of physical therapy to prevent contractures.
        4. Possible counseling or community support group for assistance in accepting long-term condition.
        5. Teach special skin care to prevent decubitus ulcers.
        6. Teach use of assistive devices to maintain independence.
      4. Goal: provide psychosocial support.
        1. Answer questions of patient and family members.
        2. Provide referrals to appropriate agencies.
        3. Monitor for signs of suicide (higher incidence of suicide in patients with MS than the general population).
        4. Encourage communication.
    6. Evaluation/outcome criteria:
      1. Establishes daily routine; adjusts to altered lifestyle.
      2. Injuries prevented; no falls.
      3. Urinary and bowel routines established; incontinence decreased.
      4. Infections avoided.
      5. Symptoms minimized by medications.

  4. Myasthenia gravis: Chronic neuromuscular disease characterized by weakness and easy fatigability of facial, oculomotor, pharyngeal, and respiratory muscles. The muscle weakness increases during periods of activity and improves after periods of rest.
    1. Pathophysiology: inadequate acetylcholine or excessive or altered cholinesterase, leading to impaired transmission of nerve impulses to muscles at myoneural junction.
    2. Risk factors:
      1. Possible autoimmune reaction.
      2. Thymus tumor.
      3. Young women and older men, but can occur at any age.
    3. Assessment:
      1. Subjective data:
        1. Diplopia (double vision).
        2. Severe generalized fatigue.
      2. Objective data:
        1. Muscle weakness: hands and arms affected first.
        2. Ptosis (drooping of eyelids), expressionless facies.
        3. Hypersensitivity to narcotics, barbiturates, tranquilizers.
        4. Abnormal speech pattern, with highpitched nasal voice.
        5. Difficulty chewing/swallowing food.
        6. Decreased ability to cough and deep breathe, vital capacity.
        7. Positive Tensilon test (administration of edrophonium chloride, 10 mg IV, produces relief of symptoms within 30 sec).
        8. Positive Prostigmin test (5 mg subcutaneous neostigmine methylsulfate, produces relief of symptoms within 15 minutes; increased muscle strength within 30 min).
    4. Analysis/nursing diagnosis:
      1. Ineffective breathing pattern related to weakness.
      2. Risk for injury related to muscle weakness.
      3. Activity intolerance related to severe fatigue.
      4. Bathing/dressing self-care deficit related to progressive disease.
      5. Impaired physical mobility related to decrease in strength.
      6. Anxiety related to physical symptoms and disease progression.
      7. Knowledge deficit related to medication administration and expected effectiveness.
    5. Nursing care plan/implementation:
      1. Goal: promote comfort.
        1. Passive and active ROM, as tolerated, to increase strength.
        2. Mouth care: before and after meals.
        3. Diet: as tolerated, soft, pureed, or tube feedings.
        4. Skin care to prevent decubiti.
        5. Eye care: remove crusts; patch affected eye prn.
        6. Monitor respiratory status - suction airway prn.
      2. Goal: decrease symptoms.
        1. Administer medications as ordered:
          1. Anticholinesterase (neostigmine [Prostigmin], pyridostigmine [Mestinon]) to elevate concentration of acetylcholine at myoneural junction.
          2. Give before meals to aid in chewing, with milk or food to decrease GI symptoms; maybe given parenterally.
      3. Goal: prevent complications.
        1. Respiratory assistance if breathing pattern not adequate.
        2. Monitor for choking/increased oral secretion.
        3. Avoid: narcotics, barbiturates, tranquilizers.
      4. Goal: promote increased self-concept.
        1. Encourage independence when appropriate.
        2. Encourage communication; provide alternative methods when speech pattern impaired.
      5. Goal: health teaching.
        1. Medication information:
          1. Adjust dosage to maintain muscle strength.
          2. Medication must be taken at prescribed time to avoid:
            1. Myasthenic crisis (too little medication).
            2. Cholinergic crisis (too much medication).
        2. Signs and symptoms of crisis: dyspnea, severe muscle weakness, respiratory distress, difficulty in swallowing.
        3. Importance of avoiding upper respiratory infections.
        4. Determine methods to conserve energy, to maintain independence as long as possible, while avoiding overexertion.
        5. Refer to Myasthenia Gravis Foundation and other community agencies for assistance in reintegration into the community and plans for follow-up care.
    6. Evaluation/outcome criteria:
      1. Independence maintained as long as possible.
      2. Respiratory arrest avoided.
      3. Infection avoided.
      4. Medication regimen followed and crisis avoided.

  5. Parkinson’s disease: progressive disease of the brain occurring generally in later life; characterized by stiffness of muscles and by tremors.
    1. Pathophysiology: depigmentation of the substantia nigra of basal ganglia —> decreased dopamine (neurotransmitter necessary for proper muscle movement) —> decreased and slowed voluntary movement, masklike facies, and difficulty initiating ambulation. Decreased inhibitions of alpha-motoneurons —> increased muscle tone —> rigidity of both flexor and extensor muscles and tremors at rest.
    2. Risk factors:
      1. Age >40; most often 50-60 years.
      2. Affects men and women equally.
      3. Cause unknown; possibly connected to arteriosclerosis or viral infection.
      4. Drug-induced parkinsonian syndromes have been linked to:
        1. Phenothiazines.
        2. Reserpine (Serpasil).
        3. Butyrophenones (haloperidol).
    3. Assessment:
      1. Subjective data:
        1. Insomnia.
        2. Depression.
        3. Defects in judgment related to emotional instability; dementia (memory loss).
      2. Objective data:
        1. Limbs, shoulders: stiff, offer resistance to passive ROM.
        2. Loss of coordination, muscular weakness with rigidity.
        3. Shuffling gait: difficulty in initiating, then propulsive, trunk bent forward.
        4. Tremors: pill-rolling of fingers, to-andfro head movements.
        5. Loss of postural reflexes.
        6. Weight loss, constipation.
        7. Difficulty in maintaining social interactions because of impaired speech, lack of facial affect, drooling.
        8. Facies: wide-eyed, decreased eye blinking, decreased facial expression.
        9. Akinesia (abnormal absence of movement).
        10. Excessive salivation, drooling.
        11. Speech: slowed, slurred.
        12. Judgment defective (e.g., poor decision making); intelligence intact.
        13. Heat intolerance.
    4. Analysis/nursing diagnosis:
      1. Impaired physical mobility related to loss of coordination.
      2. Altered health maintenance related to defective judgment.
      3. Risk for injury related to altered gait.
      4. Dressing/grooming self-care deficit related to muscular rigidity.
      5. Sleep pattern disturbance related to insomnia.
      6. Body image disturbance related to tremors and drooling.
      7. Social isolation related to altered physical appearance.
      8. Altered nutrition, less than body requirements, related to lack of appetite.
      9. Impaired swallowing related to excessive drooling.
      10. Constipation related to dietary changes.
    5. Nursing care plan/implementation:
      1. Goal: promote maintenance of daily activities.
        1. ROM exercises, skin care, physical therapy.
        2. Encourage ambulation; discourage sitting for long periods.
        3. Assist with meals - high protein, high calorie; soft diet; small, frequent feedings; encourage increased fluids.
        4. Encourage compliance with medication regimen:
          1. Dopamine agonists:
            1. Levodopa: given in increasing doses until symptoms are relieved; given with food to decrease GI symptoms. Side effects: nausea, vomiting, anorexia, postural hypotension, mental changes, cardiac arrhythmias. Levodopa (L-Dopa) helps restore dopamine deficiency in striated muscles: 500-1000 mg/day in divided doses; increase by 100-750 mg/day every 3-7 days until response reached; usual maintenance dose should not exceed 18 g/day.
            2. Carbidopa-levodopa (Sinemet): 25/250 mg/day in 3-4 divided doses. Limits the metabolism of levodopa peripherally and provides more levodopa for the brain.
          2. Anticholinergics: effective in lessening muscle rigidity.
            1. Benztropine mesylate (Cogentin): 0.5-6 mg/day in 1-2 divided doses.
            2. Biperiden (Akineton): 2 mg 3-4 times daily, not to exceed 16 mg/day.
            3. Trihexyphenidyl (Artane): 1-2 mg/day; increased by 2 mg every 3-5 days; usual maintenance dose 5-15 mg/day in 3-4 divided doses.
          3. Antihistamines: have mild central anticholinergic properties.
      2. Goal: protect from injury.
        1. Monitor BP, side effects of medications, , orthostatic hypotension.
        2. Monitor for GI disturbances.
        3. Avoid pyridoxine (vitamin B6): cancels effect of levodopa.
        4. Levodopa contraindicated with:
          1. Glaucoma (causes increased intraocular pressure).
          2. Monoamine oxidase (MAO) inhibitors (causes possible hypertensive crisis).
      3. Goal: health teaching.
        1. Teach patient and family about medications: dosage range, side effects, not discontinuing medications abruptly.
        2. Exercise program to maintain ROM and normal body posture; also to get adequate rest to prevent fatigue.
        3. Dietary adjustment and precautions regarding cutting food in small pieces to prevent choking, taking fluid with food for easier swallowing.
        4. Importance of adding roughage to diet to prevent constipation.
        5. Assist patient and family to adjust to this chronic debilitating illness.
    6. Evaluation/outcome criteria:
      1. Activity level maintained.
      2. Symptoms relieved by medications; no drug interactions.
      3. Complications avoided.

  6. Amyotrophic lateral sclerosis (ALS; Lou Gehrig’s disease): progressive degeneration of motor neurons within the brain, spinal cord, or both, leading to death within 2-7 years, usually from infection (pneumonia) or consequences of respiratory or bul- bar paralysis. There are three types of ALS: classic sporadic, familial, and Mariana Islands (Guam).
    1. Pathophysiology: myelin sheaths destroyed, replaced by scar tissue; involves lateral tracts of spinal cord, eventually medulla and ventral tracts.
    2. Risk factors:
      1. Affects men more than women.
      2. Usually in middle age.
      3. Viral infection possible causal agent.
      4. Possible familial or genetic component.
    3. Assessment:
      1. Subjective data:
        1. Early symptoms: fatigue, awkwardness.
        2. Dysphagia, dysarthria.
        3. Alert, no sensory loss.
      2. Objective data:
        1. Symptoms depend on which motor neurons affected.
        2. Decreased fine finger movement.
        3. Progressive muscular weakness, atrophy, especially lower limbs at onset of disease; later, arms, hands, and shoulders.
        4. Spasticity of flexor muscles; one side of body becomes more involved than other.
        5. Progressive respiratory difficulties —> diaphragmatic paralysis.
        6. Progressive disability of upper and lower extremities.
        7. Fasciculations (muscle twitching visible under skin).
        8. Diagnostic tests:
          1. Electromyography (EMG).
          2. Nerve conduction velocities (NCV).
    4. Analysis/nursing diagnosis:
      1. Ineffective airway clearance related to difficulty in coughing.
      2. Ineffective breathing pattern related to progressive respiratory difficulties and eventually respiratory paralysis.
      3. Altered health maintenance related to inability to perform self-care activities.
      4. Impaired physical mobility related to progressive muscular weakness.
      5. Self-care deficits: bathing/hygiene and dressing/grooming.
      6. Powerlessness related to lifestyle of progressive physical helplessness.
      7. Impaired swallowing related to disease progression.
    5. Nursing care plan/implementation:
      1. Goal: maintain independence as long as possible.
        1. Assistance with ADL; splints, prosthetic devices to support weak limbs and maintain mobility.
        2. Skin care to prevent decubiti.
        3. Respiratory assistance as needed; ventilators as disease progresses and diaphragm becomes involve
        4. Soft/liquid diet to aid in swallowing, prevent choking; suction prn; head of bed elevated when eating.
        5. Arrange long-term care arrangements if home maintenance no longer feasible.
        6. Emotional support, when patient is alert; continue involving patient in decisions regarding care.
        7. Medications: riluzolet (Rilutek); has some effect in reducing disease progression; other drugs offer temporary relief of symptoms.
      2. Goal: health teaching.
        1. Skin care to prevent decubitus ulcer.
        2. Explain ramifications of disease so patient and family can make decisions regarding future care, whether patient will remain at home as disease progresses or enter a long-term care facility.
        3. How to use suction apparatus to clear airway.
        4. Care of nasogastric or gastrostomy feeding tube.
    6. Evaluation/outcome criteria:
      1. Obtains physical and emotional support.
      2. Complications avoided in early stage of disease.
      3. Remains in control of ADL as long as possible.
      4. Skin breakdown avoided.
      5. Peaceful death.