Multiple Sclerosis

Multiple sclerosis (MS) is an immune-mediated, progressive demyelinating disease of the CNS. Demyelination refers to the destruction of myelin—the fatty and protein material that surrounds certain nerve fibers in the brain and spinal cord; it results in impaired transmission of nerve impulses. MS affects nearly 400,000 people in the United States and may occur at any age, but the age of peak onset is between 25 and 35 years; it affects women more frequently than men.

Disease Course

MS has various courses:

Benign course: Symptoms are so mild that patients do not seek health care or treatment.
Relapsing remitting (RR) course (85%): Patients experience complete recovery between relapses; 50% of these patients progress to a secondary progressive course, in which disease progression occurs with or without relapses.
Primary progressive course (15%): Disabling symptoms steadily increase, with rare plateaus and temporary improvement; this course may result in quadriparesis, cognitive dysfunction, vision loss, and brain stem syndromes.
Progressive relapsing course (least common, about 5%): This course is characterized by relapses with continuous disabling progression between exacerbations.

The cause of MS is an area of ongoing research. Autoimmune activity results in demyelination, but the sensitized antigen has not been identified. Multiple factors play a role in the initiation of the immune process. In MS, sensitized T cells inhabit the CNS and facilitate the infiltration of other agents that damage the immune system. The immune system attack leads to inflammation that destroys myelin and oligodendroglial cells that produce myelin in the CNS. Plaques of sclerotic tissue appear on demyelinated axons, further interrupting the transmission of impulses.

MS may occur at any age but typically manifests in young adults between the ages of 20 and 40; it affects women more frequently than men. Geographic prevalence is highest in northern Europe, New Zealand, southern Australia, the northern United States, and southern Canada. MS is considered to have many risks, including genetic factors. However, it has not been found to be genetically transmitted.

Signs and symptoms: varied and multiple and reflect location of the lesion (plaque) or combination of lesions
Primary symptoms: fatigue, depression, weakness, numbness, difficulty in coordination, loss of balance, and pain
Visual disturbances: blurring of vision, diplopia (double vision), patchy blindness (scotoma), and total blindness
Spastic weakness of the extremities and loss of abdominal reflexes; ataxia and tremor
Cognitive and psychosocial problems; depression, emotional lability, and euphoria
Bladder, bowel, and sexual problems possible

Secondary Manifestations Related to Complications

Urinary tract infections, constipation
Pressure ulcers, contracture deformities, dependent pedal edema
Pneumonia
Reactive depression and osteoporosis
Emotional, social, marital, economic, and vocational problems

Exacerbations and Remissions

Relapses may be associated with periods of emotional and physical stress.

Outline

Secondary Manifestations Related to Complications
Exacerbations and Remissions

MRI (primary diagnostic tool) to visualize plaques
Electrophoresis study of the cerebrospinal fluid (CSF); abnormal immunoglobulin G antibody (oligoclonal banding)
Evoked potential studies and urodynamic studies
Neuropsychological testing as indicated to assess cognitive impairment
Sexual history to identify changes in sexual function

Because no cure exists for MS, the goals of treatment are to delay the progression of the disease, manage chronic symptoms, and treat acute exacerbations. An individualized treatment program is indicated to relieve symptoms and provide support. Management strategies target the various motor and sensory symptoms and the effects of immobility that can occur.

Pharmacologic Therapy

Disease Modification

Interferon beta-1a (Rebif) and interferon beta-1b (Betaseron) are administered subcutaneously. Another preparation of interferon beta-1a, Avonex, is administered intramuscularly once a week.
Glatiramer acetate (Copaxone), to reduce the rate of relapse in the RR course of MS, is administered subcutaneously daily. Teriflunomide (Aubagio), fingolimod (Gilenya), and dimethyl fumarate (Tecfidera) are oral alternatives that may be better tolerated by the patient who has difficulty with injection reactions.
IV methylprednisolone is given to treat acute relapse in the RR course of MS.
Mitoxantrone (Novantrone) is administered via IV infusion every 3 months for patients with secondary progressive or worsening RR MS.

Symptom Management

Baclofen (Lioresal) is the medication of choice for treating spasticity; benzodiazepines (Valium), tizanidine (Zanaflex), and dantrolene (Dantrium) may also be used to treat spasticity.
Amantadine (Symmetrel), pemoline (Cylert), or dalfampridine (Ampyra) can be used to treat fatigue.
Beta-adrenergic blockers (Inderal), anticonvulsant agents (Neurontin), and benzodiazepines (Klonopin) are given to treat ataxia.

Management of Related Bowel and Bladder Problems

Anticholinergic medications, alpha-adrenergic blockers, or antispasmodic agents may be used to treat problems related to elimination, and patients may be taught to perform intermittent self-catheterization as well. Additional measures include assessment of urinary tract infections; ascorbic acid treatment to acidify urine; and antibiotic use when appropriate.

Outline

Pharmacologic Therapy
Management of Related Bowel and Bladder Problems

Gerontologic Considerations

The life expectancy for patients with MS is 5 to 7 years shorter than patients without MS. Those diagnosed with secondary progressive disease live an average of 38 years after onset. Older adult patients with MS have specific physical and psychosocial challenges.

The Patient With MS

Assessment

Assess actual and potential problems associated with the disease: neurologic problems, secondary complications, and impact of disease on patient and family.
Assess patient's function, particularly ambulation, when patient is well rested and when fatigued; look for weakness, spasticity, visual impairment, incontinence, and disorders of swallowing and speech.
Assess how MS has affected the patient's lifestyle, how the patient is coping, and what the patient would like to improve.

Diagnosis

Nursing Diagnoses

Impaired physical mobility related to weakness, muscle paresis, spasticity
Risk for injury related to sensory and visual impairment
Impaired urinary and bowel elimination related to nervous system dysfunction
Impaired verbal communication and risk for aspiration related to cranial nerve involvement
Chronic confusion related to cerebral dysfunction
Ineffective individual coping related to the uncertainty of the disease's progression
Impaired home maintenance management related to physical, psychological, and social limits imposed by MS
Potential for sexual dysfunction related to lesions or psychological reaction

Planning and Goals

The major goals of the patient may include promotion of physical mobility, avoidance of injury, achievement of bladder and bowel continence, promotion of speech and swallowing mechanisms, improvement of cognitive function, development of coping strengths, improved home maintenance management, and adaptation to sexual dysfunction.

Nursing Interventions

Promoting Physical Mobility

Encourage relaxation and coordination exercises to promote muscle efficiency.
Encourage progressive resistance exercises to strengthen weak muscles.
Encourage walking exercises to improve gait.
Apply warm packs to spastic muscles; avoid hot baths due to sensory loss.
Encourage daily exercises for muscle stretching to minimize joint contractures.
Encourage swimming, stationary bicycling, and progressive weight bearing to relieve spasticity in legs.
Avoid hurrying patient in any activity, because hurrying increases spasticity.
Encourage patient to work up to a point just short of fatigue.
Advise patient to take frequent, short rest periods, preferably lying down, to prevent extreme fatigue.
Prevent complications of immobility by assessment and maintenance of skin integrity and through coughing and deep-breathing exercises.

Preventing Injury

Teach patient to walk with feet wide apart to increase walking stability (if motor dysfunction causes lack of coordination).
Teach patient to watch the feet while walking if there is a loss of position sense.
Provide a wheelchair or motorized scooter if gait remains insufficient after gait training (walker, cane, braces, crutches, parallel bars, and physical therapy).
Assess skin for pressure ulcers if patient is confined to wheelchair.

Enhancing Bladder and Bowel Control

Keep bedpan or urinal readily available, because the need to void must be heeded immediately.
Set up a voiding schedule, with gradual lengthening of time intervals.
Instruct patient to drink a measured amount of fluid every 2 hours and to attempt to void 30 minutes after drinking.
Encourage patient to take prescribed medications for bladder spasticity.
Teach intermittent self-catheterization, if necessary.
Provide adequate fluids, dietary fiber, and a bowel training program for bowel problems, including constipation, fecal impaction, and incontinence.

Managing Speech and Swallowing Difficulties

Arrange for evaluation by a speech therapist. Reinforce this instruction and encourage patient and family to adhere to the plan.
Reduce the risk for aspiration by careful feeding, proper positioning for eating, and having a suction apparatus available.

Nutrition

Similar to the population at large, many patients with MS are overweight or have obesity. Contributing factors include the use of corticosteroids for exacerbations of symptoms and mobility impairments as a result of the disease. Interventions to promote healthy eating and weight reduction need to take into account that fatigue and mobility impairments are barriers to engagement in nutritional behaviors for people with MS.

Quality and Safety Nursing Alert

Impaired swallowing increases the patient's risk of aspiration. To reduce that risk, the nurse implements strategies such as having suction apparatus available, ensuring careful feeding, confirming correct food and liquid consistency, and positioning properly for eating.

Improving Sensory and Cognitive Function

Provide an eye patch or eyeglass occluder to block visual impulses of one eye when diplopia (double vision) occurs.
Advise patient about no-cost talking-book services.
Refer patient and family to a speech-language pathologist when mechanisms of speech are involved.
Provide compassion and emotional support to patient and family adapting to a new self-image and coping with a life disruption.
Keep a structured environment; use lists and other memory aids to help patient maintain a daily routine.

Strengthening Coping Mechanisms

Alleviate stress and make referrals for counseling and support to minimize adverse effects of dealing with chronic illness.
Provide information on the illness to patient and family.
Help patient define problems and develop alternatives for management.

Improving Home Management

Suggest modifications that allow independence in self-care activities at home (raised toilet seat, bathing aids, telephone modifications, long-handled comb, tongs, modified clothing).
Maintain moderate environmental temperature; heat increases fatigue and muscle weakness and extreme cold may increase spasticity.

Promoting Sexual Function

Suggest a sexual counselor to assist patient and partner with sexual dysfunction (e.g., erectile and ejaculatory disorders in men; orgasmic dysfunction and adductor spasms of the thigh muscles in women; bladder and bowel incontinence; urinary tract infections).

Promoting Home, Community-Based, and Transitional Care

Educating Patients About Self-Care

Instruct patient and family in the use of assistive devices, self-catheterization, and administration of medications.
Assist patient and family in dealing with new disabilities and changes as disease progresses.

Continuing and Transitional Care

Refer for home health care nursing assistance as indicated.
Assess changes in patient's health status and coping strategies, provide physical care to the patient if required, coordinate outpatient services and resources, and encourage health promotion, appropriate health screenings, and adaptation.
Encourage the patient to contact the primary provider if changes in the disease or its course are noted.
Encourage patient to contact the local chapter of the National Multiple Sclerosis Society for services, publications, and contact with others who have MS.

Evaluation

Expected Patient Outcomes

Reports improved physical mobility
Remains free of injury
Attains or maintains improved bladder and bowel control
Participates in strategies to improve speech and swallowing
Compensates for altered thought processes
Demonstrates improved coping strategies
Adheres to plan for home maintenance management
Adapts to changes in sexual function

For more information, see Chapter 69 in Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth's textbook of medical-surgical nursing (14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Outline

Assessment
Diagnosis
Planning and Goals
Nursing Interventions
Evaluation

section name header

Introduction ⬇

Pathophysiology ⬆ ⬇

Clinical Manifestations ⬆ ⬇

Assessment and Diagnostic Findings ⬆ ⬇

Medical Management ⬆ ⬇

Gerontologic Considerations ⬆ ⬇

Nursing Process ⬆