MULTIPLE SCLEROSIS

• Chronic, progressive, degenerative disorder of the central nervous system (CNS)

• Characterized by disseminated demyelination of nerve fibers of the brain and spinal cord

WHO

• Disease usually affects young to middle-aged adults

• Onset between 15 and 50 years of age

• Women are affected more than men

ETIOLOGY AND PATHOPHYSIOLOGY

• Cause is unknown

• Related to infectious, immunologic, and genetic factors

• Multiple genes confer susceptibility to multiple sclerosis (MS)

• Possibility that the association between pathogenetic agents and MS is random and there is no
cause-and-effect relationship

• Possible precipitating factors include

o Infection o Excessive fatigue

o Physical injury o Pregnancy

o Emotional stress o Poor state of health

• Characterized by chronic inflammation, demyelination, and gliosis(scarring) in the CNS

• An autoimmune disease orchestrated by autoreactive T cells

• Initially triggered by a virus in genetically susceptible individuals

• Activated T cells migrate to CNS causing blood-brain disruption

• Subsequent antigen-antibody reaction leads to demyelination of axons

• Disease process consists of

o Loss of myelin

o Disappearance of oligodendrocytes

o Proliferation of astrocytes

• Changes result in plaque formation

o Plaques scattered throughout the CNS

• Initially the myelin sheaths of the neurons in the brain and spinal cord are attacked, but the nerve fiber is not
affected

• Patient may complain of noticeable impairment of function

• Myelin can regenerate, and symptoms disappear, resulting in a remission

• Myelin can be replaced by scar tissue

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 • Nerve impulses slow down without myelin

• With destruction of axons, impulses are totally blocked

• Results in permanent loss of nerve function

CLINICAL MANIFESTATIONS

• Vague symptoms occur intermittently over months and years

• Disease may not be diagnosed until long after the onset of the first symptom

• Characterized by

o Chronic, progressive deterioration in some

o Remissions and exacerbations in others

• Types:

o Relapsing-remitting

o Primary-progressive

o Secondary-progressive

o Progression-relapsing

• Common signs and symptoms include

o Motor problems

 Weakness or paralysis of limbs, trunk, and head

 Diplopia-double vision

 Scanning speech-pronouce words in syllables, or slowly hesitating

 Spasticity of muscles

o Sensory problems

 Numbness and tingling

 Blurred vision

 Vertigo and tinnitus

 ↓ Hearing

 Chronic neuropathic pain

o Cerebellar problems

 Nystagmus-involuntary eye mvmnt

 Ataxia-failure or irregularity of muscle coordination when voluntary movement is attempted

 Dysarthria-difficult speech d/t muscle impairment of tongue or other muscles for speech

 Dysphagia-difficulty swallowing

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 o Emotional problems

 Anger

 Depression

 Euphoria

o Bowel and bladder functions may be impaired

 Constipation

 Spastic bladder

 Small capacity for urine results in incontinence

 Flaccid bladder

 Large capacity for urine and no sensation to urinate

o Sexual dysfunction can occur in MS

 Erectile dysfunction

 Decreased libido

 Difficulty with orgasmic response

 Painful intercourse

 Decreased lubrication

DIAGNOSTIC

1. Based primarily on history, clinical manifestations, and presence of multiple lesions over time measured by MRI

2. Certain laboratory tests are used as adjuncts to clinical examination

3. Cerebral spinal fluid (CSF) analysis

a. ↑ In oligoclonal immunoglobulin G

b. Contains a higher number of lymphocytes and monocytes

4. Evoked responses are often delayed because of ↓ nerve conduction from the eye and ear to the brain

5. Magnetic resonance spectroscopy may also be used to evaluate patients with MS

DRUG THERAPY

• Corticosteroids

o Treat acute exacerbations by reducing edema and inflammation at the site of demyelination

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 o Do not affect the ultimate outcome or degree of residual neurologic impairment from exacerbation

• Beneficial effects in patients with progressive-relapsing, secondary- progressive, and primary-progressive Multiple
Sclerosis

• Potential benefits counterbalanced against potentially serious side effects

• Azathioprine, methotrexate, cyclophosphamide

COLLABORATIVE CARE: Immunomodulators

• Interferon β-1b (Betaseron)

• Interferon β-1a (Avonex, Rebif)

• Glatiramer (Copaxone)

• Mitoxaantrone (Novantrone)

• Other drugs therapy

o Antispasmodics: spasticity

o CNS stimulants: fatigue

o Anticholinergics: bladder symptoms

o Tricyclic antidepressants and antiseizure drugs: chronic pain

COLLABORATIVE CARE

• Tremors or spasticity that is uncontrolled or unmanageable

o Surgery: neurectomy, rhizotomy( nerve root), cordotomy-cut lateral pathways

o Dorsal-column electrical stimulation

o Intrathecal baclofen pump

• Physical therapy

o Relieve spasticity

o Improve coordination

o Train patient to substitute unaffected muscles for impaired muscles

o Exercise, water training

• Nutritional Therapy

o Include megavitamins and diets consisting of low-fat, gluten-free food and raw vegetables

o High-protein diet with supplementary vitamins is often prescribed

NURSING ASSESSMENT: SUBJECTIVE DATA

• Health history

o Viral infections or vaccinations o Residence in cold or temperate climates

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 o Physical and emotional stress o Elimination problems

o Medications o Weight loss, dysphagia

o Muscle weakness or fatigue, tingling or numbness, muscle spasms

o Blurred or lost vision, diplopia, vertigo, tinnitus

o Decreased libido, impotence

o Anger, depression, euphoria, isolation

NURSING ASSESSMENT: OBJECTIVE DATA

• Apathy, inattentiveness • Ataxia • Paresis

• Pressure ulcers • Spasticity • Paralysis

• Scanning speech • Hyperreflexia • Foot dragging

• Tremor • ↓ Hearing • Dysarthria

• Nystagmus • Muscular weakness

NURSING DIAGNOSIS

• Impaired physical mobility

• Dressing/grooming self-care deficit

• Risk for impaired skin integrity

• Impaired urinary elimination pattern

• Sexual dysfunction

• Interrupted family processes

PLANNING: OVERALL GOALS

• Maximize neuromuscular function

• Maintain independence in activities of daily living for as long as possible

• Optimize psychosocial well-being

• Adjust to the illness

• Decrease factors that precipitate exacerbations

NURSING IMPLEMENTATION

• Help patient identify triggers and develop ways to avoid them or minimize their effects

• Reassure patient during diagnostic phase

• Assist patient in dealing with anxiety caused by diagnosis

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 • Prevent major complications of immobility

• Focus teaching on building general resistance to illness

• Avoiding fatigue, extremes of hot and cold, exposure to infection

PATIENT TEACHING

• Good balance of exercise and rest • Self-catheterization if necessary

• Nutrition • Adequate intake of fiber to aid in regular bowel

habits
• Avoiding the hazards of immobility

CASE STUDY

• Mary Smith is a 40 year old female with hx of MS x 10 years. Ms. Smith has had a three day history of productive
cough and fever. She uses a cane when walking and is having increased difficulty maintain balance when walking.
She seems disinterested when you speak to her. Her admitting dx is r/o pneumonia.

• Functional Health Patterns

o Nutrition

o Elimination

o Activity

o Cognitive-perceptual

o Sexuality

o Coping-stress tolerance

• Systems

o General affect

o Skin

o Neurologic

o M/S

o Respiratory

o Cardiovascular/Peripheral Vascular

• Impaired Physical Mobility r/t muscle weakness, paralysis or spasticity

• Impaired urinary elimination pattern r/t sensorimotor deficits

• Sexual Dysfunction r/t neuromuscular deficits

• Impaired skin integrity r/t effects of pressure and sensorimotor dysfunction

• Ineffective airway clearance r/t immobility, stasis of secretions and ineffective cough