38 Multiple sclerosis
Overview/pathophysiology
The course of MS is highly variable, with several general categories of progression. Motor or coordination symptoms from onset and/or frequent attacks during the first 2 yr of the disease usually indicate a poor outlook. In the benign form of MS (10% of patients), attacks are few and mild. Complete or nearly complete clearing of symptoms occurs with little or no disability. At least initially, most patients (70%-80%) have the relapsing-remitting form characterized by episodes of neurologic impairment (“attacks,” exacerbations), followed by complete or nearly complete recovery and stability with no disease progression (remission). Typically, an increasing number of symptoms occur with each exacerbation, with less complete clearing of symptoms and with deficits becoming cumulative. Over time, the relapsing-remitting form usually transitions to the secondary progressive form in which neurologic impairment progresses continuously with or without superimposed relapses. A small portion of patients (10%-20%) initially begin with the primary progressive form, characterized by gradual ongoing accumulation of symptoms and deficits, with absence of clear-cut exacerbations and remissions. The progressive relapsing form (5%) is characterized by a progressive disease course from onset, with clear acute exacerbations. Progression continues during the periods between disease exacerbations. In the most severe cases of acute MS, significant disability may occur in weeks or months.
Health care setting
Primary care or long-term care, with possible hospitalization resulting from complications
Assessment
Damage to motor and sensory control centers:
Urinary frequency, urgency, or retention; urinary and fecal incontinence; constipation.
Diagnostic tests
Electroencephalogram:
Shows abnormal slowing in one third of patients with MS because of altered nerve conduction.
Positron emission tomography:
Nursing diagnosis:
Chronic pain (and spasms)
related to motor and sensory nerve tract damage
Desired Outcomes: Within 1-2 hr of intervention, patient’s subjective evaluation of pain and spasms improves, as documented by pain scale. Objective indicators, such as grimacing, are absent or reduced.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Maintain a comfortable room temperature. Advise patient to keep environment cool in warm weather and avoid hot baths or showers. | Heat tends to aggravate MS symptoms. |
| Provide passive, assisted, or active range of motion q2h and periodic stretching exercises. Teach these exercises to patient and significant other, and encourage their performance several times daily. Explain that sleeping in a prone position may help decrease flexor spasm of the hips and knees and that splints or cones for hands with elastic bands may help control hand spasms. | These interventions reduce muscle tightness and spasms, maintain joint function, and prevent contractures. Physical therapy (PT), occupational therapy (OT), and assistive devices or braces may be prescribed to maintain mobility and independence with activities of daily living (ADLs). Placing weights on the affected limbs may help with mild tremors. |
| Administer antispasmodics as prescribed. | See discussion of baclofen and dantrolene, earlier. |
| Administer tranquilizers (e.g., diazepam) as prescribed. | These medications may be given for both their anxiety-reducing and muscle relaxant effects, which may help spasms and tremors. |
| Administer analgesics (e.g., acetaminophen) and neuropathic pain medications as prescribed. | Neuropathic pain medications include anticonvulsants such as carbamazepine, gabapentin, topiramate, lamotrigine (see “Seizures and Epilepsy,” p. 302, for side effects/precautions), and tricyclic antidepressants (e.g., amitriptyline or imipramine). Uncontrolled pain may require nerve blocks or surgical intervention. |
| For other interventions, see “General Care of Patients with Neurologic Disorders,” Acute Pain, p. 248. |
Nursing diagnosis:
Deficient knowledge
related to unfamiliarity with factors that aggravate and exacerbate MS symptoms
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess patient’s health care literacy (language, reading, comprehension). Assess culture and culturally specific information needs. Determine patient’s knowledge base about MS. | This assessment helps ensure that materials are selected and presented in a manner that is culturally and educationally appropriate. |
| Teach patient and significant other to avoid heat, both external (hot weather, bath) and internal (fever). | Heat tends to aggravate weakness, pain, and other symptoms of MS. |
| Teach preventive measures, such as avoiding hot baths or showers and using acetaminophen or aspirin to reduce fever, if present. | Coolants and antipyretics aid in reducing body temperature. |
| Also instruct patient in use of fans or air conditioning, chilled drinks, cool showers, and cool cloths. | High humidity with heat is especially problematic. |
| Caution patient to avoid exposure to persons known to have infections of any kind. | Infection often precedes exacerbations. Patients should receive immunizations and instructions in importance of and proper technique for hand washing and hand antisepsis. |
| Teach indicators of common infections and importance of seeking prompt medical treatment in case they occur. Instruct patient to check body temperature periodically for fever and indications that a urinary tract infection (UTI) has reached the kidneys (e.g., costovertebral angle tenderness, chills, flank pain). In addition, teach patient to monitor for increased frequency, urgency, or incontinence and to check urine for changes in odor or presence of cloudiness or blood. | A person with MS is especially susceptible to UTI because of urinary retention. Because of the disease process, patients may not feel any pain with urination and therefore need to be alert to other signs of UTI. See “Care of the Renal Transplant Recipient,” pp. 216-217, for a discussion of common infections. |
| Teach relationship between stress and fatigue to the exacerbations. Encourage patient to reduce factors that cause stress. Encourage use of stress reduction techniques such as progressive relaxation, self-coaching, and guided imagery. | Avoiding stress and fatigue may prevent exacerbations. |
| If patient is depressed, suggest that he or she discuss use of antidepressants (e.g., amitriptyline, fluoxetine, sertraline) with health care provider. | Depression caused by cerebral lesions can contribute to sense of fatigue. These antidepressants may be given for both their anxiety-reducing and muscle relaxant effects, which may help with spasms and tremors. |
| Encourage patient to get sufficient rest, stop activity short of fatigue, schedule activity and rest periods, and conserve energy in ADLs. | Patient can conserve energy during ADLs by sitting while getting dressed, rather than standing; sliding heavy objects along work surfaces, rather than lifting them; using a wheeled cart to transport items; having work surfaces at the proper height; and using assistive devices and delegating. |
| Suggest that patient ask health care provider about antifatigue medications. | Antifatigue drugs (e.g., amantadine, fluoxetine, modafinil) relieve fatigue associated with MS. See “Parkinsonism,” p. 292, for side effects and precautions when using amantadine. Fatigue is the most common complaint and does not correlate with level of disability. |
| Encourage patient to plan each day, break projects into smaller tasks, distribute tasks throughout the day, rest before difficult tasks, take planned recovery time after tasks, identify priorities, and eliminate nonessential activities. | Conserving energy and decreasing fatigue are effective strategies for decreasing exacerbations. |
| Provide information about birth control measures to female patients who desire counseling. | There may be a decreased relapse rate during pregnancy but increased exacerbations postpartum. Those planning a pregnancy should consult and work with their health care providers before pregnancy. |
| As appropriate, reassure patient and significant other that most persons with MS do not become severely disabled. | Optic neuritis is common with damage to sensory nerve tracts and can be particularly frightening, but usually remits. Blindness occurs rarely. |
| Encourage continued activity and normal lifestyle even when limitations are necessary. | Deconditioning can be reduced with a planned exercise program that can be incorporated into a scheduled activity/rest plan. |
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