11/22/2012

Multiple Sclerosis by Marlene Overton

Multiple Sclerosis
Chronic autoimmune disease Affects the myelin sheath and conduction pathway of the CNS The leading cause of neurologic disability in young adults Characterized by remissions and exacerbations Patients progress at different rates Normal life expectancy as long as effects are treated

Multiple Sclerosis
Usually occurs between 20 & 40 years of age. Women affected 2-3x more than men More prevalent in colder climates of North America and Europe, Canada Whites more affected than Hispanics, Blacks, or Asians

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Etiology
Exact cause unknown Research findings suggest an immunogeneticviral disease May be triggered by viral infection Viruses well recognized as causes of demyelination and inflammation Genetic susceptibility alters the bodys immune response to the viral infection MS tends to occur among family members; especially siblings

Pathophysiology
Myelin: a highly conductive fatty material that surrounds the axon and speeds conduction of nerve impulses along the axon Both autoimmune and infectious agents are implicated in the pathogenesis of MS Activated T-cells and macrophages enter brain and begin the inflammatory process Plaques form along myelin sheath cause scarring and distruction of the myelin sheath

Pathophysiology
An inflammatory response results in patchy areas of plaque in the white matter of CNS The results is the myelin sheath is damaged & its thickness is reduced: aka demyelinated Impulses are still transmitted but not as effective as before over time they may become blocked completely

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4 Major Types of MS
Relapsing-remitting RRMS Primary progressive PPMS Secondary progressive SPMS Progressive-remitting - PRMS

Relapsing-remitting (RRMS)
Symptoms develop and resolve in a few weeks to months, Patient then returns to baseline Approximately 85% of people are intially diagnosed with this type of multiple sclerosis (MS) About 50% of these patients progress to Secondary progressive course and stop having remissions

Primary progressive
Involves a steady and gradual neurologic deterioration without remission of symptoms Progressive disability with no acute attacks Patients tend to be between 40-60 yrs of age at onset

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Secondary progressive
Begins as a relapsing-remitting course that later becomes steadily progressive Functioning continues to decline with no clear times of remission

Progressive-relapsing
Characterized by frequent relapses with some partial recovery but not a return to baseline Progressive, cumulative symptoms and deterioration occur over several years

Assessment/Clinical Manifestations
A wide variety of manifestations are possible The unpredictable nature of MS poses many challenges for patients and families Course of illness varies from patient to patient Often looks like other neurological diseases & makes diagnosis difficult & prolonged Major patient concern: the time it takes to make a diagnosis

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Assessment/Clinical Manifestations
Random distribution of MS plaques leads to: Weakness or tingling sensations of one or more extremities caused by involvement of the cerebrum or spinal cord Vision loss from optic neuritis Incoordination that is due to cerebellar involvement Bowel and bladder dysfunction as a result of spinal cord involvement

Assessment/Clinical Manifestations
Fatigue and stiffness of extremities:
Efficiency of demyelinated nerves deteriorates with use Assess pts ability to move particularly the legs Fatigue is most disabling manifestation Often associated with continuous sensitivity to temperature Easily induced by a short walk

Assessment/Clinical Manifestations
Flexor spasms/ataxia Spasms may awaken patient from sleep Due to: hyperactive deep tendon reflexes Gait may be unsteady leg weakness & spasticity Risk for falls and injury increased

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Assessment/Clinical Manifestations
Cerebellar involvement findings: Intention tremor (tremor when performing an activity) Dysmetria (inability to direct or limit activity) Motor movements are often clumsy Patients may lose balance easily Patients may exhibit signs of poor coordination

Assessment/Clinical Manifestations
Cranial nerves & brainstem involvement: Tinnitus (ringing in the ears) Vertigo (dizziness) Hearing loss Assess for facial weakness and dysphagia Speech: dysarthia (slurred speech) & slow, scanning speech

Assessment/Clinical Manifestations
Visual involvement: Blurred vision Diplopia (double vision) Decreased visual acuity Scotomas (changes in peripheral vision) Nystagmus ( involuntary, rapid eye movements)

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Assessment/Clinical Manifestations
Bladder dysfunctions: May have areflexic bladder May experience frequency, urgency, or nocturia Bowel: May have constipation or incontinence Sexuality: May experience various sexual problems

Assessment/Clinical Manifestations
Psychosocial: Depression is common may be partly due to young adult onset Euphoria Emotional instability Apathy

Triggers that may exacerbate symptoms.

Infection, especially URI and UTI Trauma Immunization Emotional stress Excessive physical exertion Change in climate Fatigue Extreme heat (hot baths, fever)

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Diagnosis
CT scan: may show inc. density in white matter & MS plaques MRI: demonstrates presence of plaques and is considered diagnostic for MS CSF: elevated protein level & inc. WBC CSF electrophoresis: inc. myelin basic protein and presence of oligoclonal (IgG0 bands) IgG bands: seen in most patients with MS By exclusion of other neurologic diseases

Nursing Diagnoses
Fatigue related to disease state Disturbed visual perception related to altered sensory reception Impaired physical mobility related to neuromuscular impairment Impaired urinary elimination related to sensorymotor impairment Imbalanced nutrition: less than body requirements related to difficulty swallowing

Medical Management Drug therapy covered in pharmacology TENS transcutaneous electrical nerve stimulation: helpful for dysesthesias

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Nursing Management
Thorough assessments Plan an exercise program: ROM and stretching exercises Teach to avoid rigorous activities Speech therapy: for evaluation & treatment dysarthria or dysphagia Swallowing evaluations Provide periods of rest

Nursing Management
Bladder: Self-catheterization program Indwelling catheter Insertion of bladder pacemaker: patient activates it and bladder is stimulated; patient voids Patient at risk for UTIs

Nursing Management
Focus on ADLs and maintaining independence Evaluate home for safety: remove clutter, rugs, etc Teach patient to recognize & to avoid stressors Teach importance of medication management Make appropriate referrals