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Nursing Care and Pathophysiology for Multiple Sclerosis (MS)

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Pathophysiology: This occurs when there has been an insult to the nervous system caused by a previous virus in a person that is genetically at risk of an abnormal response by the immune system. Irreversible damage to the tissue occurs by the body. There is inflammation and demyelination throughout the central nervous system that progress. There are changes to the gray matter of the brain including loss. Brain atrophy occurs and progresses. And damage to the myelin.

Overview

  1. Chronic, progressive demyelination of the neurons in the CNS 
  2. Memory Aid: Multiple Sclerosis → Myelin Sheath

Nursing Points

General

  1. Remission and exacerbation     
  2. Primarily ages 20-40 years old
  3. Cause Unknown

Assessment

  1. Fatigue
  2. Tremors
  3. Weakness
  4. Spasticity of muscles
    1. Can be painful
  5. Bowel and Bladder dysfunction
    1. Incontinence
    2. Diarrhea or Constipation
  6. Decrease peripheral sensation (pain, temperature, touch)
    1. High risk for injury
  7. Visual disturbances
  8. Emotional instability

Therapeutic Management

  1. No cure – supportive therapy
    1. Analgesics
    2. Muscle relaxants
  2. Energy conservation
  3. Provide bowel and bladder training
  4. Maintain adequate fluid intake 2000 mL/day
  5. Encourage activity independence
  6. Regulate temperatures on water heaters, baths, and heating pads
    1. Risk for burns
  7. Ensure in home safety (rugs, cords, etc)
    1. Risk for falls

Nursing Concepts

  1. Safety
  2. Comfort
  3. Coping

Patient Education

  1. Coping strategies
  2. Cluster activities, provide periods for rest
  3. Importance of fluid intake
  4. Bowel and bladder training
  5. Check temperature of water

Reference Links

Study Tools

Video Transcript

Let’s talk about Multiple Sclerosis. This is something you’ll definitely see in your time in nursing school and for sure when you’re working.

Multiple sclerosis or MS is a chronic, progressive disease that causes demyelination of the neurons. If you remember from the anatomy lesson, the axons of the neurons are surrounded by this myelin sheath. The purpose is to make the nerve impulses travel smoother and faster. With demyelination, the axon is exposed and we lose that myelin sheath – we’ll look closer at that in just a second. A key point about MS is that it is cyclical, it has periods of remission and exacerbation. Sometimes they’ll feel great and others they won’t be able to get out of bed. It primarily begins between the ages of 20 and 40 and the cause is entirely unknown at this point.

So again remember that the axons are covered with this myelin sheath that helps the impulse to travel smoother and faster down the length of the neuron. In demyelination, that myelin sheath degrades and the axon is exposed. So…logically speaking, since the myelin sheath makes impulses travel smoother and faster…if we lose that myelin sheath and the axon is exposed, we’re going to get impulse transmission that is neither smooth, nor fast. And MS affects both sensory (or afferent) and motor (or efferent) neurons. So you have jumpy or spastic nerve impulses and/or super slow or lost nerve impulses. Pause the video if you want to brainstorm what this looks like in a patient before we talk about it.

So let’s see practically what this looks like in a patient. Remember there’s sensorimotor spasticity and slowness. So they’re very weak and fatigued. We will see tremors and spastic muscle movements – again that’s the jumpy, spasticity of the nerve impulses. We’ll also see bowel and bladder dysfunction as a result of that loss of nerve impulses. They can have incontinence of both, but could also get constipation because the gut has slowed way down. They will also have a significant sensory loss peripherally. Their ability to sense pain or temperatures is dramatically decreased which can lead to a multitude of other problems. Because of the effects on the neurons in the brain and central nervous system, we could also see visual disturbances and emotional instability. So already you can imagine that this is not a pleasant disease to live with. Many people are able to live with it for years while others don’t last as long because their bodies can’t handle the stress of it.

There is no cure for MS, so most of what we do is supportive therapy. We can give analgesics and muscle relaxers as needed, but there are behaviors we can encourage in the patient that will help them cope with their condition. We encourage them to conserve energy by clustering their activities and providing time for rest. We will encourage independence as long as possible – many of these patients will lose their independence as the disease progresses. We will help them with bowel and bladder training where they plan to go to the bathroom at certain times to avoid accidents. Then, we want to encourage adequate fluid intake. Many of these patients will stop drinking so much because of their bladder incontinence – they think if they drink more they will have more accidents. But then they end up getting super constipated and dehydrated – so if we can encourage that bladder training, they can keep their fluid intake up as well. Now these last two are extremely important because they deal with safety. It’s important to regulate temperatures on water heaters in the home – you can actually set the max temperature to be lower. Remember these patients can’t really feel pain or temperature well, they could sustain severe burns from hot water because they couldn’t tell it was hot. So they should have someone check temps for them or turn their water heater down. Then because they have decreased sensation and slowed motor response, they’re at high risk for falls. So we make sure we secure rugs, move cords and cables, etc. to prevent falls.

The priority nursing concepts for a patient with MS are safety, comfort, and coping. Of course we can’t do much about what’s going on with the patient’s nerves, but we can keep them safe from injury, keep them comfortable and independent, and help them find coping strategies to manage their disease. Check out the care plan attached to this lesson for more details.

I loved this quote and I think it sums up life with MS so well. “MS can be an overwhelming challenge. One day you can feel strong and resilient, but the next day you can feel helpless and isolated.” This is very frustrating for the patient and we can play a huge role in making this even a little easier for them.

So remember that MS is progressive and cyclical with periods of remission and exacerbation. The nerves are demyelinated which causes spastic and slow nerve impulse transmission, both motor and sensory. So we wee sensorimotor loss – tremors, weakness, decreased pain sensation, bowel and bladder dysfunction, etc. We need to encourage independence and help patients learn how to cope with their disease. Many people live with MS for decades and have a great life. We can encourage our patients to do the same.

Now, go out and be your best selves today. And, as always, happy nursing!

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