Multiple sclerosis

Multiple SclerosisMultiple Sclerosis

• Chronic, progressive, degenerativeChronic, progressive, degenerative
disorder of the CNS characterized bydisorder of the CNS characterized by
disseminated demyelination of nervedisseminated demyelination of nerve
fibers of the brain and spinal cordfibers of the brain and spinal cord

• Usually affects young to middle- agedUsually affects young to middle- aged
adults, with onset between 15 and 50adults, with onset between 15 and 50
years of ageyears of age
• Women affected more than menWomen affected more than men

EtiologyEtiology
• Unknown causeUnknown cause
• Related to infectious, immunologic, andRelated to infectious, immunologic, and
genetic factorsgenetic factors

EtiologyEtiology
• Possible precipitating factors includePossible precipitating factors include
 InfectionInfection
 Physical injuryPhysical injury
 Emotional stressEmotional stress
 Excessive fatigueExcessive fatigue
 PregnancyPregnancy
 Poor state of healthPoor state of health

PathophysiologyPathophysiology
• Mylelin sheathMylelin sheath
• Segmented lamination that wrapsSegmented lamination that wraps
axons of many nerve cellsaxons of many nerve cells
• Increases velocity of nerve impulseIncreases velocity of nerve impulse
conduction in the axonsconduction in the axons
• Composed of myelin, a substance withComposed of myelin, a substance with
high lipid contenthigh lipid content

• Characterized by chronic inflammation,Characterized by chronic inflammation,
demyelination, and gliosis (scarring) indemyelination, and gliosis (scarring) in
the CNSthe CNS
• Initially triggered by a virus inInitially triggered by a virus in
genetically susceptible individualsgenetically susceptible individuals
• Subsequent antigen-antibody reactionSubsequent antigen-antibody reaction
leads to demyelination of axonsleads to demyelination of axons

Pathogenesis of MSPathogenesis of MS
Fig. 57-1

• Disease process consists of loss of myelin,Disease process consists of loss of myelin,
disappearance of oligodendrocytes, anddisappearance of oligodendrocytes, and
proliferation of astrocytesproliferation of astrocytes
• Changes result in plaque formation withChanges result in plaque formation with
plaques scattered throughout the CNSplaques scattered throughout the CNS

• Initially the myelin sheaths of theInitially the myelin sheaths of the
neurons in the brain and spinal cord areneurons in the brain and spinal cord are
attacked, but the nerve fiber is notattacked, but the nerve fiber is not
affectedaffected
• Patient may complain of noticeablePatient may complain of noticeable
impairment of functionimpairment of function
• Myelin can regenerate, and symptomsMyelin can regenerate, and symptoms
disappear, resulting in a remissiondisappear, resulting in a remission

Etiology and PathophysiologyEtiology and Pathophysiology
• Myelin can be replaced by glial scarMyelin can be replaced by glial scar
tissuetissue
• Without myelin, nerve impulses slowWithout myelin, nerve impulses slow
downdown
• With destruction of axons, impulses areWith destruction of axons, impulses are
totally blockedtotally blocked
• Results in permanent loss of nerveResults in permanent loss of nerve
functionfunction

Clinical ManifestationsClinical Manifestations
• Vague symptoms occur intermittentlyVague symptoms occur intermittently
over months and yearsover months and years
• MS may not be diagnosed until long afterMS may not be diagnosed until long after
the onset of the first symptomthe onset of the first symptom

• Characterized byCharacterized by
• Chronic, progressive deterioration inChronic, progressive deterioration in
somesome
• Remissions and exacerbations in othersRemissions and exacerbations in others

• Common signs and symptoms includeCommon signs and symptoms include
motor, sensory, cerebellar, and emotionalmotor, sensory, cerebellar, and emotional
problemsproblems

• Motor manifestationsMotor manifestations
• Weakness or paralysis of limbs, trunk,
and head
• Diplopia (double vision)
• Scanning speech
• Spasticity of muscles

• Sensory manifestationsSensory manifestations
• Numbness and tinglingNumbness and tingling
• Blurred visionBlurred vision
• Vertigo and tinnitusVertigo and tinnitus
• Decreased hearingDecreased hearing
• Chronic neuropathic painChronic neuropathic pain

• Cerebellar manifestationsCerebellar manifestations
• NystagmusNystagmus
• Involuntary eye movements
• AtaxiaAtaxia
• DysarthriaDysarthria
• Lack of coordination in articulating
speech
• DysphagiaDysphagia
• Difficulty swallowing

• Emotional manifestationsEmotional manifestations
• AngerAnger
• DepressionDepression
• EuphoriaEuphoria

Other Clinical ManifestationsOther Clinical Manifestations
• Bowel and bladder functionsBowel and bladder functions
• ConstipationConstipation
• Spastic bladder: small capacity forSpastic bladder: small capacity for
urine results in incontinenceFlaccidurine results in incontinenceFlaccid
bladder: large capacity for urine andbladder: large capacity for urine and
no sensation to urinateno sensation to urinate

Other Clinical ManifestationsOther Clinical Manifestations
• Sexual dysfunctionSexual dysfunction
 Erectile dysfunctionErectile dysfunction
 Decreased libidoDecreased libido
 Difficulty with orgasmic responseDifficulty with orgasmic response
 Painful intercoursePainful intercourse
 Decreased lubricationDecreased lubrication

Diagnostic StudiesDiagnostic Studies
• Based primarily on history, clinicalBased primarily on history, clinical
manifestations, and presence of multiplemanifestations, and presence of multiple
lesions over time measured by MRIlesions over time measured by MRI
• Certain laboratory tests are used asCertain laboratory tests are used as
adjuncts to clinical examadjuncts to clinical exam

Diagnostic StudiesDiagnostic Studies
• Diagnosis based primarily on:Diagnosis based primarily on:
• history and clinical manifestationshistory and clinical manifestations
• ruling out other causes of symptomsruling out other causes of symptoms
• No definitive diagnostic testNo definitive diagnostic test
• MRI – demonstrates presence of plaquesMRI – demonstrates presence of plaques

Collaborative CareCollaborative Care
Drug TherapyDrug Therapy
• CorticosteroidsCorticosteroids
• Treat acute exacerbations by reducing
edema and inflammation at the site of
demyelination
• Do not affect the ultimate outcome or
degree of residual neurologic impairment
from exacerbation

• Immunosuppressive Therapy
• Because MS is considered an autoimmune
disease
• Potential benefits counterbalanced against
potentially serious side effects

• Antispasmotics (muscle relaxants)

• Physical therapy helpsPhysical therapy helps
 Relieve spasticityRelieve spasticity
 Increase coordinationIncrease coordination
 Train the patient to substituteTrain the patient to substitute
unaffected muscles for impaired onesunaffected muscles for impaired ones

• Nutritional therapy includesNutritional therapy includes
megavitamins and diets consisting of low-megavitamins and diets consisting of low-
fat, gluten-free food, and raw vegetablesfat, gluten-free food, and raw vegetables
• High-protein diet with supplementaryHigh-protein diet with supplementary
vitamins is often prescribedvitamins is often prescribed

Nursing AssessmentNursing Assessment
• Health HistoryHealth History
 Risk factorsRisk factors
 Precipitation factorsPrecipitation factors
 Clinical manifestationsClinical manifestations

Nursing DiagnosesNursing Diagnoses
• Impaired physical mobilityImpaired physical mobility
• Dressing/grooming self-care deficitDressing/grooming self-care deficit
• Risk for impaired skin integrityRisk for impaired skin integrity
• Impaired urinary elimination patternImpaired urinary elimination pattern
• Sexual dysfunctionSexual dysfunction
• Interrupted family processesInterrupted family processes

Nursing PlanningNursing Planning
• Maximize neuromuscular functionMaximize neuromuscular function
• Maintain independence in activities ofMaintain independence in activities of
daily living for as long as possibledaily living for as long as possible
• Optimize psychosocial well-beingOptimize psychosocial well-being
• Adjust to the illnessAdjust to the illness
• Reduce factors that precipitateReduce factors that precipitate
exacerbationsexacerbations

Nursing ImplementationNursing Implementation
• Help identify triggers and develop waysHelp identify triggers and develop ways
to avoid them or minimize their effectsto avoid them or minimize their effects
• Reassure patient during diagnostic phaseReassure patient during diagnostic phase
• Assist in dealing with anxiety caused byAssist in dealing with anxiety caused by
diagnosisdiagnosis
• Prevent major complications ofPrevent major complications of
immobilityimmobility

• Focus teaching on building generalFocus teaching on building general
resistance to illnessresistance to illness
Avoiding fatigue, extremes of hot and
cold, exposure to infection
• Teach good balance of exercise and rest,Teach good balance of exercise and rest,
nutrition, avoidance of hazards ofnutrition, avoidance of hazards of
immobilityimmobility

• Teach self-catheterization if necessaryTeach self-catheterization if necessary
• Teach adequate intake of fiber to aid inTeach adequate intake of fiber to aid in
regular bowel habitsregular bowel habits

Multiple sclerosis

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