Multiple Sclerosis: Pathophysiology, Treatment and Procedures

Multiple Sclerosis

 Multiple Sclerosis (MS) is an autoimmune disorder that affects the central nervous system. This disease results in dysfunction of the voluntary muscles.  The exact etiology of MS is unknown.

 Multiple Sclerosis is characterized by relapses and exacerbation periods. It usually does not adversely affect the life expectancy. However, the patient can eventually become quadriplegic as a result of this disease. MS is one of the most common causes of disability among adults in the United States. There is currently no cure for MS.

Pathophysiology

 MS causes axonal injury and demyelination through an inflammatory process. As the myelin is destroyed, patches of scarring develop in the white matter of the CNS. These patches are known as ‘plaques’. MS normally affects the neurons in the spinal cord and brain (Ignatavicius, 2016).

Since the myelin are responsible for transmitting messages, the plaques can disort or delay impulse transmissions between the CNS and the body. During the initial phase of MS, remyelination can occur. However, new lesions can also develop, which eventually cause neuronal injury and atrophy. Damage becomes permanent after multiple exacerbation periods. As the extent of damage expands, the patient loses voluntary muscle function, which leads to quadriplegia (Ignatavicius, 2016).

Risk Factors

 MS chiefly affects people between the ages of 20 and 40. It also affects women twice as often as men. The specific etiology of MS is unknown. In many cases, there is a family history of MS, most often in a first degree relative.

 Though the cause is unknown, the disease is thought to be an autoimmune response or viral infection. Factors that trigger relapses include viruses and infectious agents, physical injuries, emotional stress, pregnancy, and overexertion. MS also occurs most commonly among whites, but can affect people of all races (Ignatavicius, 2016).

Clinical Manifestations

Since the clinical manifestations of MS are variable, it can sometimes be difficult to relate them to the disease process, and ultimately leads to a delayed diagnostic period.  The clinical symptoms may result from involvement of sensory, motor, visual, and brainstem pathways (Garg & Smith, 2015). It is important for the healthcare team to gather as much information on the patient’s noticeable changes in order to make a diagnosis as soon as possible.

One of the most common clinical findings of MS is fatigue and weakness, especially of the lower extremities. Other findings may include pain or paresthesia, vision changes, vertigo, dysphagia, and generalized muscle weakness. Bladder and bowel changes can also be a manifestation.

Complications

 The biggest complication of MS is paralysis, which can progress to quadriplegia. This complication itself leads to many other complications including impaired skin integrity, and decreased activity tolerance. Decreased sensation from myelin damage can also lead to bladder and bowel issues, such as incontinence and UTIs. It is important for the patient to be mindful of these complications, so they can be proactive and stop serious issues arising from these.

 Speech changes and dysphagia are both common complications of MS. This complication can lead to more serious things, such as choking or decreased nutritional intake. Speech therapy is a good resource for MS patients to aid in management of this complication (Henry, et al., 2016).

Cognitive changes are also seen in patients with MS. This complication can manifest as confusion, or even just irritability. The patient’s cognitive status should be monitored regularly. The caretakers and healthcare team should have an interventional plan to promote cognitive function. This plan should include keeping the patient in a routine, and reorienting the patient when needed (Henry, et al., 2016).

Standards of Practice

Medical Management

 Since there is not an established cure for MS, medical management can be complicated. It normally revolves around caring for the patient’s specific complications. Lessening the affects of the usual complications is a focal point for care. This can be a crucial part of long term care of the patient.

It is important that the patient is aware of exacerbation triggers and knows how to avoid them. For example, exercise and stretching is important to maintain muscle function. But, overexertion and overheating can lead to relapses. Physical therapy and occupational therapy consults should be initiated for home environment assessment. These professionals can help the patient ease into changes in mobility and promote independence as the disease progresses (Henry, et al., 2016).

Pharmacological Treatment

Pharmacological treatment varies and depends on the phase of the disease. Treatment may include corticosteroids, antispasmodics, anticonvulsants, stool softeners, anticholinergics, beta-blockers, and immunosuppressive agents (Henry, et al., 2016). Some of these medications are used to target and delay the disease process, while other are used to treat the complications caused by the disease.

Corticosteroids, such as prednisone, reduce inflammation during relapses. Dantrolene, tizanidine, baclofen, and diazepam are antispasmodics which are used to treat muscle spasticity. Anticonvulsants, such as Carbamazepine, are used for paresthesia. Beta-blockers, such as Primidone and clonazepam, are used to help control tremors (Henry, et al., 2016).

A few medications are used to promote normal elimination patterns. Docusate sodium is a stool softener used for constipation. Propantheline is used for bladder dysfunction.  Regular elimination is an important part of management of MS (Henry, et al., 2016).

The most significant progress has been the development of immunomodulatory therapies (IMTs). Interferon beta is a common medication used from the immunomodulator class. These medications help alter the course of the disease, and are also used to treat acute relapse. However, they also produce nasty side effects, including flu-like symptoms, elevated liver enzymes, and depression (Garg & Smith, 2018).

Laboratory Data and Diagnostic Procedures

  There is no single laboratory test or diagnostic procedure that is a definite diagnostic tool for MS. Collective results of multiple test or diagnostic tools can work together to diagnose MS. Abnormal CSF findings, including elevated protein levels and elevated white blood cell counts.

Most patients with MS have noticeable IgG bands in their CSF fluid as well (Ignatavicius, 2016).

 According to Kamm, Uitdehaag, & Polman (2014), “The diagnosis of MS is based on the demonstration of MS-typical CNS lesions disseminated in space (DIS) and time (DIT) based upon clinical findings alone or a combination of clinical and MRI findings”. MRI studies will show plaques on the brain and spine. This is the most diagnostic evidence, but is used comparatively with CSF lab test.

Nutritional Considerations

Nutritional considerations for the patient with MS can change as the disease progresses. One important nutritional change should be an increase of fluid intake.  The patient should also eat a balanced diet, as described below.

The patient’s diet should be low-fat, high-fiber foods. The should also increase their intake of dietary potassium (Silverstri, 2014). The patient’s nutritional status should be assessed and monitored regularly, and modified as needed. It is important for the patient’s intake to meet the metabolic needs.

Standards of Care

Priority Nursing Actions

 Priority nursing actions for the treatment of MS include monitoring the complications, and informing the patient and family about what they should be expecting as the disease progresses. Nursing actions should focus on patient safety, since that is the priority.

The nurse should monitor cognitive changes and plan interventions to promote cognitive functions (Henry, et al., 2016). Another important nursing action is to promote energy conservation. This is especially important because overexertion and exhaustion can lead to exacerbation on the disease. Maintaining safe hospital and home environment is very important to reducing the risk of injury.

Client Education

Client education is very important for these patients, since they will be going through many changes as their disease progresses. This education should focus on patient safety and injury prevention. The client and family member will need to be educated on medications, safety considerations, and nutritional changes.

Instruct the client to avoid fatigue and stress as much as possible. This can be done by balancing moderate activity with rest periods. The client should be instructed about nutritional changes and considerations, as described above. The client and family should also be instructed about sensory changes that will take place. The client should use a thermometer to check the temperature of bath water, and should avoid heating pads. Using assistive devices can help with motor loss (Silvestri, 2014).

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Another important education topic is safe self-administration of prescribed medications, especially self injections. It is important for the injection sites to be rotated periodically. When presenting the client this information, it would be helpful for them to have a support person with them to help recall the information later. Supplemental pamphlets for the patient to have at home can be very helpful with the educational aspects.

References

• Ignatavicius, D. D., (2016). Care of Patients with Arthritis and Other Connective Tissue Diseases. In Ignatavicius, D. D. Editor, & Workman, M. L. Editor (8^th Ed.), Medical-Surgical Nursing (pp. 290-325). St. Louis, MO: Elsevier.
• Henry, N., McMichael, M., Johnson, J., DiStasi, A., Ball, B., Holman, H., Elkins, C.B., Janowski, M.J., Hertel, R.A., Barlow, M.S., Leehy, P., Lemon, T. (2010) RN Adult Medical Surgical Nursing (10^th Ed.). Burlington, MA: Ascend Learning.
• Garg, N., & Smith, T. W. (2015). An update on immunopathogenesis, diagnosis, and treatment of multiple sclerosis. doi:10.1002/brb3.362
• Kamm, C.P., Uitdehaag, B.M,, Polman, C.H. (2014). Multiple Sclerosis: Current Knowledge and Future Outlook. Eur Neurol 2014;72:132-141. doi: 10.1159/000360528
• Silvestri, L. A. (2014). Adult-Neurological pp 939-940. In Saunders comprehensive review for the NCLEX-RN examination(6th ed.), (pp. 939-940). St. Louis, MO: Elsevier/Saunders.