MULTIPLE SCLEROSIS Adult Health Summer Session: 2004

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MULTIPLE SCLEROSISAdult Health Summer Session
2004
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DEFINITION / PATHOPHYSIOLOGY

• Chronic, frequently progressive disease of CNS
• Characterized by small patches of demyelination
  in the brain, brain stem spinal cord
• Patches are called plaques.
• Plaques become sclerosed interrupt the flow of
  nerve impulses.
• MS lesions may occur in 2 stages
• Sequential develop of small inflammatory lesions.
• Lesions extend consolidate.

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PATHO (cont.)

• Classifictions of MS
• Relapsing-remitting
• Primary progressive
• Secondary progressive
• Progressive-relapsing
• Is remyelination possible?

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INCIDENCE

• Most common cause of progressive neurological
  disability of young adults
• Onset 20-40 years of age in 75 of cases
• Twice as many females as males
• Incidence highest in temperate climates
• Familial tendency may be due as much to
  environment as heredity

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CAUSES

• UNKNOWN
• Most common popular theory
• Autoimmune reaction
• Four General Hypotheses
• Genetic Features
• Virological Features
• Epidemiologic Features
• Immunologic Features

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PRECIPITATING FACTORS

• Infections
• Trauma
• Pregnancy

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DIAGNOSIS

• Clinical judgment
• MRI
• No universally accepted definitive test for MS
• MRI, along with clinical judgment, is accepted by
  most medical authorities as definitive.
• CT
• PET
• ? Gamma globulin in CSF
• Color vision alteration
• EEG
• R/O (rule out) other neurological diseases

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CLINICAL MANIFESTATIONS

• Variable depending on which nerves are damamged
  extent of demyelination
• Characterized by remissions exacerbations
• Occasionally an MS client will have steady
  decline.
• MS can be mistaken for neurosis, peripheral
  neuropathy or spinal lesions.

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EARLY MANIFESTATIONS

• Fatigue
• Weakness /or paresthesia
• Most common symptom
• Usually starts in lower extremities
• Total or partial loss of vision in 1 eye
• Unsteady gait
• Muscle spasticity
• Diplopia
• Dizziness

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EARLY MANIFESTATIONS (cont.)

• Blurred vision
• Nystagmus
• Nausea / vomiting
• Signs of facial trigeminal nerve involvement
• Bladder dysfunction
• Retention /or incontinence
• ? or absence of touch sensation

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EARLY MANIFESTATIONS (cont.)

• Clients tend to get disgusted early in the
  disease process if no diagnosis is made. This
  frequently results in
• Depression
• Irritability
• Emotional instability
• Hyperexcitability

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MANIFESTATIONS (cont.)AFTER SEVERAL YEARS

• Signs / symptoms probably more severe
• Most patients develop Charcots Triad
• Nystagmus
• Intention tremors
• Scanning speech

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LATE MANIFESTATIONS

• Partial or total paralysis of lower extremities
• Use of upper extremities may be severely limited
• Small percent have gross loss of memory
• Crippling joint contractures
• Muscle atrophy

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PHYSICAL FINDINGS IN MS CLIENTS

• Visual
• Pallor of disks
• Abnormal fields of vision
• Strabismus
• Nystagmus in 70
• Scotomas
• Marcus-Gunn phenomenon

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PHYSICAL FINDINGS (cont.)

• Motor Findings
• Weakness or paralysis of extremities
• Ankle clonus
• Ataxia
• Muscular atrophy in late stages
• ? motor function after hot bathes
• Manual dysmetria

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PHYSICAL FINDINGS (cont.)

• Sensory Alterations
• ? perception of pain, touch temperature
• ? or absence of proprioception
• ? or absence of vibration sense
• Lhermittes Sign
• Electric sensation down the spine upon passive
  flexion of the neck.
• Zipper Effect

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PHYSICAL FINDINGS (cont.)

• Reflex Findings
• Exaggerated tendon reflexes
• ? or absence of skin reflexes
• ? or absence of cremasteric reflex
• Babinski Sign
• Hoffmanns Sign
• Charcots Triad

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POSSIBLE MENTAL CHANGES

• Early
• Apathy
• Euphoria
• Inattentivenss
• Late
• Depression
• Confusion
• Disorientation
• Memory defects
• Impaired judgment

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ASSESSMENT

• Client History Be alert for
• Signs / symptoms of MS
• Info regarding timing of initial, as well as
  recurring S/Sxs
• Factors which may have triggered initial S/Sxs
  or periods of exacerbation
• Head-to-Toe Assessment

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ASSESSMENT (cont.)

• Lab Findings / Diagnostic Procedures
• In addition to diagnostic procedures presented
  earlier . . .
• EMG may be grossly abnormal in advanced MS
• Tests to measure visual, auditory and brain stem
  function may be grossly abnormal.

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What are some commonNURSING DIAGNOSESwhich
would apply to MS clients?
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INTERVENTIONS

• No cure
• Medications
• Physical Therapy
• Occupational Therapy
• Experimental and Alternative Therapies

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MEDICATIONS

• BMRs (biologic response modifiers
• Avonex (interferon beta-1a)
• Betaseron (interferon beta-1b)
• Copaxone (glatiramer acetate)
• Steroids
• Used during exacerbations to?? inflammation of
  demyelinated areas.
• Examples
• Solu-Medrol (methylprednisolone)
• ACTH (adrenocorticotrophic hormone
• Decadron (dexamethasone)

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MEDICATIONS (cont.)

• Immunosuppressive Therapy
• A combination of Cytoxan (cyclophosphamide) and
  Solumedrol (methylprednisolone) may be used to
  stabilize the disease process.
• Adjunctive Drug Therapy
• Muscle relaxants to decrease spasticity
• Symmetrel (amantadine hydrochloride) for fatigue
• Inderal (propranolol hydrochloride for ataxia
• Klonopin (clonazepam) for ataxia
• Ditropan (oxybutynin chloride) for bladder
  problems
• Urispas (flavoxate HCl) for bladder problems

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NURSING CARE

• Help client/family/significant other to set
  realistic goals.
• Involve appropriate health team members.
• Educate client/family/significant other
  regarding
• Disease process
• Nutrition
• Rest
• Safety measures