NURSING CARE OF THE PERSON WITH MS By Marci Catanzaro The nurse may come in contact with the person who has multiple sclerosis in a wide range of primary, acute, or long-term care settings. The chronic aspects of this demye- linating disease emphasize a need for care that cuts across these settings, and includes the mainte- nance of physical, psychological, and social health; evaluation and management of symptoms; and ap- propriate referrals. The physiologi- cal, social, and behavioral responses of the person to the illness are an integral part of nursing care. The Congress for Nursing Practice of the American Nurses' Association has defined Standards of Nursing Pmctice(l). These stan- dards guide the systematic practice of nursing and provide criteria for evaluating the quality of nursing care, regardless of the setting. Care of the person with multiple sclero- sis is discussed here in terms of these standards. Standard 1: The collection of data about the health status of the ii-idi- vidual is systematic and continu- ous. These data are recorded, re- trievable, and communicated to appropriate persons. Data are obtained through in- terviews. physical examination, clinical observations based on knowledge of the biological and behavioral sciences, review of re- cords and reports, and consulta- --------------------------------------------- MARCI CATANZARO, RN, M.S.N., is the patient servim coordinator at the Puget Sound Chapter of the Multiple Sclerosis Society in Seattle, Wash. and is also a clinical nurse specialist in the Department of Rehibihta- tion Medicine at the University of Washing- ton, Seattle, Wash. --------------------------------------------- tions. Interview data from family these symptoms? What do you members and significant others in think can be done to help your dis- the person's life are important in ease? assessment, if the nursing care is to 2. The sequence or pattern of be appropriate to the situation in symptoms, therapy, and rehabilita- which the person lives. The priority lion progrurm, and the individual's of data collection is determined by perception of and reaction to these. the Immediate health care prob- This area of assessment is re- lems of the individual. For exam- lated to the first area in that the ple, the assessment of the acutely ill person's expectations for treatment person will focus on those areas will affect how he or she perceives that are directly related to this ill- what is actually being done. The ness. On the other hand, assessment ability to cooperate with recom- of the person who is in a chronic mended management regimens Will phase will be more comprehensive. be determined, in part, by the con- Data about the person with gruence between ideas about the multiple sclerosis include, but are cause of symptoms and the pro- not limited to: posed intervention. 1. The individual's and fami- It is also important to know ly's perceptions and expectations what treatment or management reltiting to health-illness states and regimens have been recommended. health care services. How effectively have we communi- The current state of knowl- cated with the person? Does the edge about MS indicates that the person understand how to carry out cause, treatment, and cure are un- these suggestions? We often see known. Do the persons concerned people with MS who were told not comprehend these facts, and how is to get overtired or to get adequate this comprehension reflected in rest who have followed this advice their expectations for care? Does by abandoning their usual occiipa- the person comprehend what medi- tional and social activities to spend cal science can do or cannot do to their days sitting in a chair. alleviate symptoms and cure the Some questions that may be disease? Often problems arise if the helpful in assessing this area in- person with MS and the significant clude the following: When did you others are not at the same level of first notice symptoms of a neurolo- understanding nor at the same gical disease? What were those stages of adaptation. For example, symptoms? What did you think was the person with MS may have ac- happening? Did you tell anyone cepted the illness and proceed to about these symptoms? What hap- make necessary adjustments, while pened after-that? What have you a family member is insisting that discovered that helps you? the diagnosis is incorrect and a cure 3. Information about the occu- is available. pational and educational history, Some questions that will assist health beliefs, recreations inter- in assessing perceptions about the ests, cultural background, and spir- nature of the disease and its man- itual beliefs of the individual and agenient include the following: significant others as they relate to What do you think may be causing habits and social and work roles. Who is this person? To what extent have the components of indi- viduality been affected by MS? Data can be obtained through care- ful observation of behavior and conversation with the person and significant others, as well as from written records of previous con- tacts with the health system. "Tell me about how you spend your day" will often trigger a lengthy description of the person's interests and underlying beliefs that make these things important. Fur- ther discussion can effectively take the form of genuine interest in the persons description. For example, "What kind of preparation did you need to get that job?" or "How do you feel about the time you have to do the things you want to do?" 4. The psychosocial behavior of the individual and family re- sponse to illness-their fears and their past and present patterns Of coping. Weisman defined coping as "what one does about a problem in order to bring about relief, reward, quiescence, and equilibrium"(2). In order to cope, the person must rec- ognize that a problem exists from which some sort of relief, respite, and resolution is sought; then some- thina must be done about the prob- lem. Weisman suggested some questions that will assist the nurse to know more about how the per- son copes: "What problems, if any, do you see this illness creating? How do you plan to deal with them? When faced with a problem you must do something about, what happens? What do you do? How does it usually work out? To whom do you turn when you need help? What kinds of problems usually tend to get you down or upset?"(3) 5. Family dynamics, including communication styles and interac- tion patterns and role relation- ships. How does the person define his or her family? Who are the meni- bers of this family, and what roles do they assume in it? -------------------------------------------------------------- Directions for Patients On Cholinergics The problem: The testing done in the clinic today showed that your bladder is areflexic. It does not con- tract effectively, causing urine to stay in your bladder. With the retained urine, your bladder gets full twice as fast. Before long it is so full it runs over. Urine left in the bladder provides a very good place for bacterid to grow and results in frequent infections. The treatment The bethane- chol chloride (Urecholine) prescribed for you today is intended to strengthen the contraction of your bladder and decrease the amount of urine that stays in your bladder when you void. This will decrease the probability that your bladder will get too full and run over. It will also help to get rid of a leftover pool of urine that encourages the growth of bacteria and infection. Ini tially you may notice a worsening of your bladder symptoms. The amount of medication prescribed today Mdy need to be changed after we have had an opportunity to awess your response to this drug. Cautions: If you have a history of low blood pressure, heart trouble, al- lergies, hyperlhyroidism, or have stom- ach or intestinal problems, please be sure that we know that. Combining the Urecholine with such drugs as epinephrine (found in some inhalators for asthma or allergies) May cause a serious asthmatic aftack. even m people with no history of asth- ma. Do not take any prescription or nonprescription drug with your blad- der medication unless you have checked with your pharmacist. Side effects: like all drugs, Ure- choline has some side effects. In the dosage prescribed, these are rare. Di-. arrhea is the most common. This is usu- ally only temporary and can be treated with Kaopectate. In high doses, this drug may cause a lowering of your blood pressure. If you should begin to feel fight-headed, especially upon ing in the morning, please call us immediately. -------------------------------------------------------------- What is the effect on this per- son's illness on the family? How has the family constellation changed since the onset of MS? Marriage or divorce may have occurred, the presence of children in the family may have changed, the extended family may have become more or less involved. Have role relation- ships within the family changed since the onset of the disease? The perception of what is communicated may vary between the sender and the recipient of the message. The person with MS may believe that a problem or belief has been successfully communicated when the significant others believe otherwise. For example, the invisi- ble problem of fatigue may not be understood by family members, who continue to expect a mother to maintain her former level of activi- ty at home and in school- or work- related activities. At what stage of development are the children? What do they know and understand about the condition of a parent? How do the children respond? Do they bring friends home? What about their social interaction in school? Where do grown children fit into the fami- ly, and what roles and responsibili- ties do they assume? Lesions in the central nervous system may affect all aspects of the human person. Damage may alter responsiveness, sensitivity, mood, humor, personality, and the ability to interact. When certain areas are affected, the way in which intimacy is expressed may also be affected. For example, a man with a lesion in the sacral spinal cord may be un- able to obtain an erection; bladder dysfunction may result in urinary incontinence during coitus; or, ad- ductor spasms in a woman may necessitate alternate positioning during intercourse. Not every nurse possesses the necessary skills to assess the expres- sion of sexuality, nor will all nurses be comfortable in assessing this area. These factors do not cancel the nurse's obligation to obtain this and their family members. Neuro- ophthalmoplegia, and central sco- inforimation. In such cases, referral logical and rehabilitation clinics are toina are among the most frequent- to another nurse, a social worker, a sponsored by some of the Society's ly encountered visual problems. counselor, or other members of the chapters, th'e availability of service's The nurse needs to know whether health care team is appropriate. varying with each chapter. What the person has experienced optic Accurate information in the does the local Multiple Sclerosis symptoms in the past. Are these area of family interaction patterns chapter provide that may be of ser- present now? If so, how do these is difficult to obtain in an interview. vice to this particular person? symptoms interfere with activities Therefore, observation of verbal The proliferation of health of daily living? How does the per- and nonverbal interaction among specialties and the complexities of son cope? What are the person's family members is essential. This the health care system have made expectations for the future in rela- can be accomplished during visiting an interdisciplinary approach to tion to vision? hours in the hospital setting, in the chronic illness both a reality and a Speech can also be affected by waiting room of an outpatient facil- necessity. A prerequisite for using MS. Most commonly these difficul- ity, or in the person's home. Family such a complex system to the ad- ties are evidenced bv a slow, scan- members need to realize that their vantage of the person with MS is an niiig speech pattern. Words may role in the care of the ill person is understanding of how each special- become slurred to the point where an important concern of the iitirse. ty role articulates with others and verbal communication is nearly im- 6. What are the available and -who is responsible for each aspect possible. Weakness of mtiseles in- accessible human and material re- of this person's care. Further, it is volved in breathing and speech may sources? essential to know which parts of make speaking a chore. Areas of The person who lives in close this complex system are accessible assessment include the following: proximity to a major metropolitan to the person in the local communi- To what extent is speech impaired? area clearlv has different resources ty. Physical, occupational, or How does the person manage corn- available than someone who lives in speech therapy-urology, psyebolo- munication problems with familv a rural area. Also, the attitudes of gy or any number of other special- and with strangers? What other the person toward asking for and ties-may not be available where abilities does the person possess receiving help from others are im- the person lives. that may be used for commtinica- portant points to consider when Lefton and Lefton identified tion? For example, can the person planning care. What does the per- hierarchies of authority and chan- write or use a typewriter? son know to be available? nels of communication as two orga- People with MS complain of Friends are an important hu- nizational variables that determine deficits in short-term memory. Is man resource. Some questions how the' team functions in the con- this a problem, and is it recognized might be asked about friends: Have text of larger social organiza- as such? What are some of the ways there been any changes in your tions(4). Who is assuming the lead- the person has found to compensate relationships with friends? How of- ership in determining the involve- for this deficit? ten do you visit or phone each oth- ment and role of team members? Is 8. The clinical assessment Of er? How close do you feel to them? everyone, including the recipient of physical function and status, in- Do you have much to talk about care, clear about this leadership? cluding the ability to perform activ- with them? Have you made any 7. What is the level of compre- ities of daily living. new friends since the diagnosis? hension and expression of the spo- Multiple sclerosis is a very un- Local church, community, and ken word, written word, gesture, stable disease. Not only does the fraternal groups are often capable and visual image? clinical course vary over time, but of providing a wide variety of ser- Since demyelination can occur the ability of the person to perform vices needed by those with MS. Has in any part of the central nervous activities of daily living mav vary the person had any contact with system, there is a potential for from moment to moment. The fa- these resources? What is the per- lesions that interfere with those tigue that is so often an integral son's perception of these groups? abilities that allow a person to corn- part of MS may be the only thing The National Multiple Sclero- mtinicate. The ability to speak-, that limits the person's functional sis Society has chapters throughout hear, see, write, and to comprehend ability. It should be noted if fatigue the country. These chapters may the spoken and written word can be is a component and whether it lend such equipment as ambtiiation compromised by MS. interferes with activities. How does aids, wheelchairs, and hospital Optic signs of MS are not the person cope with fatigue now? beds, and may provide counseling uncommon. Optic neuritis as an Does the person understand for indiviidals and groups as well as onset symptom occurs frequently. adaptive behaviors that near, help social activities for people with MS Nystagmus, bilateral internuclear to deal with fatigue? Can the person bathe, dress, prepare and eat food, and carry out other activities of daily living inde- pendently in the setting in which or she actually lives? If not, what arrangements exist now? Are these arrangements satisfactory? is more independence desired, and how might this be achieved? What are the family's expecta- tions for independence in daily ac- tivities? How does the person get about in the home and outside? Are mobility aides used appropriately? How does the person find using these mobility aides? Is transporta- tion available for trips? It is also important to ascertain other symptoms of neurological damage. Some of the motor distur- bances that result from MS include intention tremor, muscle weakness, and spasticity. Sensory changes in- clude numbness, paresthesia, pain, and decreased vibratory and posi- tion sense. Lesions affecting the autonomic nervous system may re- sult in bladder and bowel distur- bances and loss of libido. Mental changes, such as depression, eupho- ria, emotional lability, and simple deterioration, may also occur. Are some of these symptoms more troublesome than others to this person? What is the person doing about those symptoms? If medication or other treatments have been prescribed, how are these followed? What effect do these interventions have on the per- son? Are symptoms of other dis- ease present? The nurse is not necessarily responsible for collecting all these data personally from the person with MS; in fact, other members of the health care team may more appropriately assess certain areas. For example, physical an occupa- tional therapists are prepared to assess architectural accessibility of the home in relation to the person's current and future needs. All data, regardless of their iource, must be recorded, retrievable, and commu- nicated to the appropriate person. Standard II: Nursing diag- noses are derived from health sta- tus data. A nursing diagnosis is a concise statement of judgments or coticlu- sions derived from the assessment phase and is based on identifiable data. Determined by continuous analvsis and interpretation of data abo@t the strengths, limitations, methods of adapting to health devi- ations or potential deviations, as compared to the established norins, the nursinig diagnosis is consistent with current scientific knowledge and congruent with the individuals perception of the situation. The National Conference on the Classification of Nursing Diag- nosis lists possible diagnoses in the area of physical.health, mastery competence, interpersonal and so- cial competence, symbolic and pur- osive mastery, and self-actualiza- tion (5). This guide may be helpful to the nurse in suggesting ways to state a nursing diagnosis, based on assessment parameters. Some nurs- ing diagnoses that may be relevant to the person with MS include sen- sory impairment, social isolation, altered self-concept, altered ability to perform self-care functions, or impairment of urinary elimination. Standard III: The plan of nurs- ing care includes goals derived from the nursing diagnoses. A goal is the end state toward which nursing action is directed. Goals are derived from the nursina diagnosis and are stated in terms of observable outcomes. They are for- mulated by the individual, family, health personnel, and significant others. Goals are congruent with the individual's present and poteii- tial phvsical capabilities and behav- ioral patterns and are attainable through the use of available and appropriate human resources. All goals are achievable within an iden- tifiable time frame and are assigned appropriate priorities. An example of an appropriate goal may be this: The individual is able to achieve optimum indepen- dence with limitations imposed by a neurological deficit through psy- chosocial copying mechanisms and remaining phvsical abilities. Standard IV: The plan of nurs- ing care includes priorities and the prescribed nursing approaches or measures to achieve the gouls de- rived front the nursing diagnoses. The plan for nursing care de- scribes a systematic method to -------------------------------------------------------------- Bowel Program For Patients Constipation is a common prob- lem in MS. It may be the result of poor dietary habits, inactivity a lesion in the spinal cord, or the side effect of a drug- A bowel program is effective in man- aging constipation, regardless of its cause. What follows is a program that has proven effective in relieving con- stipation. 1. Eat a bowl of bran cereal every evening. About one hdlf-cup of cereal is sufficient. The bran adds the neces- swy bulk to your diet. Do not take a laxative of anykind. 2. Eat breakfast in the morning and drink a cup of warm liquid, for example, coffee or tea. This starts the normal reflexes working in your intesti- nal tract. 3. Sit on the toilet for 10 to 20 min- utes after breakfast. Do not strain to have a bowel movement. 4. If you are unable to have a bow- el movement today, forget about it. It is not necessary that you have one each day. If you do not have a bowel move- ment in 2 to 3 days, add the following to your bowel program. After you have unsuccessfully tried to have a bowel movement after breakfast, use a glyc- erine or Dulcolax suppository. Be sure that it is resting against the wall of your rectum. This will stimulate the lower intestinal tract and produce a bowel movement. The above bowel program works well for nearly everyone. Only those with severe spinal corcf damage in the sacral area need to use additional rec- stimulation. Laxatives and repeated enemas are never necessary. --------------------------------------------------------------- meet the goal, including priorities for appropriate action, alternative interventions for achieving goals, and a loeical sequence of actions to attain tge goals. The plan is based on current scientific knowledge, is specific, and can be implemented. It includes appropriate health care professionals who function as an interdisciplinary team and incorpo- rate available and appropriate ma- terial resources and environmental controls. The plan reflects dynamic changes in the individual and in the environment and reflects consider- ation of the "Patient's Bill of Rights"(6). The plan specifies what nursing actions are performed; how, when, and where these actions are to be performed; and who is to perform the activities. There is no treatment known to medical science today that will alter the demyelination process. Successful management of the dis- ease is based on the individual's ability to build general resistance, avoid excessive fatigue, avoid ex- tremes of hot and cold, prevent exposure to infection, and under- take early and vigorous treatment when infection does occur; balance rest and exercise within his or her capacity, and eat a nutritious and well-balanced diet(7). Price and Wood further discuss ways of achieving these goals(8). Drug therapy may play an im- portant role in the management of symptoms of MS. The person with MS who is taking medication is expected to be able to name the drug(s) and the dosage prescribed; recognize the expected positive and negative effects of the drug(s) used; differentiate side effects requiring symptom management, for exam- ple, dry mouth from anticholiner- gic drugs, and those requiring noti- fication of the care provider (urina- ry retention from anticholinergic drug(s) safely self-administer the drug(s) and avoid prescription and nonprescription drugs that may in- teract with others beina taken. Persons experiencing an acute ---------------------------------------------------------- Directions for Patients On Anticholinergics Tht problem: The testing done in the clinic today showed that your bladder is hyper-rellexic. It responds in an exaggerated manner to filling with urine, causing you to void frequently and to have little time to get to the bathroom when you need to void. The treatment: The medication prescribed for you (Pro-Banthine or Ditropan) is intended to make your bladder less sensitive. You will not have to void as often and will have a bit more time to get to the bathroom. The amount of medication prescribed to- day may need to be changed after we have an opportunity to awess your. response to this drug. You may not notice a drastic change in your syrnp- toms right away. Cautions: If you have a history of glaucoma, enlarged prostate. intestinal obstruction, or heart trouble. please be sure that we know about that. The Pro-Banthine or Ditropan that you are taking will increase the effect of some other medications. Some of these include over-the-counter drugs such as Sominex and many of the cold or allergy remedies. Also affected are such prescription drugs as some of those used to treat depression and ,ulceri. Check with your pharmacist before taking any other drugs, whether prescription or nonprescription, with your bladder medication. Side effects: Like all drugs, this one has some side effects. However, in the dosage prescribed, these are rare. Dryness of mouth is the most common. Blurred vision, constipation. increased heart rate, and flushing may accompa- ny larger doses of these drugs. All of these tide effects are easily managed. For example, chewing gum and hard candy will alleviate dryness of mouth. Adding bran to your diet will help to relieve the constipation. Changing the dosage of the drug may be necessary. Too much of this drug may, in rare cases, make it very difficult or impossi- ble for you to empty your bladder. If rthis should happen, call us immediate- ly or go to the nearest emergency room and explain what medication you have been taking and that you cannot void. They may insert a catheter to empty your bladder. Then contact us. -------------------------------------------------------------------- exacerbation of symptoms may re- ceive. ACTH or corticosteroias to reduce edema and the acute inflam- matory response at the site of de- ipyelination. The symptoms result- ing from acute inflammation are expected to subside. Side effects of the drugs may incliide edema, eu- phoria, or depression. Marked ede- ma or shortness of breath requires prompt notification of the care pro- vider. These drugs may interact with salicylates, phenylbutazone, antihistamines, diphenylhydantoirn, and hypoglycemic agents, includ- ing insulin. Elimination problems are not uncommon in MS. Urinary reten- tion, frequency, or incontinence are frequently encountered. Major goals of management include the prevention of urinary tract infec- tion and subsequent renal damage and maintaining social acceptance. The location of the lesion in the central nervous system will deter- mine the management regimen. An uninhibited (spastic) bladder can be successfully managed with an anti- cholinergic drug. Cholinergic drugs may be a part of the management of an areflexic (flaccid) bladder. The nurse may also need to demonstrate and teach the person to perform other interventions to facilitate the complete emptving of the bladder. These may include Crede maneuvers, stimiilating re- flex contraction of the bladder by stroking the abdomen or stretching th@ reettim, intermittent catheteri- zation, or application of an external catheter for males. The effect of muscle weakness and incoordination can be de- creased by encouraging activity within the limitations of the indi- vidual. While muscles that lack innervation cannot be restored by exercise, active and passive range of motion exercises to all extremities will prevent coiitractures and assist in maintaining tone in unaffected muscles. The National Multiple Sclerosis Society published two ex- ercise manuals that are available through local chapters-one for am- for dealing with loss of sensation. bulatory and ambulatory-assisted Standard V: Nursing actions persons, and another for nonambu- provide for client/patient partici- latory persons. pation in health promotion, main- Bracing and other assistive de- tenance, and restoration. vices are often needed to overcome The care plan is developed muscle weakness. Referral to spe- with and comniunicated to the indi- cialists in physical medicine and vidual, family, significant others, rehabilitation should be made early and health personnel as appropri- in the course of the disease. When ate. These people are kept in- improper techniques have been formed about the health status of learned or deformity has occurred, the person with MS, about the nurs- it is far more difficult to restore ing care. plan and how it articulates functional ability. with the total health care plan, and Intention tremor may be the about the roles of health personnel most disabling svmptoni the person in implementing the plan of care. experiences. This tremor is notori- The person and familv are provided ously resistant to pharmacological with information necessary to make management. In carefully selected decisions about promoting, main- cases, cryothalamectomy has been taining, and restoring health, and effective in relieving tremor(9). employing appropriate resources to Some patients are able to use bio- achieve these goals. feedback techniques to control The problems encountered by some of their intention tremor. people with a chronic disease do It is important for the person not differ markedly from those con- with intention tremor to maintain fronted by people with acute dis- as much self-care activity as possi- eases, except that the problems of ble, but to avoid frustration and a MS often persist and are relatively sense of failure. The use of assistive more permanent than the problems devices may be helpful. An electric encountered by someone with an toothbrush is an example of a de- acute illness. This chronicity ex- vice that decreases the number of pands the person's responsibility movements required to complete for self-care and the involvement of an activity. Stabilizing an extremity family, friends, acquaintances, and against a solid surface may control even strangers. Much of the per- some tremor. For example, placing son's time is spent at home, away an elbow firmly on the table top from health professionals. The cli- may control enough tremor in the ent's role in symptom management proximal extremity to allow the then becomes central, and success person to eat independently. or failure depends heavily upon his Spasticity may interfere with or her judgment and incenuitv as he many actvities of daily living. or she continuously readjusts life- Drugs used for the management of styles in order to accommodate these problems may include Val- changing status(10). ium, dantroline sodium (Dantrium), Standard VI: Nursing actions or Lioresal. Each has advantages assist the client/patient to maxi- and disadvantages that need to be mize his health capabilities. weighed carefully in each case. Nursing actions designed to Sensory changes in skin can be achieve the goals set for the person annoying as well as disabling to the with MS do not differ from those person with MS. When sensation is practiced in the caring for others. lost, the person must learn self-pro- Documentation of these nursing ac- tection techniques to avoid skin tions is of prime importance, given trauma. Textbooks on the care of the long-term nature of MS and the the spitial cord-initired person can fact that numerous other health help to provide many suggestions care providers will be involved. Standard VII: The client's/ patient's progress or lack of pro- gress toward goal achievement is determined by client/patient and the nurse. The role for the person with MS is central to the ongoing effort to achieve goals. The mutual ex- change of information about prog- ress toward goal achievement is critical to the nursing process. Standard VM: The client's/ patient's progress or lack of prog- ress toward goal achievement di- rects reassessment, reordering pri- orities, new goal setting and revi- sion of the plan of nursing care. Multiple sclerosis is a nonsta- ble neurological disease, which may go into remission, exacerbate, or steadily progress over brief or extended periods of time. The indi- vidual, family, significant others, and health care personnel must be actively involved in continual reas- sessment. Otherwise the plan of care may become outmoded. For example, a cane may serve to assist walking for the person with weak- ness in one leg, but increasing atax- ia mav make it impossible for the person to continue safely to place the cane. References 1. American Nurses' Association, Congress for Nursing Practice. Standands of Nursing Prac- tice. Kansas City, Mo., The Association. 1973. L Weisman, A. D. Coping With Cancer. New York, McGraw-Hill Book Co., 1979, p. 27. 3. lbid, P. 29. 4. Lefton, Eva, and Lefton, Mark. Heith care and treatment for the chronically ill: toward a conceptual framework. J.Chonic Dis. 32:339- 344, 1979. 5. Gebbie, K. M., &W Livin M. A., eds. Classifi- cation of Nursing Diagnosis. St Louis, CV. Mosby Co., 1975. 6. American Hospital Association. Statement on a patient's bill of rights; affirmed bv the Board of Trustees, Nov. 17, 1972. Hospitals 47:41. Feb. 16, 1973. 7. Price, Gail, and Wood, J. J. MS training in your facility. (journal Minibook) J,Am.Health Care Assoc. 5:51-74. Mar. 1979. 8. Ibid. pp. 55-62. 9. Cooper, 1. S, Living ith Chonic Neurologic Disease: A Handbook for Patient ad Family. New York, W. W. Norton & Co., 1976, pp. 267-271 10. Strauss, A.A. Chronic Illness and the Quality of Life. St. Louis, C.V. Mosby Co., 1975