CNS: Caring For Patients with Multiple Sclerosis

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CARING FOR PATIENTS WITH MULTIPLE SCLEROSIS

by Judith E. Meissner, RN, MSN
Professor Emeritus
Bucks County Community College
Newtown, Pennsylvania

A major cause of chronic disability in young adults, multiple sclerosis (MS) has a highly uncertain prognosis. Here's what you'll need to know to assess for MS and manage exacerbations and complications.

What is MS?

A progressive central nervous system disease, MS is characterized by exacerbations and remissions of widespread, varied neurologic dysfunction. Symptoms reflect gradual demyelination of the white matter of the brain and spinal cord.

The cause of MS isn't known, but current theories include a slow-acting viral infection, an autoimmune response to the nervous system, or an allergic response to an infectious agent. Other possible causes include trauma, anoxia, toxins, nutritional deficiencies, vascular lesions, and genetic factors. In some cases, emotional stress, fatigue, pregnancy, and acute respiratory tract infections precede the onset of MS.

Common complications

Patients with MS may suffer urine retention and urinary tract infections, constipation, joint contractures, pressure ulcers, rectal distension, and pneumonia. As the disease advances, it may cause blindness, ataxia, incontinence, muscle atrophy, spastic paraplegia, hemiplegia, and complete paralysis.

Identifying signs and symptoms

No definitive test for MS has been developed, although magnetic resonance imaging (MRI) can identify lesions as the disease progresses. In the disease's early stages, diagnosis is based on eliminating other potential conditions and on clinical findings-for example, a history of neurologic dysfunction with remissions and exacerbations. Signs and symptoms for MS vary widely, sometimes from day to day with no predictable pattern. And they may be transient or last for hours or weeks. Symptoms can be so bizarre that the patient may have a hard time describing them.

When taking his history, observe him closely for evidence of motor and sensory impairments. Look for poor coordination, weakness, or paralysis. Ask about urinary incontinence, urgency, and frequent infections. Also ask about numbness and tingling (paresthesia), blurred vision, diplopia, and scotoma (dark spots in the visual field).

Assess him for emotional lability, a common symptom, by asking about mood swings, irritability, euphoria, and depression. As the patient speaks, listen for scanning (hesitating speech pattern) of poorly articulated speech.

An MRI is the most sensitive method of detecting MS lesions. More than 90% of patients with MS show multifocal white matter lesions of the brain and spinal cord. A computed tomography scan, cerebrospinal fluid analysis, an electroencephalogram, and evoked potential studies may also be ordered.

Treating MS: Your role

Goals of treatment are to shorten exacerbations and, if possible, relieve neurologic deficits so the patient can resume a normal life. Other goals include keeping him as mobile as possible, ensuring nutritional balance, and controlling discomfort during exacerbations.

As the disease progresses, you'll need to promote adequate urine elimination and respiratory function to prevent infections. Because MS may have allergic and inflammatory causes, the doctor may order corticosteroids to reduce inflammation and hasten remission. But they don't prevent further exacerbations.

The doctor may also prescribe interferon beta-1b to reduce the frequency of exacerbations, baclofen or dantrolene to relieve spasticity, and bethanechol or oxybutynin to relieve urine retention and minimize frequency and urgency.

Supportive measures include antibiotics to treat bladder infections, physical and occupational therapy, and counseling.

How to intervene

Your interventions will depend on the severity of the disease and the patient's symptoms. Here's what you'll need to do during acute exacerbations:

If the patient is on bed rest, maintain proper body alignment when positioning him.
Protect his skin from friction, pressure, and excessive heat, moisture, or dryness.
Keep the bedpan or urinal nearby; the need to void is usually immediate. The patient may require intermittent catheterization or a condom catheter.
Promote bladder and bowel elimination by increasing fluids, using intermittent bladder catheterization, and administering drug therapy as ordered.
Offer comfort measures, such as gentle massage and warm-not hot-baths.
Help the patient establish a daily routine to maintain optimal functioning. Stress the importance of limiting his activities and taking regular rest periods to prevent fatigue and symptom exacerbations.
Encourage daily exercise and assist with physical therapy.
Tell him that walking may improve his gait. If motor dysfunction puts him at risk for falling, provide a quadripod cane or walker as needed.
Teach him about his medications and assess for adverse drug reactions.
Explain the importance of eating a nutritious, well-balanced diet that contains enough roughage to prevent constipation.
Explain how to use suppositories, if needed, to help establish a regular bowel schedule. Encourage adequate fluid intake and regular urination.
Provide emotional support for the patient and family. Evaluate their understanding of MS and their ability to make lifestyle adjustments.

For more information, refer them to the National Multiple Sclerosis Society, 733 Third Ave., New York, NY 10017; telephone: 1-800-532-7667.