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 re- sponse 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 respira- tory tract infections precede the onset of MS. Common complications Patients with MS may suffer urine retention and uri- nary 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, hemi- plegia, and complete paralysis. Identifying signs and symptoms No definitive test for MS has been developed, al- though magnetic resonance imaging (MRI) can iden- tify lesions as the disease progresses. In the disease's early stages, diagnosis is based on eliminating other potential conditions and on clinical findings -for ex- ample, a history of neurologic dysfunction with remis- sions and exacerbations. Signs and symptoms for MS vary widely, sometimes from day to day with no pre- dictable 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 ]ability, a common symp- tom, by asking about mood swings, irritability, eu- phoria, and depression. As the patient speaks, listen for scanning (hesitating speech pattern) of poorly ar- ticulated 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 bal- ance, and controlling discomfort during exacerba- tions. 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 corti- costeroids to reduce inflammation and hasten remis- sion. 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 oxy- butynin to relieve urine retention and minimize fre- quency and urgency. Supliortive 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: o If the patient is on bed rest, maintain proper body alignment when positioning him. o Protect his skin from friction, pressure, and exces- sive heat, moisture, or dryness. o Keep the bedpan or urinal nearby; the need to void is usually immediate. The patient may require inter- mittent catheterization or a condom catheter. o Promote bladder and bowel elimination by increas- ing fluids, using intermittent bladder catheterization, and administering drug therapy as ordered. o Offer comfort measures, such as gentle massage and warm-not hot-baths. o Help the patient establish a daily routine to main- tain optimal functioning. Stress the importance of limiting his activities and taking regular rest periods to prevent fatigue and symptom exacerbations. o Encourage daily exercise and assist with physical therapy. o Tell him that walking may improve his gait. If mo- tor dysfunction puts him at risk for falling, provide a quadripod cane or walker as needed. o Teach him about his medications and assess for ad- verse drug reactions. o Explain the importance of eating a nutritious, well- balanced diet that contains enough roughage to pre- vent constipation. Explain how to use suppositories, if needed, to help establish a regular bowel schedule. Encourage adequate fluid intake and regular urina- tion. o Provide emotional support for the patient and fam- ily. Evaluate their understanding of MS and their abil- ity to make lifestyle adjustments. For more informa- tion, refer them to the National Multiple Sclerosis So- ciety, 733 Third Ave., New York, NY 10017; tele- phone: 1-800-532-7667. 1