Multiple sclerosis (MS) is a chronic, progressive, degenerative disease of the central nervous system. It is an autoimmune disease characterized by inflammation that destroys the myelin and axons, affecting the brain and spinal cord.
In this article:
- Types of Multiple Sclerosis
- Cause and Progression
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Urinary Elimination
- Ineffective Protection
- Powerlessness
- Self-Care Deficit (Feeding)
Types of Multiple Sclerosis
Relapsing-Remitting MS (RRMS): The most common form of MS is characterized by flares or relapses and periods of remission where symptoms may disappear. Remission may last for weeks, months, or years.
Secondary Progressive MS (SPMS): This often occurs after an initial diagnosis of RRMS, where the disease slowly worsens.
Primary Progressive MS (PPMS): 15% of patients may receive this diagnosis which is a steady worsening of neurological function without any periods of remission or flares.
Cause and Progression
The cause of MS is unknown. However, possible precipitating factors of this condition include a genetic predisposition, a history of viral infections like Epstein-Barr, smoking, other autoimmune diseases, and low levels of vitamin D.
Clinical manifestations of MS often appear slowly and gradually, with symptoms occurring periodically over several months or years. Since the symptoms are vague in most cases, patients with MS usually do not seek treatment until later in the disease process—other patients, however, experience MS with rapid and progressive deterioration in neurological function.
Nursing Process
There is no established cure for MS at this time. Its treatment is aimed at limiting disease progression and providing symptomatic relief. Nurses play a vital role in the treatment regimen of patients with MS as they provide interventions that can shorten flares and manage neurologic deficits. Nurses encourage patients with MS to stay active, combat fatigue, and use stress reduction techniques to boost their immune system and live a normal lifestyle.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to multiple sclerosis.
Review of Health History
1. Ask about the patient’s general symptoms.
MS symptoms can vary with each patient and may include any of the following:
- Vision changes
- Muscle cramping or weakness
- Poor balance and coordination
- Paresthesias
- Speech impairments
- Hearing loss
- Dizziness
- Tremors
- Severe disabling fatigue
- Intolerance to heat
- Cognitive difficulties
- Sexual, urinary, or bowel dysfunction
2. Note the onset of symptoms.
MS occurs slowly and gradually. Symptoms normally occur over several months or years.
3. Identify the patient’s risk factors.
The age of onset is usually between 15-45, but can occur at any age. Other risk factors include:
- Female gender
- Family history of MS
- Smoking
- Low levels of vitamin D
- Obesity
4. Ask the patient’s location of origin.
The patient’s geographic location may increase the incidence of multiple sclerosis. MS is less common in tropical areas that receive lots of sunshine, which is why low vitamin D levels seem to play a role in the disease. Research shows this may be especially crucial in younger children who develop MS as adults.
MS is significantly more prevalent in temperate areas, such as:
- Canada
- United States
- New Zealand
- Southern Australia
- Europe
5. Review the patient’s medical history.
Look for any history of viral infections like Epstein-Barr or autoimmune conditions as they increase the risk of developing MS.
Physical Assessment
1. Conduct a thorough physical assessment.
Document the observations found during the comprehensive physical examination. Findings depend on the course of the disease and if the patient is experiencing an exacerbation.
2. Assess the neuromuscular status.
MS may impact the neurologic, cognitive, and muscular systems. Observe for the following signs and symptoms:
- Localized weakness
- Hyperreactive reflexes
- Stiff or spastic extremities
- Cognitive dysfunction (attention, memory, problem-solving)
- Bulbar function (swallowing, speaking)
3. Observe the patient’s balance and coordination.
Poor coordination of upper and lower extremities and a wide-based gait may be seen.
4. Assess the HEENT.
Examine for the presence of optic neuritis, which may be the first neurological symptom in some patients. It manifests as loss of vision in one eye and pain upon eye movement.
Other findings in HEENT may include:
- Involuntary and rapid eye movement (nystagmus)
- Double vision (diplopia)
- Hearing loss
5. Investigate the bladder and bowel status.
Most patients with MS experience bladder and bowel symptoms at some point during the disease process.
- Urinary symptoms include:
- Urgency
- Frequency
- Incontinence
- Nocturia
- Bowel symptoms include:
- Constipation
- Fecal impaction
6. Assess any complaints of pain.
30 to 50% of patients experience pain at some point.
There are two types of pain in MS:
- Primary pain is related to the demyelinating process and is a type of neuropathic pain described as burning or shooting.
- Secondary pain is characterized by musculoskeletal discomfort from poor posture, poor balance, or abnormal use of muscles or joints due to spasticity.
7. Check for the presence of heat intolerance.
When exposed to high temperatures (whether from exercise, hot showers or baths, fever, or hot, humid weather), patients with MS experience worsening symptoms due to the elevated body temperature, further impairing the demyelinated nerves.
8. Utilize clinical rating scales.
The Expanded Disability Status Scale (EDSS) is a 0-10 scale that assesses the severity of the patient’s clinical status, though it mainly evaluates the patient’s physical mobility. Lower scores indicate minimal disability, while higher scores indicate a higher degree of assistance required for movement and self-care.
Diagnostic Procedures
1. Create a clinical picture.
In the past, two attacks were required to diagnose MS. (An attack is defined as a neurological symptom of any kind lasting at least 24 hours with a minimum of 30 days between attacks). In recent years, criteria has been updated so that one attack, along with evidence of two or more lesions on MRI, can diagnose MS.
2. Consider lab testing.
In patients with MS, blood tests tend to be normal but may be completed to rule out other conditions with similar symptoms.
3. Prepare the patient for an MRI.
Magnetic Resonance Imaging (MRI) is the confirmatory imaging test for detecting MS and tracking the disease’s course in the brain and spinal cord. It is the most sensitive imaging technique for identifying spinal cord MS and monitoring treatment effectiveness.
4. Consider other imaging scans.
Additional imaging modalities may be considered to assess for related complications or if the MS diagnosis is not confirmed. These include:
- Computed tomography (CT) scan
- Plain X-rays
- Angiography
- Ultrasonography
5. Assist the patient in testing evoked potentials.
Evoked potentials record the central nervous system’s responses to visual or electrical stimuli to evaluate how quickly information is transmitted through nerve pathways.
6. Anticipate a possible lumbar puncture.
Although lumbar puncture is no longer a standard procedure for MS, it may be utilized if MRI results are unavailable. Results show that patients with MS often have immunoglobulins present in the cerebrospinal fluid.
7. Prepare for neuropsychological testing.
A neuropsychologist may administer tests to evaluate the patient’s thinking and memory, as MS often causes cognitive impairment.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with multiple sclerosis.
Manage and Prevent Disease Progression
1. Support the patient’s treatment plan.
Treatment should begin as soon as the MS diagnosis is confirmed to decrease lesion activity and prevent disease progression for as long as possible.
The standard goals of MS treatment include the following:
- Minimize new radiographic and clinical relapses
- Manage MS symptoms
- Promote recovery from attacks
- Reduce the disease’s development
2. Treat acute MS attacks.
Acute MS attacks are treated in two ways:
- Corticosteroids treat nerve swelling and speed recovery from an acute exacerbation.
- Plasma exchange is used for severe attacks if steroids are ineffective or contraindicated. During plasma exchange (plasmapheresis), plasma is separated from the blood cells, mixed with albumin, and reintroduced into the body.
3. Anticipate disease-modifying therapies (DMTs).
The cornerstone of treatment for relapsing-remitting MS is disease-modifying medications. They aid in lowering relapses and prevent MS from advancing. Additionally, they can stop the development of new lesions on the brain and spinal cord.
Examples of common disease-modifying medications include:
- Natalizumab
- Dimethyl fumarate
- Fingolimod
- Interferon-beta preparations
- Alemtuzumab
The following medication is used to treat primary progressive MS (PPMS):
- Ocrelizumab
The following medications are used to treat secondary progressive MS (SPMS):
- Siponimod
- Mitoxantrone
- Ublituximab
- Ofatumumab
4. Suggest supplementing with vitamin D.
Research shows that people with high vitamin D levels are at a lower risk of MS. Vitamin D may reduce the relapse rate in patients with RRMS.
Manage Symptoms
1. Relieve muscle stiffness.
Administer the following muscle relaxants to patients with muscle stiffness or spasticity:
- Tizanidine
- Baclofen
- Cyclobenzaprine
- Gabapentin
2. Decrease MS-related fatigue.
Fatigue is one of the most common symptoms of MS. While there are no approved medications to treat MS fatigue, the following medications may be prescribed:
- Amantadine
- Modafinil
- Fluoxetine
- Methylphenidate (controlled substance; high potential for abuse)
Patients may manage fatigue through energy conservation, frequent rest, and preventing overheating. Exercise may seem counterintuitive, but regular exercise actually improves fatigue.
3. Treat pain.
Up to half of MS patients will experience pain at some point during their illness. The disease process itself may cause pain and is best treated with tricyclic antidepressants or anticonvulsants. Secondary causes of pain are related to muscle pain and are treated with NSAIDs.
Nonpharmacologic treatment for secondary pain includes:
- Moderate heat
- Stretching/exercise
- Massage
- Transcutaneous electrical nerve stimulation (TENS)
4. Discuss treatment for depression.
Major Depressive Disorder (MDD) is common among patients with MS. Selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants are beneficial for treating depression.
5. Improve the patient’s mobility.
Dalfampridine (Ampyra) may assist in boosting walking ability. Encourage physical therapy to enhance muscle tone, strength, balance, and coordination.
6. Educate on preventing overheating.
A rise in body temperature can exacerbate symptoms. Educate the patient on the following:
- Limit time outside to the early morning or evening hours
- Try not to overdo activities or exercise
- Use cooling garments and wear loose clothing
- Avoid saunas and hot tubs
- Seek air conditioning in the summer months
- Treat fevers with antipyretics
7. Instruct on ways to treat urinary and bowel issues.
MS can affect the patient’s ability to urinate and defecate. Urinary concerns may include incontinence as well as difficulty emptying, and the nurse can offer the following interventions:
- Scheduled voiding
- Medications such as oxybutynin
- Catheterization
- Limiting fluids in the evening
- Eliminating caffeine or alcohol that increases diuresis
Constipation is the most common bowel issue in MS. Educate on the following ways to prevent and manage constipation:
- Increase daily water intake
- Ensure adequate fiber consumption
- Walk to incorporate daily movement
- Utilize stool softeners and laxatives
8. Discuss ways to overcome sexual dysfunction.
Sexual issues are often related to other symptoms like fatigue and pain, so ensure those are properly managed first. Men may struggle with erectile dysfunction, which can be treated with sildenafil, tadalafil, or penile pumps. Women may experience vaginal dryness, which is easily remedied with lubrication.
9. Manage stress.
Stress may exacerbate MS symptoms. Encourage the patient to utilize stress management techniques, such as:
- Deep breathing exercises
- Meditation
- Yoga
- Tai chi
- Massage
10. Refer to other professionals for cognitive decline.
Medications are not effective in managing the cognitive symptoms of MS. Patients may benefit from therapy provided by speech or occupational therapists.
11. Encourage smoking cessation and limiting alcohol consumption.
Drinking alcohol can worsen symptoms of MS, and smoking has been shown to increase disease progression. Recommend cessation programs and other supportive measures.
12. Provide emotional support.
There is no cure for MS. As MS progresses, patients lose their independence, and quality of life may decrease. Provide support not only to the patient but also to the family. Refer to necessary professionals, programs, resources, and support groups.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for multiple sclerosis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for multiple sclerosis.
Impaired Physical Mobility
Impaired mobility is one of the most common and disruptive effects of MS. It can affect the patient’s independence and quality of life. Other symptoms of MS that interfere with mobility include spasticity, dizziness, fatigue, vertigo, pain, and numbness.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Disease process
- Fatigue
- Neuromuscular impairment
- Pain
As evidenced by:
- Altered gait
- Decreased fine motor skills
- Decreased gross motor skills
- Decreased range of motion
- Difficulty turning
- Movement-induced tremor
- Postural instability
- Slowed movement
- Spastic movement
- Uncoordinated movement
Expected outcomes:
- Patient will verbalize increased strength and demonstrate an increased ability to move.
- Patient will utilize mobility aids to improve physical mobility and ambulation.
Assessment:
1. Assess the extent of physical mobility impairment.
Assessment of mobility impairment, functional difficulties, and self-care deficits can help ensure client safety and plan appropriate rehabilitation interventions.
2. Assess the causative factors of mobility impairment.
Mobility impairment may have a physiologic cause that psychological and motivational factors can also aggravate. Some patients are less active because of fear of falling or pain.
Interventions:
1. Encourage the use of mobility aids as needed.
Mobility aids like walkers and wheelchairs can help decrease fatigue and enhance comfort, safety, and independence. Overhead trapeze bars, slide boards, and braces can support mobility.
2. Perform passive range of motion exercises.
Range of motion exercises can help strengthen muscles and bones to improve mobility.
3. Encourage exercise.
Patients with MS often struggle with fatigue, but exercise is shown to improve symptoms. Patients should participate in moderate aerobic exercise while staying cool and hydrated.
4. Administer medications as ordered.
Baclofen can help relieve muscle spasms and rigidity in patients diagnosed with multiple sclerosis.
5. Refer the patient to a PT/OT.
Patients with MS can have problems with functional abilities like vision, coordination, movement, and sensations. An occupational or physical therapist can help assess the patient’s functional abilities and formulate an appropriate plan of care.
Impaired Urinary Elimination
Impaired urinary elimination and bladder dysfunction occur in approximately 80% of people diagnosed with multiple sclerosis. This can lead to complications such as urinary retention, incontinence, and urinary tract infections.
Nursing Diagnosis: Impaired Urinary Elimination
Related to:
- Disease process
- Ineffective toileting habits
- Involuntary sphincter relaxation
- Weakened bladder muscles
- Impaired mobility
As evidenced by:
- Urinary urgency
- Urinary retention
- Urinary incontinence
- Urinary hesitancy
- Frequent voiding
- Dysuria
- Nocturia
Expected outcomes:
- Patient will demonstrate elimination patterns within normal limits.
- Patient will remain free from urinary complications, including infection, overactive bladder, and retention.
- Patient will verbalize strategies to prevent impaired urinary elimination problems.
Assessment:
1. Assess the patient’s urinary elimination patterns.
Assessment of the patient’s current urinary elimination patterns can provide data about the degree of urinary problems. Assess for incontinence, difficulty emptying, hesitancy, or pain/burning with urination.
2. Assess and review the patient’s drug regimen.
Medications like antidepressants, sedatives, and diuretics may interfere with bladder function.
3. Assess and monitor laboratory values.
A urinalysis, along with urine culture and sensitivity, can help monitor for an infectious process and other complications.
Interventions:
1. Encourage adequate fluid intake.
Adequate hydration promotes urinary output and prevents urinary stasis. Ensure daily water intake, limiting intake several hours before bedtime to prevent nocturia.
2. Initiate a bladder training program.
Bladder training involves scheduling voiding at set times, whether the urge is felt or not, gradually increasing the time between bathroom trips, and training the bladder to hold more urine. This can help restore adequate bladder functioning and reduce the occurrence of incontinence, frequency, and urgency.
3. Instruct the patient to avoid bladder irritants like caffeine and alcohol.
Bladder irritants can cause the bladder to become overstimulated and irritated, leading to urinary frequency, urgency, spasms, and pain.
4. Demonstrate intermittent catheterization.
Patients who exhibit incomplete emptying and experience frequent UTIs may require intermittent catheterization. The nurse can demonstrate how to perform this skill to prevent the introduction of bacteria.
5. Administer medications.
For patients with an overactive bladder, antispasmodics like oxybutynin can be taken to decrease bladder spasms and symptoms of urgency.
Ineffective Protection
Multiple sclerosis is an autoimmune disease characterized by disabling mobility impairment that increases the risk of injury and various other symptoms that affect the patient’s immunity and health status.
Nursing Diagnosis: Ineffective Protection
Related to:
- Disease process
- Impaired mobility
- Physical deconditioning
- Medication regimen
- Ineffective health self-management
As evidenced by:
- Fatigue
- Weakness
- Impaired physical mobility
- Maladaptive stress response
- Vision problems
- Speech and swallowing difficulties
- Neurogenic bladder
Expected outcomes:
- Patient will remain free from infection, falls, and injury.
- Patient will demonstrate interventions that improve physical endurance.
Assessment:
1. Assess the patient’s current activity level, functional impairment, and overall physical condition.
Assessing overall functionality and level of impairment can help develop a plan of care for patients with MS. Consider utilizing clinical rating scales such as the Expanded Disability Status Scale (EDSS) to monitor changes in the patient’s limitations.
2. Assess for fatigue and weakness.
Fatigue and weakness experienced by patients with MS can be debilitating and significantly impact their ability to protect themselves from injury or perform activities of daily living. Assess the severity and frequency of these symptoms.
3. Review medications.
Treatment for acute MS exacerbations includes corticosteroids, which suppress inflammation. Disease-modifying drugs are the cornerstone of therapy for MS and work by suppressing the immune system to prevent progression of the disease. The downside of these drugs is that they reduce the immune system’s ability to fight infections.
Interventions:
1. Aggressively treat infections.
Educate patients that infections and illness are triggers of MS exacerbations. Fevers must be controlled as increases in temperature can worsen symptoms and affect disease progression. Administer antibiotics and antipyretics as prescribed.
2. Instruct on strategies to prevent urinary tract infections.
Urinary tract infections commonly affect patients with MS as bladder dysfunction prevents effective emptying, and stagnant urine allows bacteria to thrive. The nurse should educate on these measures to reduce UTIs:
- Drink plenty of water to flush out the kidneys and bladder
- Prevent constipation, as this can further obstruct urine flow
- Always wipe from front to back after urinating and defecating
- If self-catheterizing, practice clean techniques to prevent introducing bacteria
3. Refer the patient to rehabilitation and physical therapy.
PT can help patients with MS with stretching and strengthening exercises that will make it easier to perform daily tasks and promote effective protection against injury and falls.
4. Refer the patient to a speech-language pathologist.
SLPs can help patients with MS overcome speech and swallowing difficulties and reduce the risk of aspiration.
5. Educate on strategies to prevent infection.
Patients with MS must take extra care to prevent infections and illnesses that can exacerbate MS, such as:
- Avoiding sick people and large crowds
- Practicing proper hand hygiene
- Receiving recommended vaccinations
- Monitoring for signs of infection (fever, chills, cough, skin breakdown, etc.)
Powerlessness
Multiple sclerosis steals from a person’s independence, and since there is currently no cure, a sense of powerlessness can develop.
Nursing Diagnosis: Powerlessness
Related to:
- Progressive nature of the disease
- Anxiety
- Depression
- Debility
- Inadequate motivation to improve one’s situation
- Inadequate social support
- Ineffective coping strategies
- Low self-esteem
- The perceived complexity of the treatment regimen
As evidenced by:
- Depressive symptoms
- Expresses doubt about role performance
- Expresses frustration about the inability to perform previous activities
- Expresses a lack of purpose in life
- Expresses shame
- Withdrawal
- Loss of independence
- Reports an inadequate sense of control
Expected outcomes:
- Patient will acknowledge feelings of powerlessness and actively participate in the planning and implementation of care.
- Patient will verbalize areas in which they do/do not have control.
Assessment:
1. Assess factors that contribute to feelings of powerlessness.
Identifying factors that make the patient feel powerless can help plan interventions to channel patient behavior effectively.
2. Assess the patient’s sense of control over their current situation.
Powerlessness is often associated with feelings of loss of control over the current medical situation. Note if there have been other changes in roles, their career, environment, social relationships, etc.
Interventions:
1. Encourage the patient to express feelings and thoughts about their condition.
The patient’s perceived barriers and susceptibility to the disease can affect the patient’s motivation to take action to participate in the treatment regimen, self-care management, and complication prevention.
2. Assist the patient in planning and identifying health goals.
Patients with MS often lose their sense of control over their health. Allowing them to plan their care can motivate them and promote a sense of control over their situation.
3. Acknowledge the reality of the patient’s health condition while expressing hope.
Even though the prognosis of MS can be discouraging, new treatments and technological advancements are occurring. Providing hope can help patients feel motivated.
4. Refer the patient to support groups.
Support and community groups can empathize with the patient in dealing with an uncommon and progressive disease.
Self-Care Deficit (Feeding)
Multiple sclerosis is a progressive condition and can cause self-care deficits as functional abilities deteriorate over time.
Nursing Diagnosis: Self-Care Deficit
Related to:
- Neuromuscular impairment
- Decreased strength
- Impaired physical mobility
- Fatigue
- Depression
- Memory Loss
As evidenced by:
- Tremor
- Muscle spasms
- Difficulty feeding self
- Difficulty swallowing food
- Difficulty using assistive devices
- Difficulty preparing and handling food
Expected outcomes:
- Patient will be able to feed themselves safely and effectively.
- Patient will demonstrate using assistive feeding devices.
Assessment:
1. Assess the degree of functional impairment that is causing a self-care deficit.
Multiple sclerosis is a progressive condition and can cause varying degrees of impairment.
2. Observe the patient feeding self/swallowing.
Establishing a baseline of the patient’s current abilities can help develop an appropriate plan of care for rehabilitation.
Interventions:
1. Encourage the patient to perform self-care as capable.
This will help promote independence and a sense of control while promoting strength and endurance.
2. Assist the patient in feeding and other self-care needs.
If unsafe to perform tasks, the nurse or other staff can assist the patient in feeding.
3. Provide small frequent meals with plenty of time.
Multiple sclerosis may affect swallowing later in the disease, and fatigue can occur with chewing. Smaller meals may be easier, and allowing plenty of time without rushing will lessen the risk of choking or aspiration.
4. Implement weighted utensils.
Weighted utensils can help with hand tremors or muscle spasticity.
References
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- Luzzio, C. (2023, June 30). Multiple sclerosis workup: Approach considerations, McDonald criteria for MS diagnosis, blood studies. Diseases & Conditions – Medscape Reference. Retrieved November 2023, from https://emedicine.medscape.com/article/1146199-workup#c14
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