Med-Surg: Chapter 37: Multiple Sclerosis

Question 1

Multiple Sclerosis (MS)

Answer 1

chronic neurological disorder in which the nerves of the CNS (brain and spinal cord) degenerate

• derives its name from the build up of scar tissue (sclerosis) or plaques that for during demyelination (destruction of myelin sheath)
• autoimmune disease; the immune system mistakenly identifies normal body substances and tissues as foreign and attacks them; the immune system attacks the brain and spinal cord (CNS)

Question 2

Risk Factors

Answer 2

• 20 to 50 years old
• women
• positive family hx
• immunological factors
• viral infections
• higher in colder, more northern latitudes

Question 3

4 Main types of MS

Answer 3

• Relapsing-remitting
• Secondary progressive
• Progressive relapsing
• Primary progressive

Question 4

Types of MS: Relapsing-Remitting

Answer 4

• most common form
• characterized by relapses (exacerbations) during which new clinical manifestations appear and old ones worsen or reappear
• relapses can last days or months
• relapses are followed by periods of remission during which the patient has either a partial or total recovery; this can be slow or instantaneous

Question 5

Types of MS: Secondary Progressive

Answer 5

the patient who initially had relapsing-remitting develops gradual worsening of the disease

• in the early phase, the patient still may experience relapses, but these will progress into a general deterioration
• no real recovery occurs

Question 6

Types of MS: Progressive relapsing

Answer 6

progressive course with a gradual worsening of clinical manifestations from onset, and the relapses may or may not have recovery

Question 7

Types of MS: Primary progressive

Answer 7

gradual progression with no remissions

• may be temporary plateaus
• affects women and men equally
• occurs late 30’s early 40s
• initial disease activity is in the spinal cord, not the brain, so these patients less likely to develop cognitive problems

Question 8

Pathophysiology

Answer 8

• myelin is the protective sheath that covers the spinal cord and nerves; it not only protects the nerve, but it also helps the impulses travel along the nerves at a faster rate; these impulses control muscle movements, as well as transmitting sensory data
• the CNS contains the blood-brain barrier that separates circulating blood from the brain’s extracellular fluid; barrier is composed of tight junctions between endothelial cells in the CNS vessels that restrict the passage of solutes from the bloodstream
• Demyelination is the loss of the myelin sheath; it begins with the breakdown of the blood-brain barrier that allows immune cells (T lymphocytes) to infiltrate and attack the myelin
• in MS, the immune system attacks the brain and spinal cord (CNS)

Question 9

Demyelination

Answer 9

the loss of the myelin sheath

Question 10

Clinical Manifestation

Answer 10

the resulting inflammation in MS destroys the myelin, resulting in impaired sensation, movement, and thinking

• nerves can regain myelin, but this occurs more slowly than deterioration in MS
• nerve conduction is slowed or irregular due to loss of myelin that facilitates impulse transmission

> manifestations:

• numbness or weakness in one or more limbs
• partial or complete vision loss, often with pain during eye movement (optic neuritis)
• double or blurred vision
• tingling or pain
• electric-shock sensations that occur with head movements
• tremor, lack of coordination, or unsteady gait
• fatigue
• dizziness

Question 11

Diagnosis

Answer 11

-no specific test; can be difficult to diagnose
-may not be diagnosed for months to years after onset of clinical manifestations
-diagnosis is made by ruling out conditions with similar presentations
-detailed hx, physical, and neurological examination are performed
-blood samples are sent to the laboratory to r/o other inflammatory or infectious diseases that may have the same clinical manifestations; vitamin B12 and E deficiencies, Lyme titer, antineutrophil antibodies (ANA) for autoimmune diseases, angio-tensin converting enzyme for sarcoidosis, HIV/HTLV (human T-lymphotropic virus), erythrocyte sedimentation rate (ESR) for inflammation, rapid plasma reagin (RPR) for neurosyphilis, anticardiolipin antibodies, and lupus anticoagulant for coagulopathy/vascular conditions
>a lumbar puncture performed to send CSF sample to be tested for abnormal levels of WBC or proteins and help r/o viral infections
-MRI scans for brain lesions (plaques)
-Electrophysiological tests, and evoked potentials to examine how quickly impulses are traveling through the nerves

Question 12

For a definitive diagnosis

Answer 12

patient must have at least 2 separate symptomatic events or MRI changes in at least 2 separate locations

Question 13

Treatment

Answer 13

• no cure
• focuses on improving the speed of recovery from attacks, reducing the number of attacks, and slowing the progression of the disease
• lifestyle management: adequate rest, exercise, staying cool, healthy balanced diet, and relieving stress because these can all trigger exacerbation or flare of MS
• physical therapy used to help strengthen muscles and improve daily function
• Betaseron (Interferon beta-1b) modifies/slows the disease process

Question 14

Medical Management

Answer 14

> First, medications used to modify the disease course; these are used to slow the progression of the disease

• beta interferons: interferon beta-1a (Avonex, Betaseron, and Rebif); interferon beta-1b (Extavia)
• glatiramer (Copaxone)
• fingolimod (Gilenya)
• immunosuppressive agents: natalizumab (Tysabri) and mitoxantrone (Novantrone)

> Second, strategies used to treat attacks include
-corticosteroids and plasma exchange (plasmapheresis) to decrease the inflammatory and immunologic factors involved in the exacerbation

> Final focus, treat clinical manifestations
-muscle relaxants such as baclofen (Lioresal and Kemstro) and tizanidine (Zanaflex) decrease spasticity

> medications may also be prescribed to help reduce fatigue and used to treat depression, pain, and bladder or bowel problems

Question 15

Medication: Interferon beta-1a (Avonex, Refib)

Answer 15

immunomodulator

• use to modify the disease course; slow the progression of the disease
• alters the immune system by reducing the body’s ability to make antibodies; these antibodies are what attack the myelin; therefore, this slows the attack on myelin and slows disease progression

Question 16

Medication: Interferon beta-1b (Betaseron, Extavia)

Answer 16

immunomodulator

• used to modify the disease course; slow the progression of the disease
• alters the immune system by reducing the body’s ability to make antibodies; these antibodies are what attack the myelin; therefore, this slows the attack on myelin and slows disease progression

Question 17

Medication: Glatiramer (Copaxone)

Answer 17

immunomodulator-synthetic protein

• used to modify the disease course; slow the progression of the disease
• alters the immune system by reducing the body’s ability to make antibodies; these antibodies are what attack the myelin; therefore, this slows the attack on myelin and slows disease progression

Question 18

Medication: Fingolimod (Gilenya)

Answer 18

immunomodulator-synthetic protein

• used to modify the disease course; slow the progression of the disease
• alters the immune system by reducing the body’s ability to make antibodies; these antibodies are what attack the myelin; therefore, this slows the attack on myelin and slows disease progression
• first oral immunomodulator for MS

Question 19

What Medications are used to modify the disease course?

Answer 19

• Interferon beta-1a (Avonex, Rebif)
• Interferon beta-1b (Betaseron, Extavia)
• Glatiramer (Copaxone)
• Fingolimod (Gilenya)
• Immunosuppressants (Natalizumab (Tysabri), Mitoxantrone (Novantrone)

Question 20

Medication: Immunosuppressants

Answer 20

-Natalizumab (Tysabri)
-Mitoxantrone (Novantrone)
>modify the disease process
-suppresses body’s immune response to prevent leukocytes from attacking each other

Question 21

Medication: Muscle relaxant and antispasmodic

Answer 21

-Baclofen (Lioresal, Kemstro)
-Tizanidine (Zanaflex)
>depress CNS to reduce pain and inhibit reflexes at the spinal level to decrease muscle spasm

Question 22

Medication: Corticosteroid

Answer 22

• Prednisone
• Cortisone
• Hydrocortisone
• Methylprednisolone sodium succinate (Solu-Medrol)

> mimic the effects of hormones produced in the adrenal glands; decrease inflammation by blocking the production of substances that trigger allergic and inflammatory reactions (e.g. prostaglandins)

Question 23

Medication: Anticholinergic; antispasmodic

Answer 23

• Oxybutynin chloride (Ditropan)

- inhibits transmission of impulses through parasympathetic nerve fibers

Question 24

Medications: Analeptics

Answer 24

• Modafinil (Provigil)
• Armodafinil (Nuvigil)

> alter neurotransmitters to improve wakefulness

Question 25

Medications: Stool Softeners

Answer 25

- Docusate (Colace) | - absorb water in the large intestine, increasing the bulk of the stool

Question 26

Medications: Antimuscarinics

Answer 26

- Tolterodine (Detrol) | - reduces bladder spasms by inhibiting acetylcholine

Question 27

Medications: Laxatives (Osmotic)

Answer 27

- milk of magnesia - Miralax - Lactulose >pull fluids into the intestine from other tissue and blood vessels; the extra fluid makes the stool softer and easier to pass

Question 28

Medications: Laxatives (Stimulant)

Answer 28

- Correctol - Dulcolax - Senokot >irritates the intestinal lining and speeds up how quickly stool moves through the intestines

Question 29

Complications

Answer 29

-muscle stiffness or spasms -paralysis, often in the legs -problems with bladder, bowel, or sexual function -mental status changes- memory loss, problems concentrating -depression -seizures >other: pressure injuries resulting from immobility, skin breakdown caused by bladder and bowel incontinence, ataxic gait caused by weakness and loss of position sense in the legs; speech defects caused by muscle weakness; mood changes such as depression, euphoria, denial, and forgetfulness may be caused by both medications an demyelination process

Question 30

Nursing Management: Assessment and Analysis

Answer 30

because MS affects varying nerves throughout the body, the clinical presentation may change with each attack; clinical manifestations are the direct result of the demyelination process - numbness/weakness - complete or partial loss of vision - double or blurred vision - fatigue - dizziness - tremor - lack of coordination/balance - speech problems--especially articulation - memory loss >other: depression, paranoia, reduce bowel or bladder control

Question 31

Nursing Assessments

Answer 31

>Neuromuscular function -evaluate for changes in clinical presentation or for new symptoms to be addressed as the disease progresses and new areas of demyelination occur >Vision/eye movement -demyelination of cranial nerves can result in optic neuritis, causing visual changes >Skin integrity -immobility promotes breakdown as a result of compression of soft tissue between a bony prominence and an external surface; this compromises blood flow and decreases delivery of oxygen and nutrients to cells, resulting in cellular death and injury to the surrounding tissue >Ability to perform ADLs -evaluate need for assistive devices to decrease danger of falls >Bowel and Bladder Function -impaired innervation to the bladder and bowel may result in incontinence and constipation

Question 32

Nursing Actions

Answer 32

>Encourage ROM exercises -increase venous return, prevent stiffness, and maintain muscle strength and endurance >Administer interferon beta-1b (Betaseron) -used to decrease exacerbations and slow disease progression >Administer corticosteroids during exacerbations -during an exacerbation of MS, typically a result of some type of stress, corticosteroids decreases the inflammatory process associated with the flare >Implement Safety Measures -b/c of changes in mobility, sensation, and vision, the patient is at increased risk for falls and injury >Patch each eye daily as needed in patients with visual deficits and/or diplopia -alternating the patching of each eye several times per day improves balance and vision

Question 33

Teaching

Answer 33

>Take Medications as prescribed -decrease exacerbations/slow progression; to treat clinical manifestations >Importance of rest periods and preventing fatigue and overheating -fatigue, overexertion, and overheating stimulate MS exacerbations >Clinical Manifestations of MS exacerbation -to detect early signs to receive early tx >Visual Scanning -b/c peripheral vision may be decreased in patients with MS, visual environment scanning decreases risk of injury >Check water temperature prior to entering the bathtub or shower -decreased sensation secondary to demyelination makes the patient at risk of burn injuries if the water is too hot >Maintain ideal body weight -impaired immobility may increase weight gain and increased weight is associated with complications with mobility and fatigue in patients with MS >Review disease process and prognosis -helps increase understanding and enhance patient's ability to make informed choices

Question 34

Evaluating Care Outcomes

Answer 34

patients with MS live their lives never knowing when the next exacerbation or attack will occur - compliance with medication regimen, specifically Betaseron, helps reduce these exacerbations - patient and family education important regarding medication regimen. clinical manifestations of exacerbation, and importance of getting rest and exercise - goals of care: keep patient as active and functional as possible, provide symptomatic relief, and provide continued support