MULTIPLE SCLEROSIS:

DEFINITION

Multiple sclerosis or disseminating sclerosis is a chronic, progressive, degenerative disease of central nervous system that affects myelin sheath and conduction pathways. it is characterized by inflammation, demyelination and scarring of myelin sheath.

INCIDENCE:

• It typically manifests in young adults between the age group of 20-40 years.
• Women are more frequently affected than men.
• Caucasians are affected more than any other race.

 

ETIOLOGY AND RISK FACTORS

• The exact cause is not known.
• Some environmental factors may trigger the initiation of disease like viral infection. The specific virus that is capable of initiating auto immune response has not been identified.
• Genetic pre disposition is indicated by presence of specific cluster (haplotype) of human leukocyte antigen on the cell wall.
• Auto immune activity.
• Non infectious environmental risk factors are stress; smoking, occupational exposure to toxins and some vaccinations may trigger the development of multiple sclerosis.

 
Types of multiple sclerosis:
 
There are mainly four types.

• Relapsing- remitting disease: this continues over 10 years period with minimal increase in deficits. in 50-70% of patients, it progress to secondary progressive type.
• Primary progressive disease: it is gradually progressive in which exacerbations occur but the patient does not return to the base line and is left with increasing residual disability.
• Secondary progressive disease: the disease starts as relapsing- remitting and becomes progressive after 2 decades. it is very difficult to adjust.
• Progressive relapsing disease: a progressive decline in inability follows symptom onset with progression during remission phases.

 
PATHOPHYSIOLOGY: (steps)
1. Due to causative factors
2. Sensitized T cells cross blood brain barrier and remains in the CNS
3. It promotes infiltration of other agents that damage immune system.
4. Destruction of myelin and oligodendral cells.
5. Interrupts flow of nerve impulses.
6. Produces variety of manifestation depending on the nerve affected.
The course of multiple sclerosis is highly variable and unpredictable. Sites of inflammatory demyelination can occur anywhere in brain and spinal cord and produces wide range of symptoms.
 
SIGNS AND SYMPTOMS:

Based on the symptoms they are divided into various categories.

 
SENSORY :

• Numbness and tingling sensation on the face or involved extremities.
• paresthesia ( burning, pricking)_
• Decreased proprioception
• Decreased sense of temperature, vibration and depth.
• Lhermitte’s sign: electric shock or shock like sensation that extends down the arm, back or lower trunk upon flexor of neck. This is due to buckling effect of the dorsal roots from sclerotic plaques.

MOTOR :

• Weakness or feeling of heaviness in lower extremities.
• Spasticity of limbs interferes with ambulation
• Bowel and bladder dysfunction.
• Diplopia.
• Uthoff’s sign: decline in the motor function after exposure to hot bath.

CEREBELLAR

• Ataxia.
• Loss of balance and co-ordination.
• Intentional tremor and nystagmus.
• Slurred speech and dysarthria.

NEURO BEHAVIORAL SYMPTOMS :

• emotional lability and depression
• Difficulty in learning new information.
• Short attention span.
• Poor judgment.
• Loss of short term memory.

OTHER

• Optic neuritis.
• impotence and sexual dysfunction
• fatigue, etc

 
DIAGNOSTIC FINDINGS:

• Complete information is gathered in history collection regarding causes and risk factors.
• A thorough examination is done to confirm the classic symptoms in the patient.
• MRI shows multiple plaques in the report.
• CSF analysis shows presence of oligodendral or clonal banding.
• Evoked potential studies define the extent of disease progress.
• Neuro-psychological testing helps to examine cognitive impairment.
• Positron emission tomography is advisable.

 
MANAGEMENT:

• There is no exact cure for multiple sclerosis. It can be indicated to relieve symptoms and provide continuing care the goals of the treatment are are administered subcutaneously.
• glitaramer acetate ( copaxone ) reduces the rate of relapse
• Methyl prednisolone shortens the duration.
• Mitoxantone (novantrone) is administered via IV and patient must be observed for cardiac toxicity.

Symptom treatment:

• Baclofen (lirosal) is a choice of drug for spasticity.
• Benzodiazepines (valium), tizinadine (zanaflex), dontrolene are also used for spasticity.
• Amantidine (symmetrel), pemoline (cylert) are used for fatigue.
• Beta adrenergic blockers (Inderal), anti seizure agents (neurontin) and benzodiazepines (klonopin) are taken for ataxia.
• Anti spasmodics are given to relieve bowel and bladder problems.
• Ascorbic acid (Vit C) is prescribed to acidify the urine and making bacterial growth less likely.
• Antibiotics are given when needed.
• Elderly patients with multiple sclerosis are particularly concerned about increasing disability and planned future care.

NURSING MANAGEMENT:

• Impaired physical mobility related to weakness, muscle paresis and spasticity.
• Impaired urinary and bowel elimination ( incontinence, urgency and constipation) related to nervous system dysfunction.
• Impaired verbal communication, related to cranial nerve impairment
• Risk for impaired skin integrity related to immobility,sensorimotor skillsand inadequate nutrition
• Sexual dysfunction related to neuromuscular deficits as manifested by impotence,verbalization of problem,decreased libido
• Interrupted family process related to changing family roles,potential family problems as manifested by strained family relations ,ineffective communication,verbalization
• .Disturbed thought process( loss of memory and dementia), related to cerebral dysfunction.
• Risk for injury, related to sensory and visual impairment.
• Ineffective individual coping, related to uncertainty of the course of multiple sclerosis.

 
NURSING DIAGNOSIS
Impaired physical mobility related muscle weakness or paralysis and muscle spasticity as manifested by by inability to ambulate,intermittent muscle spasms,,pain associated with muscle spasms

• Use assistive devices as indicated to decrease fatigue and enhance independence,comfort and safety
• Do range of motion exercises atleast 2 times a day to minimize contracturs and to prevent muscle atrophy
• Encourage and assist with ambulation
• Change the position of the patiet every 2^nd hourly to prevent circulatory problems and to prevent pressure sores especially in bed ridden patients
• Perform stretching exercises every 6-8 hours to prevent spasm and contractures

 
Impaired urinary and bowel elimination ( incontinence, urgency and constipation) related to nervous system dysfunction.

• Administer cholinergic drugs as ordered to improve the muscle tone of the bladder and facilitate bladder emptying
• Follow intermittent catheterization if the patient has complaints of dribbling,bladder distension
• Maintain fluid intake of 3000ml daily
• Teach the patient signs and symptoms of urinary tract infection
• Initiate bladder trtaining programme to restore adequate bladder function

 
Risk for impaired skin integrity related to immobility,sensorimotor skillsand inadequate nutrition

• Assess the skin for redness and breakdown to monitor changes in skin integrityand make appropriate plan for interventions
• Take care of the bony prominences
• Provide high protein diet to promote healthy skin and to prevent breakdown

 
Interrupted family process related to changing family roles,potential family problems as manifested by strained family relations ,ineffective communication,verbalization

• Initiate sexual counselling if indicated
• Suggest alternative methods of achieving sexual gratificationbecause sexual intercourse maynot be possible due to neuromuscular dysfunction

 
Sexual dysfunction related to neuromuscular deficits as manifested by impotence,verbalization of problem,decreased libido

• Facilitate open communicationamong patient and family to promote interpersonal realtions
• Promote problem solving to enable the family to handle the issues of long term illness
• Educate the family members regarding fluctuating nature of the disease

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