MULTIPLE SCLEROSIS

Definition
 Multiple sclerosis is a chronic disease
characterized by exacerbations and
remissions caused by progressive
demyelization of the white matter of the brain
and spinal cord with sporadic patches of
demyelination in various parts of the long
conduction pathways of the CNS causing wide
spread and varied neurologic dysfunction.
Def
 Multiple sclerosis is a
chronic,progressive,degenerative disorder of
the CNS characterized by disseminated
demyelination of nerve fibers of the brain and
spinal cord.
Causes
 The cause of multiple sclerosis is unknown
but there are some factors that are thought to
cause the infection.
1) Viral infections affects the white matter of
the brain and spinal cord, producing
demyelinated lesions that prevent normal
conducting of nerve impulses.
Cont’
2) The susceptibility to MS appears to be
inherited.
3) Physical injury, excessive fatigue and poor
state of health may cause MS
Pathophysiology
 Multiple sclerosis is characterized by chronic
inflammation, demyelinated and glosis
(scarring) in the CNS. The primary
neuropathologic condition is an autoimmune
disease orchestrated by auto-reactive T cell
(lymphocytes). The process may be initially
triggered by a virus in genetically susceptible
individuals. The activated T –cells in the
systemic circulation migrate to the CNS,
causing blood brain barrier disruption.
Cont’
 This is likely the initial event in the
development of MS. Subsequent antigen-
antibody reaction within the CNS results in
activation of the inflammatory response and
through multiple effector mechanism, leads to
demyelination of the axon.
 The disease process consists of loss myelin, of

digodendrocytes and proliferation of astrocytes.

These changes results in characteristics plague
formation or sclerosis with plague scattered
throughout multiple regions of the CNS.
Cont’
 Initially the myelin sheaths of the neurons in
the brain and spinal cord are attacked. Early
in the disease the myelin sheath is damaged.
However the nerve fibers is not affected and
nerve impulses are still transmitted. At this
point the patient may complain of a
noticeable impairment function eg weakness.
 However the myelin can regenerate and the

symptoms will disappear therefore the

patient experiences a remission.
Cont’
 In addition to myelin, the axon also become
involved. Myelin is replaced by glial scar
tissue which forms hard sclerotic plagues in
multiple regions of the CNS. Without myelin
nerve impulses slow down. With destruction
of nerve axons, impulses are totally blocked
resulting in permanent loss of function. In
many chronic lesions, demyelination
continues with progressive loss of nerve
function.
Clinical Manifestation
 The onset of the disease is often insidious, with
vague symptoms occurring intermittently over
months or years. The disease may not be
diagnosed untill long after the onset of the first
symptoms. The disease process has a spotting
distribution in the CNS, so the signs and
symptoms vary over time.
 The disease is characterized by chronic,

progressive deterioration in some persons and

by remissions and exacerbations in others.
Cont’
 With repeated exacerbations, however
progressive scaring of the myelin sheath
occurs, and the overall trend is progressive
deterioration in neurologic function.
 Common signs and symptoms include motor,

sensory, cerebellar and emotional problems.

 Motor symptoms include; weakness, paralysis

of the limbs, trunk or head, scarring speech

and spasticity of the muscles that are
chronically affected.
Cont’
 Sensory symptoms include; Numbness and
tingling , patchy blindness, blurred vision,
decreased hearing and chronic neuropathic
pain.
 Cerebellar signs; ataxia, dysarthria and

dysphagia.
 Emotional symptoms; severe fatigue is

present and causes significant disability for

some patients.
Cont’
 Bowel and bladder function can be affected if
the sclerotic plague is located in areas of the
central nervous system that control
elimination. A common problem in MS
patients is a spastic (inihibited]bladder. This
indicates a lesion above the second sacral
nerve, which cuts off suprasegental inhibiting
influences on bladder contractility. As the
result, the bladder has a small capacity for
urine and its contractions are unchecked.
Cont’
 Sexual dysfunction occurs in many persons
with multiple sclerosis. Physiologic erectile
dysfunction may result from spinal cord
involvement in men. Dimished sensation can
prevent a normal sexual response in both
sexes. The emotional effects of chronic
illness and loss of self esteem also contribute
to loss of sexual response.
Cont’
 The average life expectancy after the onset of
symptoms is more than 25 years. Death
usually occurs due to infective complications
(e.g.hypostatic pneumonia) of immobility or
because of an unrelated disease.
GENERAL MANAGEMENT
 INVESTIGATIONS

1. ECG (Electroencephalogram) shows

abnormalities in one third of the patients with
multiple sclerosis.
2. CSF (cerebral spinal fluid) analysis reveals
elevated immunoglobulin G (igG) but normal
total protein levels. This indicates
hyperactivity of the immune system due to
chronic demyelination.
3. MRI and CT scan may disclose lesions within
the brain’s white matter.
MEDICAL MANAGEMENT
 There is currently no cure for multiple
sclerosis, collaborative care is aimed at
treating the disease process and providing
symptomatic relief. The disease process is
treated with drugs. The symptoms are
controlled with a variety of drugs and other
forms of therapy.
DRUG SYMPTOMS SIDE EFFECTS AND PATIENT TEACHING
Drugs Used
RELIEVED In Treating MS
PRECAUTIONS

CORTICOSTERO Exacerbatio Edema, mental •Restrict salt intake.

IDS ns changes (euphoria), •Do not abruptly
ACTC, weight gain, stop therapy
Prednisolone, redistribution of body
Methyprednisol fat.
one

IMMUNOMODU Exacerbatio Flu-like symptoms, •Perform self-

LATORS ns local skin reactions, injection techniques
B-interferon, depression, monitor •Report side effects
( Betaseron, CBS, blood chemistries
Avonex, Rebif) and liver function
tests.
 Cont’RELIEVED
DRUGS SYMPTOMS SIDE EFFECTS AND PATIENT TEACHING
PRECAUTIONS

MUSCLE Spasticity Drowsiness, ataxia, •Avoid driving and

RELAXANT fatigue, similar activities
Diazepam contraindicated with because of CNS
(valium) history of narrow- depressant effects.
angle glaucoma •Be aware of addictive
potential.
•Avoid long term use.
BECLOFEN Spasticity Drowsiness, •Do not abruptly stop
Lioresal weakness, used therapy (possibility of
cautiously with a hallucination)
history of hyper- •Avoid driving and
sensitivity and renal similar activities
damage, possible because of sedative
exacerbation of effects.
seizures in patients •Take with food or
NURSING CARE
 OBJECTIVES

 To provide emotional support.

 To provide self esteem.
 To promote physical mobility
Psychological Care
 Explain the condition to the patient in the
language he/she understands in order to
alley anxiety.
 Allow the patient to ask questions and answer

his/her questions honestly in order to allay

anxiety.
 Stay with the patient during crisis periods to

prevent further complications.

 Encourage the patient by suggesting ways to

help him cope with the disease.

Exercises
 Assist with active, resistive and stretching
exercise to maintain muscle tone and joint
mobility, decreased spasticity, improve
coordination and boost morale.
 Increase patients comfort with messages and
relaxing baths, make sure the water is not too
hot because it may temporarily intensify
otherwise subtle symptoms.
 Provide rest periods between exercises because
fatigue may contribute to exacerbations
 Assist with physical therapy.
Nutrition
 Give various nutritional measures such as
megavitamin therapy (vitamin B12), vitamin C
and diets consisting of low-fat and gluten-
free food and raw vegetables.
 Give juice such as cranberry juice which can

prevent bacteria from sticking on the walls of

the bladder, which may decrease the number
of urinary infections, a common condition in
patient with multiple sclerosis.
Rest
 Encourage patient to have rest regularly to
prevent exhaustion.
Elimination
 Keep the bed pan or urinary readily accessible
because the need to void is immediate
 Evaluate the need for bowel and bladder

training during hospitalization.

 Encourage adequate fluid intake and regular

urination.
 Eventually, the patient may require urinary

draining by self-catheterization, or in men

condom catheter.
Information Education &
Communication
 Educate the patient and his family about
his/her condition or chronic disease to alert
them in case of any exacerbation or any signs
and symptoms.
 Emphases the need to avoid stress, infections

and fatigue also how to develop new ways of

performing daily activities to avoid further
complications.
 Educate the patient on the importance of

exercise which maintains muscle tone and

joint mobility and decrease spasticity.
Cont’
If the patient has trouble with position sense,
tell him/her to watch his/her feet while walking
to avoid injuries from falls and emphasise on the
importance of eating a nutritious, well balanced
diet that contains sufficient roughage and fluids
to prevent constipation.
 If the patient is in danger of falling, a wheel

chair may be required.

 Teach the patient how to use suppositories to

establish a regular bowel elimination schedule.

Complications
 Injuries from falls due to exacerbation.
 Urinary tract infections due to bacteria

invading the bladder.

 Constipation.
 Joint contractures.
 Pressure sores.
Summary
 Multiple sclerosis is a chronic, progressive,
degenerative disorder of the CNS
characterized by disseminated demyelinated
of the nerve fibers of the brain and spinal
cord.
 In multiple sclerosis a viral infection affects

the white matter of the brain and spinal cord,

producing demyelinated lesions that prevent
normal conduction of nerve impulses.
Cont’
 The demyelination results in sclerotic patches
or scarring, and the remissions, typical in
multiple sclerosis is the result of healing of
these areas. However, in times these lesions
degenerate to a point where recovery is
unlikely and the resultant disruption of
function becomes permanent.