Multiple sclerosis (MS) is a chronic, progressive, degenerative disease of the central nervous system. It is characterized by disseminated demyelination of the nerve fibers of the spinal cord and brain.
The age of onset is often between 20 to 40 years of age. This condition affects women more than men, and Caucasian people more than any other race.
There are several 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.
Secondary progressive MS (SPMS): This often occurs after an initial diagnosis of RRMS, where the disease progressively 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.
The cause of MS is unknown. However, possible precipitating factors of this condition include a family history of MS, a history of viral infections like Epstein-Barr, smoking, other autoimmune diseases, and low levels of vitamin D.
Clinical manifestations of MS often exhibit slowly and gradually, with symptoms occurring periodically over several months or years. Since the symptoms are vague in most cases, patients with MS often do not seek treatment until later in the disease process. Other patients, however, experience MS with rapid and progressive deterioration in neurologic function. MS symptoms can vary with each patient and may include any of the following:
- Vision changes
- Extremity muscle weakness
- Poor balance and coordination
- Partial or complete paralysis of the extremities
- Speech impairments
- Hearing loss
- Dizziness
- Tremors
- Severe disabling fatigue
- Sexual, urinary, or bowel dysfunction
There is no definitive diagnostic test for MS, and testing is often used to rule out other possibilities. An MRI will help visualize the plaques, atrophy, inflammation, and tissue breakdown of the brain and spinal cord.
To confirm the diagnosis of MS, the patient must have at least 2 inflammatory demyelinating lesions in different parts of the CNS, an attack occurring at different times, and all other possible diagnoses ruled out.
Nursing Process
There is no established cure for MS at this time. Its treatment is aimed at managing the disease 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 relieve neurologic deficits. They encourage MS patients to stay active, avoid fatigue, and use stress reduction techniques to help boost their immune system and live a normal lifestyle.
Nursing Assessment
Effective nursing assessment is critical in managing MS, ensuring optimal patient outcomes, and enhancing the quality of life for individuals affected by this debilitating condition.
Initial Evaluation
The initial evaluation of a patient with suspected MS involves a thorough medical history and physical examination. Key aspects to assess include:
Medical History: Review the patient’s history for risk factors such as family history of MS, recent infections, or exposure to environmental triggers. Inquire about symptoms such as visual disturbances, muscle weakness, numbness, and coordination difficulties, which are common in MS.
Physical Examination: Perform a comprehensive physical examination focusing on neurological signs, such as altered reflexes, muscle spasticity, tremors, and gait disturbances. Assess for signs of sensory dysfunction, including numbness, tingling, and pain.
Laboratory and Diagnostic Tests: Obtain baseline laboratory tests and imaging studies, including MRI scans to detect lesions in the CNS. Lumbar puncture may be conducted to analyze cerebrospinal fluid for the presence of oligoclonal bands, which are indicative of MS.
Ongoing Monitoring
Continuous monitoring of a patient with MS is essential to track disease progression and evaluate the effectiveness of interventions. Key areas to monitor include:
Neurological Status: Regularly assess the patient’s neurological status, including motor and sensory function, cognitive abilities, and coordination. Document any changes and new symptoms.
Functional Abilities: Evaluate the patient’s ability to perform activities of daily living (ADLs) and assess their need for assistive devices or modifications to their living environment.
Psychosocial Status: Monitor the patient’s emotional and psychological well-being, as MS can significantly impact mental health. Assess for signs of depression, anxiety, and stress, and provide appropriate support and referrals as needed.
Nursing Interventions
By adopting a holistic approach, nurses can significantly impact the management of MS, helping patients achieve better control over their symptoms and ultimately reducing the risk of severe health complications.
Symptom Management
Symptom management is a key aspect of MS care, and nursing interventions should focus on alleviating symptoms and improving patient comfort. Key interventions include:
Medications: Administer prescribed medications, such as disease-modifying therapies (DMTs), corticosteroids, and muscle relaxants, to manage symptoms and reduce the frequency of relapses. Educate patients on the potential side effects and the importance of medication adherence.
Physical Therapy: Collaborate with physical therapists to develop individualized exercise programs that enhance strength, flexibility, and mobility. Encourage regular physical activity to prevent muscle atrophy and maintain functional abilities.
Pain Management: Implement pain management strategies, including pharmacological and non-pharmacological approaches, to address neuropathic pain and musculoskeletal discomfort.
Patient Education and Support
Providing comprehensive education and support is crucial in empowering patients with MS to manage their condition effectively. Key areas of focus include:
Disease Understanding: Educate patients and their families about the nature of MS, its symptoms, and the importance of early intervention and ongoing management. Provide resources and information to help them make informed decisions about their care.
Lifestyle Modifications: Offer guidance on lifestyle modifications that can improve overall health and well-being, such as maintaining a balanced diet, staying hydrated, and avoiding triggers that may exacerbate symptoms.
Emotional Support: Offer emotional support and reassurance to patients experiencing the challenges of living with MS. Listen to their concerns and provide empathetic care to address their emotional and psychological needs.
Follow-Up Care
Regular follow-up care is essential to monitor the patient’s progress, reassess symptoms, and adjust the care plan as needed. Key components of follow-up care include:
Regular Follow-Up Visits: Schedule regular follow-up visits to evaluate the patient’s condition, track disease progression, and adjust treatment plans accordingly. Ensure the patient knows when to seek medical attention for worsening symptoms or complications.
Addressing Barriers: Identify and address any barriers to the patient’s progress, such as medication side effects, mobility challenges, or psychosocial factors. Collaborate with the patient to find practical solutions and provide appropriate referrals.
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.
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:
- The patient will verbalize increased strength and demonstrate an increased ability to move
- The 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.
Powerlessness
Multiple sclerosis steals from a person’s independence, and since there is currently no cure, a sense of powerlessness can develop.
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:
- The patient will acknowledge feelings of powerlessness and actively participate in the planning and implementation of care
- The 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.
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:
- The patient will be able to feed themselves safely and effectively
- The 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.
Nursing Diagnoses and Rationales for Multiple Sclerosis
1. Impaired Physical Mobility
Rationale: Multiple sclerosis (MS) often leads to impaired physical mobility due to muscle weakness, spasticity, and coordination issues. Assessing the patient’s mobility levels, providing physical therapy, and incorporating assistive devices can help maintain or improve mobility. Regular exercise and stretching routines are vital to prevent contractures and enhance muscle strength.
2. Fatigue
Rationale: Fatigue is a common and debilitating symptom for MS patients. It can be due to the disease itself, medication side effects, or secondary issues like sleep disturbances. Assessing the patient’s levels of fatigue, promoting energy conservation strategies, and encouraging a balanced diet and adequate rest can help manage this symptom. Occupational therapy can also assist in developing effective activity management plans.
3. Chronic Pain
Rationale: MS can cause chronic pain due to nerve damage, muscle spasms, and other factors. Assessing the patient’s pain level and providing a combination of pharmacological (e.g., analgesics, antispasmodics) and non-pharmacological (e.g., physical therapy, heat/cold therapy) pain management strategies can help alleviate pain. Regular follow-ups are essential to adjust treatment plans as needed.
4. Self-Care Deficit
Rationale: Due to physical limitations, MS patients may struggle with activities of daily living (ADLs). Assessing the patient’s ability to perform ADLs, providing occupational therapy, and incorporating adaptive equipment can help maintain independence. Educating patients and caregivers about strategies to manage daily tasks effectively is also crucial.
5. Risk for Infection
Rationale: MS patients may have a weakened immune system due to the disease and its treatments, increasing their risk of infections. Monitoring for signs of infection, promoting good hygiene practices, and encouraging vaccinations can help prevent infections. It is also important to educate patients and their families about recognizing early symptoms of infections and seeking prompt medical attention.
6. Impaired Urinary Elimination
Rationale: MS can cause bladder dysfunction, leading to issues such as urinary retention or incontinence. Assessing the patient’s urinary patterns, providing bladder training, and recommending appropriate medications can help manage these issues. In some cases, the use of intermittent catheterization or other interventions may be necessary.
7. Risk for Constipation
Rationale: Constipation is a common problem in MS patients due to decreased mobility, medications, and dietary factors. Assessing bowel patterns, promoting a high-fiber diet, ensuring adequate fluid intake, and encouraging regular physical activity can help prevent constipation. In some cases, the use of stool softeners or laxatives may be necessary.
8. Ineffective Coping
Rationale: The chronic and unpredictable nature of MS can lead to significant emotional distress and ineffective coping mechanisms. Assessing the patient’s emotional state, providing psychological support, and involving mental health professionals can help address these issues. Encouraging participation in support groups and promoting adaptive coping strategies are also important.
9. Risk for Depression
Rationale: The chronic and debilitating effects of MS can contribute to feelings of sadness, hopelessness, and depression. Monitoring for signs of depression, providing emotional support, and referring to mental health professionals as needed can help address this risk. Encouraging participation in enjoyable activities and fostering a positive outlook are also important strategies.
10. Risk for Social Isolation
Rationale: Social isolation is a common issue for MS patients due to mobility limitations and potential stigma. Assessing the patient’s social network, providing opportunities for social interactions, and involving them in community activities can help reduce isolation. Educating the patient and their family about the condition can also improve social support and decrease stigma.
11. Impaired Verbal Communication
Rationale: MS can affect speech and communication due to muscle weakness, spasticity, and cognitive changes. Assessing the patient’s communication abilities, providing speech therapy, and incorporating communication aids can help improve verbal communication. Educating caregivers and family members on effective communication techniques is also vital.
12. Sensory-Perceptual Alterations
Rationale: MS can cause sensory-perceptual alterations, including vision problems, numbness, and tingling. Assessing the patient’s sensory function, providing interventions to enhance safety (e.g., proper lighting, clear pathways), and educating patients about compensatory strategies are essential. Regular eye exams and appropriate treatments for vision issues are also important.
13. Impaired Swallowing
Rationale: Dysphagia, or difficulty swallowing, can occur in MS patients due to muscle weakness and coordination issues. Assessing the patient’s swallowing ability, providing speech and swallowing therapy, and recommending dietary modifications can help manage this problem. Ensuring that patients eat slowly and in an upright position can also reduce the risk of aspiration.
14. Sexual Dysfunction
Rationale: MS can impact sexual function due to physical, psychological, and neurological factors. Assessing the patient’s concerns and providing information on sexual health and intimacy can help address this issue. Referring to specialists, such as urologists or sex therapists, may be necessary for more comprehensive care.
REFERENCES
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Thompson, A. J., et al. (2024). Multiple sclerosis: Clinical challenges and ongoing management. The Lancet Neurology, 23(1), 45-62.
- Maloni H, Hillman L. Multidisciplinary Management of a Patient With Multiple Sclerosis: Part 2. Nurses’ Perspective. Fed Pract. 2015 Apr;32(Suppl 3):17S-19S. PMID: 30766114; PMCID: PMC6375496.
- Smith, K. B., & McDonald, W. I. (2023). The pathophysiology of multiple sclerosis: Understanding disease mechanisms. Journal of Neurology, Neurosurgery & Psychiatry, 94(8), 891-902.
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- Williams, M. P., et al. (2023). Contemporary nursing interventions in multiple sclerosis care. American Journal of Nursing, 123(4), 34-45.
- Brown, S. L., & Davis, C. M. (2024). Quality of life outcomes in multiple sclerosis: A nursing perspective. International Journal of MS Care, 26(1), 12-23.
- Multiple sclerosis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/multiple-sclerosis/symptoms-causes/syc-20350269
- Overview: Multiple sclerosis. NHS. https://www.nhs.uk/conditions/multiple-sclerosis/
- What is MS? National Multiple Sclerosis Society. 2022. From: https://www.nationalmssociety.org/What-is-MS
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