3. Multiple scelorosis, NERVOUS SYSTEM CONDITIONS

A disease that affects the nervous system

1. Multiple sclerosis Edson katsomyo

2. Definition

3. background Its one of the autoimmune disorders of the nervous system that attack the CNS which include the brain and the Spinal cord, or PNS consisting of the nerves that connect the CNS, other examples include myasthenia gravis, and Guillain- barre syndrome

4. Incidence

5. Risk factors and etiology The exact cause is not known It’s presumed to be caused by Epstein Barr virus. Risk factors: Age (between 20 to 40 years) Sex (mostly women) Family history (genetically susceptible) Certain infections (Epstein Barr virus). low levels of vitamin D

6. Risk factors cont. Smoking Certain auto- immune disease; higher risk with thyroid disease Stress, fatigue Pregnancy ( stress for labor or puerperium Physical injury Climate (more in cold/ temperate weather) obesity

7. Clinical manifestations

8. 1. Relapsing – remitting MS Most common initial patten Episodes of acute worsening with recovery , and a stable course between relapses 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

9. 2. Primary progressive MS Gradual, nearly continuous neurologic deterioration from onset of manifestation 15% of patients may receive this diagnosis which is a steady worsening of neurological function without any periods of remission or flares.

10. 3. Secondary progressive MS: Gradual neurologic deterioration with or without superimposed acute relapses in the client who previously had relapsing remitting MS. This often occurs after an initial diagnosis of RRMS, where the disease slowly worsens.

11. 4. Progressive relapsing MS Gradual neurologic deterioration from the onset of manifestations but with sub-sequent superimposed relapses.

12. Other symptoms are Motor : diplopia (double vision) Paralysis of limbs, head and trunk Spasticity of muscles that are chronically affected: a condition where muscles become stiff and tight, making movement difficult and sometimes causing involuntary spasms. Scanning speech: a disrupted speech pattern with long pauses between words or syllables, making speech sound monotonous or robotic.

13. Cont. Cerebellar signs Ataxia dysphagia Nystagmus dysarthria

14. Sensory Blurred vision Numbness, tingling and other paresthesia Patchy blindness vertigo, tinnitus Decreased hearing Chronic neuropathic pain. Nerve root pain

15. Emotional problems Fatigue (associated with energy needs) Deconditioning Medication side effects depression

16. Diagnostic evaluation

17. Diagnostic/ investigations 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.

18. 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.

19. 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

20. 5. 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

21. Medical management No exact cure Major aim is to prevent long term disability Treatment is under 3 categories. Treatment of acute relapse Treatment aimed at disease management Symptomatic treatment.

22. 1. Treatment of acute relapse Corticosteroid therapy given as anti-inflammatory and immunosuppressive like: methyl-prednisolone Azathioprine & cyclophosphamide (in severe cases)

23. 2. Treatment of exacerbations Treatment aimed at disease management and examples of drugs given: Interferon beta 1a Avonex for treating relapsing form of MS Interferon beta 1b like betaseron, given subcutaneously for ambulatory clients with relapsing- remitting Glatiramer acetate like copaxane for relapsing re-emitting MS

24. 3. Symptomatic treatment For constipation like suppositories, psyllium hydrophilic mucilloid For fatigue like modafinil, amantadine. For bladder dysfunction like propantheline, oxybutynin For spasticity like baclofen, dantrolene, diazepam

25. Symptomatic treatment cont. For dysesthesias like transcutaneous electrical nerve stimulation is helpful For tremor like clonazepam, propranolol, phenobarbital For dysesthesias & trigeminal neuralgia like phenytoin, carbamazepine, amitriptyline

26. 4. Nutritional therapy Patient is given megavitamin therapy like cobalamin (Vitamin B12) and vitamin C. High roughage diet to relieve constipation Low fat diet

27. 5. Other therapies Especially administered to improve neurological functioning like: Exercise Physical and speech therapies

28. Nursing management. Nursing Assessment Obtain both subjective and objective data especially gather physical, psychosocial, emotional, and diagnostic data. Review health histories 1. ask about patients' histories like: Vision changes, Muscle cramping or weakness, Poor balance and coordination, Paresthesia's, Speech impairments, Tremors, Severe disabling fatigue, Intolerance to heat, Cognitive difficulties, Sexual, urinary, or bowel dysfunction

29. 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 15-45years, and it can occur at any age. Other risk factors include: Female gender, Family history of MS, Smoking, Low levels of vitamin D, Obesity

30. 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.

31. 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.

32. 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)

33. 3 . Observe the patient’s balance and coordination. Poor coordination of upper and lower extremities and a wide-based gait may be seen.

34. 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

35. 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

36. 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.

37. 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.

38. 8. Review diagnostic tests like Magnetic Resonance Imaging (MRI) detecting MS and tracking the disease’s course in the brain and spinal cord. Consider other imaging scans. including: Computed tomography (CT) scan Plain X-rays Angiography Ultrasonography Lumber puncture results obtained in case in case MRI service is not available.

39. Nursing concerns Fatigue, Neuromuscular impairment, Pain, 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, Ineffective toileting habits, Involuntary sphincter relaxation, Weakened bladder muscles, Impaired mobility, Urinary urgency, Urinary retention, Urinary incontinence, Urinary hesitancy, Frequent voiding, Dysuria, Nocturia.

40. Nursing diagnoses 1. Impaired Physical Mobility Related to 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

41. Expected outcomes: Patient will verbalize increased strength and demonstrate an increased ability to move after 1 week Patient will utilize mobility aids to improve physical mobility and ambulation after 1 week

42. Intervention i ). Encourage the use of mobility aids as needed. Rationale: 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. ii). Perform passive range of motion exercises. Rationale: Range of motion exercises can help strengthen muscles and bones to improve mobility.

43. Intervention cont. iii). Encourage exercise. Rationale: 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. iv). Administer medications as ordered. Rationale: Baclofen can help relieve muscle spasms and rigidity in patients diagnosed with multiple sclerosis.

44. 2 . Impaired Urinary Elimination related to 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.

45. Expected outcomes: Patient will demonstrate having improved in elimination patterns within a week of interventions. Patient will remain free from urinary complications, including infection, overactive bladder, and retention after 1 week of interventions. Patient will verbalize strategies to prevent impaired urinary elimination problems within 5 days of interventions.

46. Interventions i ). Encourage adequate fluid intake. Rationale: Adequate hydration promotes urinary output and prevents urinary stasis. Ensure daily water intake, limiting intake several hours before bedtime to prevent nocturia. ii). Instruct the patient to avoid bladder irritants like caffeine and alcohol. Rationale: Bladder irritants can cause the bladder to become overstimulated and irritated, leading to urinary frequency, urgency, spasms, and pain

47. iii). Initiate a bladder training program. Rationale: 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

48. iv). Demonstrate intermittent catheterization. Rationale: 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. v). Administer medications. Rationale: For patients with an overactive bladder, antispasmodics like oxybutynin can be taken to decrease bladder spasms and symptoms of urgency.

49. Evaluation For evaluation depends on the outcome of your interventions, and guides on the next course of nursing actions.

50. Thank you for attending and active participation

51. References Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education. What is MS? National Multiple Sclerosis Society. 2022. From:  https://www.nationalmssociety.org/What-is-MS Overview: Multiple sclerosis. NHS. Reviewed: March 22. 2022. From:  https://www.nhs.uk/conditions/multiple-sclerosis/