Four forms of MS have been identified. Benign MS, which affects approximately 20% of patients, causes mild disability; infrequent, mild, early attacks are followed by almost complete recovery. Exacerbating-remitting MS, which affects approximately 25% of patients, is marked by frequent attacks that start early in the course of the illness, followed by less than complete clearing of signs and symptoms than in benign MS. Chronic relapsing MS, which affects approximately 40% of patients, has fewer, less complete remissions after an exacerbation than has exacerbating-remitting MS. Chronic relapsing MS has a cumulative progression, with more symptoms occurring during each new attack. The fourth form of MS, chronic progressive, afflicts approximately 15% of patients and is similar to chronic relapsing MS except that the onset is more subtle and the disease progresses slowly without remission.
The cause of MS is unknown. Some evidence suggests that an infective agent causes a predisposition to MS, although that agent has not been identified. Some evidence supports immunologic, environmental, or genetic factors as possible causes of the disease. The risk of developing MS is 15 times higher when the disease is present in the patient’s immediate family. Conditions such as pregnancy, infection, and trauma seem to precipitate the onset of MS or cause relapses.
Nursing care plan assessment and physical examination
Vague and unrelated symptoms often dominate the early period of MS before a definitive diagnosis is made. Brain lesions lead to central nervous system signs. Ask the patient about changes in vision and coordination. Determine whether the patient has experienced slurred speech, impotence, ataxia, or double vision (diplopia). Approximately 70% experience involuntary, rhythmic movements of the eyes (nystagmus).
Spinal cord lesions lead to motor and sensory impairment of the trunk and limbs. Ask if problems have occurred with bowel and bladder dysfunction. Determine if the patient has experienced a feeling of heaviness or weakness, numbness, or tingling in the extremities. Determine the patient’s ability to perform activities of daily living with attention to the fine movement of
fingers, as when dressing or picking up small objects. Ask if the patient has experienced burning sensation or pain, decreased temperature sensation, intention tremor (a tremor during a voluntary activity), foot-dragging, staggering, dizziness, or loss of balance. Ask if the patient has experienced decreased motor function after taking a hot bath or shower (Uhthoff’s sign), which is caused by the effects of heat on neuromuscular conduction. Roughly 50% of patients with MS lose the ability to sense position, vibration, shape, and texture.
Determine when the patient first noticed any of these difficulties and whether the symptoms later disappeared. Ask about fatigue and its progression throughout the day and what stressors precipitate symptoms. Determine whether there is a family history of the disease. Elicit a history of mild depression and short attention span.
Determine the patient’s muscle strength and symmetry, arm and leg movement, and gait. To assess arm strength, have the patient use both hands to push against you. Observe for unilateral or bilateral weakness. Ask the patient to open and close the fist and to move each arm without raising it from the bed. If no purposeful movement occurs, apply light tactile pressure to each arm, gradually increasing the pressure in an attempt to elicit a purposeful response. Assess leg movement in the same way. Ask the patient to move each leg and, if she or he cannot, press the Achilles’ tendon firmly between your thumb and index finger, observing for either a purposeful or a nonpurposeful response.
Assess gait by asking the patient to walk away from you; observe for ataxia, shuffling, or stumbling. Stay close to the patient to prevent falls. If the patient is able to perform these tasks well, test balance by having the patient walk heel-to-toe in a straight line. Observe any leaning to one side.
When a chronic illness with potential for serious debilitation and possible early death is first discovered, a patient goes through a period of grieving. This grief process may take years. Determine the patient’s place on the continuum of shock, denial, or anger, and accept the patient’s current stage of coping.
Nursing care plan primary nursing diagnosis: Impaired physical mobility related to fatigue and weakness.
Nursing care plan intervention and treatment plan
Most medical treatment is designed to slow disease progression and address the symptoms of the disease, such as urinary retention, spasticity, and motor and speech deficits. Currently, however, physicians generally prescribe steroid therapy to reduce tissue edema during an acute
exacerbation. Consult with a physical therapist if the patient needs to learn how to use assistive devices or needs to learn exercises to maintain muscle tone and joint mobility. Muscle stretching for spastic muscles and selective strengthening exercises for weakness are prescribed. A social service agency may be required to help the family deal with the often expensive and long-term financial effect of the disease. Vocational redirection may also be required. For a patient who is experiencing depression, consider a referral to a psychiatric clinical nurse specialist. Family counseling is often very helpful.
Sensory perceptual deficits in the visual fields cause dizziness, headaches, and the potential for injury. Patching each eye, alternating with the other several times a day, improves balance and visualization. Peripheral vision may be affected; teach the patient to scan the environment and to remove potential sources of injury. Ask the patient particularly to look out for hot surfaces and hot water, to which he or she may not be sensitive.
Be sure the patient understands the need to avoid becoming fatigued or overheated. Instruct the patient to alternate periods of activity with periods of rest, discussing the need for frequent rest periods as a permanent lifestyle change. Explain that baths and showers may prove relaxing but may also exacerbate MS symptoms. Conduct range-of-motion exercises at least twice daily. If necessary, teach the patient how to use a walker or a cane. Care for a neurogenic bladder includes instructing the patient to consume 1500 mL of fluid daily and void every 3 hours. If urine is retained, teach intermittent self-catheterization with clean technique to the patient who is capable. Some patients, however, are incontinent.
Teach the patient how to use special pads to avoid skin breakdown. Teach the patient to develop a regular bowel pattern, with bowel elimination about 30 minutes after the morning meal. Insert a glycerine suppository if necessary to stimulate reflex bowel activity. Provide assistance should the patient be unable to perform this self-care.
Teach the patient about the disease process, and be sure she or he knows how to contact the local MS Society. In addition to information and education, the society holds focus group seminars that study relational issues associated with the disease. The society also provides some ongoing therapy and socialization and support for home maintenance. Helping the patient learn to cope with this chronic illness is a major nursing challenge. Listen to the patient’s fears; respect her or his abilities and provide positive encouragement. The disabled patient not only loses body function but often his or her role as an active parent and spouse. With the more rapidly progressive forms of MS, the patient may have impairment of cognitive functioning; touch and voice tone can convey concern and care when the meaning of words gets lost.
Nursing care plan discharge and home health care guidelines
Be sure the patient understands any pain medication prescribed, including dosage, route, action, and side effects. Be sure the patient understands the need for adequate bladder and bowel elimination. Instruct the patient to notify the primary caregiver of any exacerbation or sudden worsening of the condition. If the patient has difficulty speaking or communicating, be sure that she or he has access to a telephone support network or some other means of calling for assistance when she or he is at home alone for any length of time. Be sure the patient understands that stress, fatigue, and being overheated stimulate exacerbations. Teach the patient how to avoid situations that produce these reactions. Be sure the patient knows how to contact community agencies such as the MS Society for use of such in-home equipment as beds and wheelchairs and home maintenance support. Determine whether a home care agency is needed to provide home supervision and ongoing physical therapy support.