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Multiple Sclerosis – Prognosis, Nursing Management

Prognosis

The prognosis is difficult to predict; it depends on the subtype of the disease, the individual patient’s disease characteristics, the initial symptoms and the degree of disability the person experiences as time advances.

  • Life expectancy of people with MS is 5 to 10 years lower than that of the unaffected population.
  • The disease evolves and advances over decades, 30 being the mean years to death since onset.
  • Female sex, relapsing-remitting subtype, optic neuritis or sensory symptoms at onset, few attacks in the initial years and especially early age at onset, are associated with a better course.
  • Almost 40% of patients reach the seventh decade of life.
  • Nevertheless, two-thirds of the deaths in people with MS are directly related to the consequences of the disease. Suicide also has a higher prevalence than in the healthy population, while infections and complications are especially hazardous for the more disabled ones.
  • Although most patients lose the ability to walk prior to death, 90% are still capable of independent walking at 10 years from onset, and 75% at 15 years.

The following typically have the best outlook

  • Females
  • People who were young (less than 30 years) when the disease started
  • People with infrequent attacks
  • People with a relapsing-remitting pattern
  • People who have limited disease on imaging studies

Chronic cerebrospinal venous insufficiency

In 2008, Italian vascular surgeon Paolo Zamboni reported research suggesting that MS involves a vascular disease process he referred to as Chronic Cerebrospinal Venous Insufficiency (CCSVI, CCVI), in which veins from the brain are constricted. He found CCSVI in the majority of MS patients, performed a surgical procedure to correct it and claimed that 73% of patients improved. Concern has been raised with Zamboni’s research as it was neither blinded nor controlled and further studies have had variable results. This has raised serious objections to the hypothesis of CCSVI originating multiple sclerosis. The neurology community currently recommends not using the proposed treatment until its effectiveness is confirmed by controlled studies, the need for which has been recognized by the scientific bodies engaged in MS research.

Nursing Management

Nursing Assessment

  • Observe general physical activity of the patient.
  • Observe motor strength, coordination, and gait.
  • Perform cranial nerve assessment.
  • Evaluate elimination function.
  • Explore coping, effect on activity and sexual function, emotional adjustment.
  • Assess patient and family coping, support systems, available resources.

Nursing Diagnoses

  • Impaired Physical Mobility related to muscle weakness, spasticity, and incoordination
  • Fatigue related to disease process and stress of coping
  • Disturbed Sensory Perception (tactile, kinesthetic, visual) related to disease process
  • Impaired Urinary Elimination related to the disease process
  • Interrupted Family Processes related to inability to fulfill expected roles
  • Sexual Dysfunction related to disease process

Nursing Interventions

Promoting Motor Function

  • Perform muscle stretching and strengthening exercises daily, or teach patient or family to perform, using a stretch-hold-relax routine to minimize spasticity and prevent contractures.
  • Apply ice packs before stretching to reduce spasticity.
  • Tell patient to avoid muscle fatigue by stopping activity just short of fatigue and taking frequent rest periods.
  • Encourage ambulation and activity, and teach patient how to use such devices as braces, canes, and walkers when necessary.
  • Inform the patient to avoid sudden changes in position, which may cause falls due to loss of position sense, and to walk with a wide-based gait.
  • Encourage frequent change in position while immobilized to prevent contractures; sleeping prone will minimize flexor spasm of hips and knees.

Minimizing Fatigue

  • Help patient and family understand that fatigue is an integral part of Multiple Sclerosis.
  • Plan ahead, and prioritize activities. Take brief rest periods throughout the day.
  • Avoid overheating, overexertion, and infection.
  • Encourage energy conservation techniques, such as sitting to perform activity, limiting trips up and down stairs, pulling, or pushing rather than lifting.
  • Help patient develop healthy lifestyle with balanced diet, rest, exercise, and relaxation.

Optimizing Sensory Function

  • Suggest use of an eye patch or frosted lens (alternate eyes) for patients with double vision.
  • Encourage ophthalmologic consultation to maximize vision.
  • Provide a safe environment for patient with any sensory alteration.
    • Orient patient to the environment, and keep arrangement of furniture and personal articles constant.
    • Make sure floor is free from obstacles, loose rugs, or slippery areas.
    • Teach the use of all senses to maintain awareness of environment.

Maintaining Urinary Elimination

  • Ensure adequate fluid intake to help prevent infection and stone formation.
  • Assess for urine retention, and catheterize for residual urine as indicated.
  • Teach patient to report signs of UTI immediately.
  • Set up bladder training program to reduce incontinence.
    • Encourage fluids every 2 hours.
    • Follow regular schedule of voiding, every 1 to 2 hours, lengthening as tolerated.
    • Restrict fluid volume and salty foods 1 to 2 hours before bedtime.

Normalizing Family Processes

  • Encourage verbalization of feelings of each family member.
  • Encourage counseling and use of church or community resources.
  • Suggest dividing up household duties and child-care responsibilities to prevent strain on one person.
  • Explore adaptation of some roles so patient can still function in family unit.
  • Expand treatment efforts to include the whole family.
  • Support mothers with MS who often face fatigue and episodic exacerbations during their child-rearing years.

Promoting Sexual Function

  • Encourage open communication between partners.
  • Discuss birth control options, if appropriate.
  • Suggest sexual activity when patient is most rested.
  • Suggest consultation with sexual therapist to help obtain greater sexual satisfaction.

Community and Home Care Considerations

  • The nurse case manager functions as care provider, facilitator, advocate, educator, counselor, and innovator aimed at intervening in a wide variety of settings to improve patient function and mobility.
  • Teach the patient and family to use their own judgment, knowledge, and ingenuity to control MS symptoms.
  • Teach patient and family how to conduct periodic self-assessment of daily functioning, so home care team can continue to make modifications in treatment plan.

Patient Education and Health Maintenance

  • Encourage the patient to maintain previous activities, although at a lowered level of intensity.
  • Teach the patient to respect fatigue and avoid physical overexertion and emotional stress; remind patient that activity tolerance may vary from day to day.
  • Advise the patient to avoid exposure to heat and cold or infectious agents.
  • Encourage a nutritious diet that is high in fiber to promote health and good bowel elimination.
  • Advise the patient that some medications may accentuate weakness such as some antibiotics, muscle relaxants, antiarrhythmics and antihypertensives, antipsychotics, oral contraceptives, and antihistamines; check with health care provider or pharmacist before taking any new medications.
  • Teach the patient receiving interferon beta-1a (Rebif, Avonex) and interferon beta-1b (Betaseron) to expect adverse effects of flulike symptoms, fever, asthenia, chills, myalgia, sweating, and local reaction at the injection site.
  • Liver function test elevation and neutropenia may also occur. Adverse effects may persist for up to 6 months of treatment before subsiding.
  • Instruct the patient receiving interferon beta-1a and interferon beta-1b in self-injection technique.
  • Try to include children in the education of MS and the relationship of fatigue and functional status.
  • Refer the patient/family for more information and support to such agencies.

Evaluation: Expected Outcomes

  • Performs exercises correctly without spasm
  • Rests at intervals, tolerating activity well
  • Moves about in environment without injury
  • Voids every 2 hours with no incontinent episodes
  • Family sharing care, discussing feelings
  • Reports satisfaction with sexual activity

Complications

  • Respiratory dysfunction
  • Infections: bladder, respiratory, sepsis
  • Complications from immobility
  • Speech, voice, and language disorders such as dysarthria
  • Depression
  • Difficulty swallowing
  • Difficulty thinking
  • Less and less ability to care for self
  • Need for indwelling catheter
  • Osteoporosis or thinning of the bones
  • Pressure Sores
  • Side effects of medications used to treat the disorder
  • UTI (Urinary Tract Infection)

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