Multiple sclerosis

Publisher Summary

This chapter discusses the pathology and nursing assessment for multiple sclerosis. Multiple sclerosis is a condition affecting the central nervous system in which there is patchy degeneration of the myelin sheath covering the nervous tissue. It is found that although the cause is unknown, certain facts are available that have given rise to various theories. Patients suffering from multiple sclerosis are deficient in the fatty acid linolenic acid which may have a protective function. Whether the deficiency is due to the type of diet or not is not known. It is thought that neurons in these people may be vulnerable to a viral infection which is more likely to occur if they grow up in a temperate climate. It is thought by some to be due to an autoimmune response. Minor physical trauma appears to act as a trigger.

PATHOLOGY

Multiple sclerosis is a condition affecting the central nervous system, in which there is patchy degeneration of the myelin sheath covering the nervous tissue. Although the cause is unknown, certain facts are available which have given rise to various theories. Patients suffering from multiple sclerosis are deficient in the fatty acid linolenic acid which may have a protective function. Whether the deficiency is due to the type of diet or not is not known. It is thought that neurones in these people may be vulnerable to a viral infection which is more likely to occur if they grow up in a temperate climate. It is thought by some to be due to an autoimmune response. Minor physical trauma appears to act as a trigger.

Patches of inflammation develop on the myelin sheath, temporarily interfering with its function of transmitting impulses. However, the myelin sheath is regenerated and function restored. After repeated episodes scar tissue forms and there is complete loss of function in that particular pathway. The disease attacks particular nerves such as the optic nerve, cerebellum and the pyramidal tracts. It may attack one or both sides. Multiple sclerosis is a condition primarily affecting those between the ages of twenty and forty, occurring slightly more in women than in men.

Initially there may be an isolated incident such as loss of vision, tripping or dropping things, and patients may easily tire. As these incidents may occur without warning there is a fear of what may happen next, and therefore increasing dependence on others. The pattern varies with each patient, but typically there will be a series of relapses and remissions of varying lengths of time. Gradually the symptoms become more severe and the remissions shorter. Eventually there may be a paraplegia with incontinence and spasticity of the limbs. Urinary infection, pneumonia and pressure sores may eventually cause death.

NURSING ASSESSMENT

Nursing care problems in multiple sclerosis are discussed here in relation to the female patient, in view of the increased incidence in females already referred to. This patient is likely to be of an age when she is married with young children, and the income from her employment may be an essential part of the family finances. The type of work her husband does and the hours he works will influence how great a part he plays in the home life. Do they run a car? If so this will increase mobility. Do they live in a bungalow

which can be easily adapted or a flat several stories high? How old are the children? Do they attend nursery school or school? Do the parents of the patient live nearby? How near to the hospital do her relatives live? Can they visit easily?

Her religion may be a very vital part of her life, therefore the name and address of the minister of her church should be noted, and whether she wishes the hospital chaplain to visit her.

General appearance

The nurse will note how well nourished the patient is, and if she is thin or emaciated the cause must be sought. It may be that her diet has been inadequate due to dysphagia or nausea. On the other hand, although she may have had a good appetite the effort of eating may have been so tiring that she could only eat small amounts at one time. Intention tremor, shaking of the hand when moved, may be very frustrating when trying to feed oneself. Facial weakness, spasticity of the hands and a tendency to tire easily are all likely to lead to a reduced diet. In the early stages of the disease the diet may deteriorate simply because she is afraid to go out alone, or due to depression. Conversely, the latter may lead to obesity. The nurse must find out tactfully how much help she needs in feeding and if she has any special equipment at home.

Condition of the skin

If there is any paralysis, and particularly if sensation is impaired, pressure sores will develop unless special care is taken. The sacral area and the heels are the most vulnerable. Diminished sensation may mean that the patient is unaware of a sore until it has become sizeable. Any spasticity of the limbs, which frequently develops in the later stages, will increase the likelihood of sores developing, as will a poor nutrition.

Mental state

The patient’s appearance will give some indication of this. Is she making the most of herself, with make-up and hair well kept, or is there a general unkemptness about her appearance. Depression, apathy, anxiety or anger may be her reaction to having the condition, although mood changes are frequently associated with multiple sclerosis. In the early stages irritability is often present, and euphoria may result in unrealistic expectations of the future. It will be necessary to find out from the doctor or her relatives how much she has been told and how she has reacted so far. If she knows her diagnosis then she may have decided to adopt the ’sick role’. It will be useful to find out what her hobbies are and if the ability to do these has been interfered with in any way. For example, she may find it difficult to sew because her fingers fumble and are less sensitive. How well does she sleep? Early waking suggests depression.

Mobility

The patient may be admitted at any stage of the disease and will have different problems accordingly. In the early stages mobility may be reduced more because of the fear of falling, or the possibility of another sudden attack of blindness, than by real limitations in movement. Blindness will inhibit the patient from moving in an unfamiliar environment, and dizzy spells, blurred vision, and general tiredness may all be factors which cause the patient to be less mobile than usual. Later, paraplegia may be present. But even with a paraplegia there will be varying degrees of dependence. Can she get in and out of a wheelchair with or without help? Does she need help with dressing? Has she been able to have a bath? These are all things the nurse needs to know.

Excretion

There may be urgency, retention with overflow, or complete incontinence, depending upon the stage of the disease. Frequency, a burning sensation on passing urine, or a raised temperature, may indicate an urinary infection. Constipation, spurious diarrhoea, or incontinence of faeces may be present and the method of control before admission must be discovered.

Special senses

There may be blurring of vision, double vision or complete loss of sight. It is necessary to know how long the patient has had these disturbances of vision because this will have influenced how well she has adapted. Occasionally there is deafness. Speech is often staccato, becoming slow and deliberate, or slurred and therefore less easy to understand.

Observations

A raised temperature may be present due to infection in the lungs or bladder, and will therefore be monitored carefully. Any drugs she has brought with her, or any self-medication, will be noted.

NURSING CARE PLAN

The patient with multiple sclerosis has a slowly progressive disease. The nursing care plan will therefore be evaluated regularly and adjusted to take into consideration new problems.

Care of the skin

As the patient develops paralysis and becomes less able to care for herself, so the role of the nurse changes. In the initial stages the patient will be taught how to relieve pressure on the buttocks by raising herself in the chair at least two hourly. Once confined to bed she will be turned by the nurses two hourly, although a ’monkey pole’ may enable her to lift herself in bed, and a sheepskin or ripple

bed help to prevent sores occurring. Particular attention needs to be paid to the heels. Regular checking of vulnerable areas is vital to prevent redness developing into a sore which is difficult to heal. If there is spasticity it is essential that where the two skin surfaces meet the skin is kept dry and clean. In the final stages a water bed may be necessary.

Nutrition

In the majority of patients this will need to be built up to prevent pressure sores developing and to give greater resistance to infection. Therefore a good nourishing diet will be given with plenty of protein and vitamin C. It will need to be given in small amounts and be easy to handle. Aids may be used to help...