Multiple Sclerosis
Plaques
- these form randomly along with myelin sheath, causing inflammation, edema, which then causes scarring and destruction
Diagnostic tests for MS: Evoked potential
- these tests measure the electrical activity of the brain in response to stimulation of sensory nerve pathways, specifically visual evoked potentials, brainstem auditory evoked potentials, and sensory evoked potentials. - These tests are able to detect the slowing of electrical conduction that is caused by demyelination of the nerves. Evoked potential tests are often useful for identifying a second demyelinating event that causes no clinical symptoms and does not create a lesion that is detectable by MRI.
Risk factors for MS
- young women (20-40) - smoking - family history - vitamin d deficiency
Managing MS Symptoms/ meds: Bladder dysfunction
Oxybutynin: - anticholinergic that relaxes the bladder muscle to prevent muscle contractions Bethanechol: cholinergic that helps with emptying the bladder by helping with bladder contraction - scheduled voiding - avoidance of diuretics - intermittent self catheterization; indwelling catheter
Different classes of symptoms for MS: Primary
Primary (resulting from demyelination) - Sensory disturbances (visual, hearing, speech, balance, pain) - Motor disturbances (weakness, paresthesias, bowel and bladder dysfunction, unsteady gait, spasticity, breathing problems) - Cognitive dysfunction (concentration, memory, reasoning, judgment, depression) Therapies - Disease modifying therapies, symptom specific medications, corticosteroids to treat exacerbation, assistive devices, PT/rehab
Managing MS Symptoms/ meds: Tremors
Propanolol: beta blocker Isoniazid: antibiotic used for infections, especially TB; helps with tremors
Different classes of symptoms for MS: Secondary
Secondary (these result from primary symptoms) - Pressure injuries, Osteoporosis, Aspiration pneumonia, UTIs. Back or hip pain, Muscle atrophy, poor postural alignment, Bone fractures Treatment - Antibiotics, analgesics, bisphosphonates, PT, Immobilization of fractures, nutrition and fluids
Different classes of symptoms for MS: Tertiary
Tertiary (psychosocial complications) - Social problems (partner, family, friends, social isolation), Vocation problems (loss of job, loss of transportation), Emotional problems (depression, irritability, hopelessness) Treatments - Psychological counseling, antidepressants, referral to home care, transport assist., social interaction, care giver support, vocational rehab
acute onset of visual changes, what form of MS is it?
- primary progressive
Symptoms of MS
- pt can have sensory, cognitive, emotional, bowel/ bladder issues depending on where the neuron is - numbness - tingling - depression - dizziness - fatigue - muscle spasm - walking difficulty - visual disturbances - trouble concentrating - sexual dysfunction - can also have nystagmus, optic neuritis, etc - + Romberg's sign
look up med gladimir? pt becomes flushed, chest pain, itching, etc. what do you as the nurse do?
- reassure pt - stay with them administer O2
Classifications of Multiple Sclerosis: Progressive-relapsing MS
- relatively rare, occurring in only 5% of individuals with MS. - These individuals experience a steady worsening of disease with acute relapses. - In contrast to relapsing-remitting MS, the periods between relapses are characterized by continued progression of the disease rather than remission of symptoms.
Cause of MS
- remains unknown - the most widely beleived theory is immune mediated inflammatory disease - this is a result of the harm inflicted to the myelin sheaths by their own immune system
Managing MS Symptoms/ meds: Depression
- pretreatment education - Bupopion - citalopram - duloxetine - sertraline - fluoxetine
Glatiramer Acetate (Copaxone) (immunomodulator)
- Protects myelin by inhibiting immune response to myelin basic protein - used for relapsing remitting MS Adverse effects: well tolerated - postinjection reactions on administration (flushing, chest pain, anxiety, urticaria) these are transient in nature
Medication class: Immunomodulators
- Recommended for all patients with relapsing remitting MS and with secondary progressive MS experiencing acute exacerbations
Interferon beta (immunomodulator)
- Reduces the frequency and severity of attacks - Reduces the number and size of MRI detectable lesions - Delays progression of disability - flu like symptoms is a common side effect
Managing MS Symptoms/ meds: Cognitive impairment
- Restorative approach; retraining exercises - Compensatory approach; improve function via substitution strategy - Medications: Donepezil (Aricept)
What makes diagnosing MS difficult?
- Symptoms of MS often go into remission after the initial manifestation of the disease
Diagnostic tests for MS: Lumbar puncture
- A lumbar puncture, or spinal tap, is used to obtain a sample of CSF. - The CSF is then tested for the presence of elevated immunoglobulins (IgG), oligoclonal bands, and myelin breakdown products, all of which are indicative of MS.
Managing MS Symptoms/ meds: Ambulation Problems/ spasms
- Ambulation Problems - therapies are tailored to the client's level of functioning. - Spasticity - Rehabilitative PT (stretching) ROM q12h Baclofen (lioresal) - medication of choice; muscle relaxant Diazepam (valium) - used to lessen muscle spasm - Surgery - Impaired balance and weakness; mobility aids and exercises - Bedrest during exacerbation - Monitor for potential complications
Diagnostic tests for MS: MRI
- An MRI is used to detect the presence of lesions in the CNS that may indicate demyelination and MS.
Managing MS Symptoms/ meds: Pain
- Analgesics, exercise, gait training, wheelchair assessment, surgery - Other medications (high dose ) IV steroids, gabapentin, carbamzepine (paresthesias), phenytoin, clonazepam (treats cerebellar ataxia)
Diagnostic tests for MS: blood tests
- Blood tests are used to rule out other infectious or inflammatory diseases that may mimic the symptoms of MS.
Mitoxantrone (immunosuppressant)
- Chemotherapy drug used in prostate and lymphoma - Administered q3months - Used more in secondary progressive MS, not indicated in primary progressive MS Therapeutic use - decreases neurologic disability and clinical relapses Mechanism of action - binds with DNA and inhibits topoisomerase (enzymes that unwind / wind DNA strands)
Why do no two patients present the same with MS?
- Clinical manifestations of MS depend on the location and severity of damage in the CNS
Nursing process: Implementation
- Encourage patient participation in decision making. Patients who participate in decision making regarding their treatment regimens have higher adherence rates and are more likely to report treatment challenges and symptom changes earlier. - Teach intermittent urinary catheterization. Patient self-catheterization promotes independence. - Administer medications as ordered to assist the patient's return to baseline. - Administer antipyretics as ordered. Even small increases in body temperature can strongly affect conduction through partially demyelinated fibers. - Teach the patient to use an incentive spirometer to promote respiratory function.
What is Disease modifying therapy (DMT's)
- Interrupts the progression of the disease
Triggers for MS
- Many patients cite stress and fatigue as contributors to flare-ups. - Some patients experience heat sensitivity, or a relapse of symptoms associated with increases in body temperature (e.g., fever caused by infection). - Infection and increased body temperature may cause a pseudoexacerbation, or a temporary aggravation of symptoms that is directly related to a trigger and subsides as soon as the trigger is removed.
Nursing process: Possible nursing diagnoses
- Mobility: Physical, Impaired - Urinary Incontinence, Functional Constipation - Fatigue - Self-Care Deficit: Bathing - Hopelessness - Body Image, Disturbed - Role Strain, Caregiver - Role Performance, Ineffective - Sexual Dysfunction - Coping, Ineffective.
Mitoxantrone: Adverse effects/ drug interactions
- Myelosupperession - LFT's - Cardiotoxicity - LVEF - Fetal harm - Decreased production of blood cells - WBC
Nursing process: Observation/ pt interview
- Observe the patient's gait, posture, and degree of independence. - The initial medical history includes onset, type, intensity, and pattern of symptoms; factors that affect symptoms; ongoing medical problems and medications; past history of surgery, trauma, or infection; health history of family members; and exposure to environmental hazards. - The nurse should also assess how current symptoms affect the patient's everyday life. Following the initial assessment of the patient's health history, recurring assessments should evaluate the progression of signs and symptoms and the patient's coping responses to any changes.
Medication class: Immunosuppresants
- Only one approved by the FDA - mitoxantrone- antineoplastic drug causes immunosuppression. - More toxic than immunomodulators - Produces greater suppression of immune function
Mitoxantrone: monitoring summary
- Perform complete blood counts, this includes WBC, at baseline and prior to each dose - Perform liver function tests at baseline and prior to each dose - Perform a pregnancy test prior to each dose Determine LVEF (Left Ventricular Ejection Fraction): - Prior to the first dose - Prior to all doses once the cumulative dose has been reached and yearly after completing treatment - Whenever signs of CHF develop
Levels of Prevention (primary, secondary, tertiary)
- Primary Prevention - None - Secondary Prevention - Avoid infection and stress management, pregnancy concerns, avoidance of hot environments - Tertiary Prevention - Maintain fluid intake, void q3h, high fiber diet, rest, muscle flexibility, minimize stress
Nursing process: Some examples of possible pt goals
- The patient will participate in physical and occupational therapy and an exercise program to maintain independent physical mobility. - The patient will state methods to reduce urinary incontinence and how to discreetly deal with urinary incontinence when outside the home. - The patient will verbalize understanding of methods to prevent and treat constipation. - The patient will receive 8 hours of sleep per night and rest as needed during the day to decrease fatigue. - The patient will demonstrate maximum independence during ADLs, such as personal care and bathing. - The patient will receive psychologic counseling as needed. - The patient will accept and adapt to debilitating symptoms and participate in programs to regain maximal function. - The patient's caregiver will receive help from home health agencies, family, and friends to provide relief from caregiver duties. - The patient will participate in vocational rehabilitation and find a job that accommodates individuals with disabilities.
Treatments for MS is continued indefinitely unless...
- Treatment is not controlling disease adequately. - Side effects are intolerable. - Person unable to follow treatment plan. - More appropriate treatment becomes available.
Damage to the axon vs the myelin sheath
- Unlike damage to the myelin sheath, which can be repaired by oligodendrocytes over time, damage to the axons is not reversible
What is an "MS hug?"
- a sensation of a tight band around the abdomen
Classifications of Multiple Sclerosis: Primary-progressive MS
- affects approximately 10% of patients with MS. - These individuals experience a slow, but nearly continuous, worsening of their disease from the time of onset with NO DISTINCT REMISSIONS - The rate of progression may vary over time, from temporary minor improvements, to plateaus, to obvious worsening of symptoms.
Managing MS Symptoms/ meds: Nutrition/ Bowel Dysfunction
- bowel training - high fiber diets, several studies are involving manipulation of fats are under investigation - nutrition altered client's ability to prepare food and eating is compromised, diet must be adapted - Digital stimulation - Exercise; changes in muscle tone, tremors, weakness - Medications; stool softeners, avoid laxatives, mini enemas - Hydration
What is the CNS consisted of?
- brain, spinal cord, and optic nerves
MS medications: beta interferon
- decreases the number of relapses and symptoms by decreasing inflammation and the immune systems response - risk for infection because it reduces the number of WBCs - drug names include Avonex, Rebif, betaferon
Classifications of Multiple Sclerosis: Secondary-progressive MS
- develops within 10 years of diagnosis in about half of the patients with relapsing-remitting MS who are NOT RECEIVING TREATMENT - experience an initial period of relapsing-remitting MS, followed by a progressive form of the disease with or without occasional flare-ups and minor remissions. - This form of MS may develop as a result of the eventual destruction of oligodendrocytes, preventing the body from repairing the myelin sheath.
Managing MS Symptoms/ meds: Corticosteroids
- for relapses of MS symptoms - drug names include methylprednisolone and prednisone
What does the myelin sheath do?
- forms a fatty insulating layer around nerve cells (axon) to increase the speed of electrical transmission along the nerve.
How should the immune system work/ how does it work in MS
- immune system should protect against infection, diseases, etc. - in MS, the IS misidentifies the myelin cells and attacks them - this causes inflammation which causes a disruption of electrical impulses
Collaboration for MS
- includes nurses, neurologists, immunologists, urologists, ophthalmologists, obstetricians, pulmonologists, cardiologists, primary care providers, therapists (physical, occupational, speech, psychologic), nutritionists, and home health agencies. - In particular, nursing care will focus on symptom management, patient teaching, emotional support, and referrals to other healthcare services, depending on the patient's disease manifestations.
What is MS?
- is an immune-mediated disorder of the CNS in which immune cells attack the myelin sheath around nerve cells, causing decreased transmission of nervous signals.
chemo drug, every 24 hours, in relapsing remitting, teaching should include...
- managing contraceptives
MS Theories
- metabolically dependent disease, while others think that it might be caused by a virus (epstein barr), triggers T cells causing inflammation response later on - because this disease is virtually absent from the tropics, it might be dependent on a deficiency of VITAMIN D - genetic pre- disposition; cluster of human leukocyte antigen on the cell wall, increase susceptibility to viruses and triggers an auto immune response
Classifications of Multiple Sclerosis: Relapsing-remitting MS
- most common form of MS at the time of diagnosis, affecting approximately 85% of patients with MS. - Individuals with relapsing-remitting MS experience clearly defined flare-ups with worsening neurologic function followed by periods of partial or complete remission with few or no symptoms. - Remission is thought to occur when oligodendrocytes repair the damaged myelin sheath (remyelination). - Patients can experience periods of relapse that last for days or months and periods of remission that last from weeks, to months, to years.
Who is MS most common in?
- most common in women - caucasian - rare in asians and children
Relapses vs Remissions
- most pts experience periods of acute clinical exacerbations alternating with periods of complete or partial recovery
Women of childbearing age/ pregnant women w/ MS
- must decide if they want to become pregnant - many MS meds are not safe for the fetus/ have not had enough testing done - bladder problems and fatigue may be intensified
What is a true MS exacerbation?
- must last at least 24 hours and must be separated from the previous attack by at least 30 days. Symptoms that last for less than 24 hours are termed paroxysmal attacks.
Nursing process: Physical exam
- observing the patient's ability to move and walk, affect, balance and coordination, hygiene, and speech
Disease Modifying Therapies for MS: Oral (I'm not memorizing these)
1. Aubagio (teriflunomide) 2012 2. Gilenya (fingolimod) 2011 3. Tecfidera (dimethyl fumarate) 2013 4. Mayzent (siponimod) 2019 (1st drug for treatmemt of secondary progressive.
Disease Modifying Therapies for MS: Infusion (not memorizing)
1. Lemtrada (alemtuzumab) 2014 2. Novantrone (mitoxantrone) 2000 3. Ocrevus (ocrelizumab) 2017 - used to tx both relapsing and progressive 4. Tysabri (natalizumab) 2007
Disease Modifying Therapies for MS: Injectables (I'm not memorizing any of these)
2. Betaseron (interferon beta - 1b) 1993 3. Copaxone (glatiramer acetate) 1996 4. Extavia (interferon beta - 1b) 5. Glatopa (glateramer acetate - generic equivlaent of Copaxone) 6. Plegridy (peginterferon beta - 1a) 8. Zinbryta (daclizumab) 2016
Differences between children with MS vs Adults
Children - more rates of relapse - seizures - mental status changes
Managing MS Symptoms/ meds: Fatigue
amantadine (symmetrel): antiviral and antiparkinsonian - it has CNS effects that helps improve fatigue in pts w/ MS Modafinil (Provigil): CNS stimulant fluoxetine - conserve energy/ avoid extreme cooling/ heat - improve mobility/ exercise, not overexertion - avoid high humidity
