NURSING PROCESS:THE PATIENT WITH MULTIPLE SCLEROSIS
Nursing assessment addresses actual and potential problems as-sociated with the disease, including neurologic problems, sec-ondary complications, and the impact of the disease on the patient and family. The patient’s movements and walking are ob-served to determine if there is danger of falling. Assessment of function is carried out both when the patient is well rested and when fatigued. The patient is assessed for weakness, spasticity, vi-sual impairment, incontinence, and disorders of swallowing and speech. Additional areas of assessment include the following: How has MS affected the patient’s lifestyle? How well is the pa-tient coping? What would the patient like to do better?
Based on the assessment data, the patient’s major nursing diag-noses may include the following:
· Impaired physical mobility related to weakness, muscle paresis, spasticity
· Risk for injury related to sensory and visual impairment
· Impaired urinary and bowel elimination (urgency, frequency, incontinence, constipation) related to nervous system dysfunction
· Impaired speech and swallowing related to cranial nerve involvement
· Disturbed thought processes (loss of memory, dementia, euphoria) related to cerebral dysfunction
· Ineffective individual coping related to uncertainty of course of MS
· Impaired home maintenance management related to phys-ical, psychological, and social limits imposed by MS
· Potential for sexual dysfunction related to spinal cord in-volvement or psychological reactions to condition
The major goals for the patient may include promotion of phys-ical mobility, avoidance of injury, achievement of bladder and bowel continence, promotion of speech and swallowing mecha-nisms, improvement of cognitive function, development of coping strengths, improved home maintenance management, and adap-tation to sexual dysfunction.
An individualized program of physical therapy, rehabilitation, and education is combined with emotional support. The nursing interventions include face-to-face and telephone interactions that address patient education to enable the person with MS to deal with the physiologic, social, and psychological problems that ac-company chronic disease (Madonna & Keating, 1999).
Relaxation and coordination exercises promote muscle efficiency. Progressive resistive exercises are used to strengthen weak muscles because diminishing muscle strength is often significant in MS.
Walking improves the gait, particularly when there is loss of po-sition sense of the legs and feet. If certain muscle groups are irre-versibly affected, other muscles can be trained to take over their actions. Instruction in the use of assistive devices may be needed to ensure their correct and safe use.
Muscle spasticity is common and, in its later stages, is character-ized by severe adductor spasm of the hips with flexor spasm of the hips and knees. If this is not relieved, fibrous contractures of these joints with resultant pressure ulcers over the sacrum and hips (due to diminished sensation and the inability to position the patient properly) occur. Warm packs may be beneficial, but hot baths should be avoided because of risk for burn injury secondary to sensory loss and increasing symptoms that may occur with an elevation of the body temperature.
Daily exercises for muscle stretching are prescribed to mini-mize joint contractures. Special attention is given to the ham-strings, gastrocnemius muscles, hip adductors, biceps, and wrist and finger flexors. Muscle spasticity is common and interferes with normal function. A stretch–hold–relax routine is helpful for relaxing and treating muscle spasticity. Swimming and stationary bicycling are useful, and progressive weight-bearing can relieve spasticity in the legs. The patient should not be hurried in any of these activities because this often increases spasticity.
The patient is encouraged to work to a point just short of fatigue. Very strenuous physical exercise is not advisable because it raises the body temperature and may aggravate symptoms. The patientis advised to take frequent short rest periods, preferably lying down.Extreme fatigue may contribute to the exacerbation of symptoms.
Because of the decrease in physical activity that often occurs with MS, complications associated with immobility, including pres-sure ulcers, expiratory muscle weakness, and accumulation of bronchial secretions, need to be considered and steps taken to prevent them. Measures to prevent such complications include assessment and maintenance of skin integrity and coughing and deep-breathing exercises.
If motor dysfunction causes problems of incoordination and clumsiness, or if ataxia is apparent, the patient is at risk for falling. To overcome this disability, the patient is taught to walk with feet wide apart to widen the base of support and to increase walking stability. If there is loss of position sense, the patient is taught to watch the feet while walking. Gait training may require assistive devices (walker, cane, braces, crutches, parallel bars) and instruc-tion about their use by a physical therapist. If the gait remains in-efficient, a wheelchair or motorized scooter may be the solution. The occupational therapist is a valuable resource person in sug-gesting and securing aids to promote independence. If incoordi-nation is a problem and tremor of the upper extremities occurs when voluntary movement is attempted (intention tremor), weighted bracelets or wrist cuffs are helpful. The patient is trained in transfer and activities of daily living.
Because sensory loss may occur in addition to motor loss, pres-sure ulcers are a continuing threat to skin integrity. Confinement to a wheelchair increases the risk.
Generally, bladder symptoms fall into the following categories: (1) inability to store urine (hyperreflexic, uninhibited); (2) inabil-ity to empty the bladder (hyporeflexic, hypotonic); and (3) a mix-ture of both types. The patient with urinary frequency, urgency, or incontinence requires special support. The sensation of the need to void must be heeded immediately, so the bedpan or uri-nal should be readily available. A voiding time schedule is set up (every 1.5 to 2 hours initially, with gradual lengthening of the interval). The patient is instructed to drink a measured amount of fluid every 2 hours and then attempt to void 30 minutes after drinking. Using a timer or wristwatch with an alarm may be help-ful for the patient who does not have enough sensation to signal the need to empty the bladder. The nurse encourages the patient to take the prescribed medications to treat bladder spasticity because this allows greater independence. Intermittent self-catheterization has been successful in maintaining bladder control in patients with MS. If the female patient has permanent urinary in-continence, urinary diversion procedures may be considered. The male patient may wear a condom appliance for urine collection.
Bowel problems include constipation, fecal impaction, and in-continence. Adequate fluids, dietary fiber, and a bowel-training program are frequently effective in solving these problems.
When the cranial nerves controlling the mechanisms of speech and swallowing are involved, dysarthrias (defects of articulation) marked by slurring, low volume of speech, and difficulties in phonation may occur. Swallowing disturbances (dysphagia) may also occur. A speech therapist evaluates speech and swallowing and instructs the patient, family, and health team members about strategies to compensate for speech and swallowing problems. The nurse reinforces this instruction and encourages the patient and family to adhere to the plan. Impaired swallowing increases the patient’s risk for aspiration; therefore, strategies (eg, having suction apparatus available, careful feeding, proper positioning for eating) are needed to reduce that risk (Galvan, 2001).
Measures may be taken if visual defects (the cranial nerves affecting vision may be affected by MS) or changes in cognitive status occur.
An eye patch or a covered eyeglass lens may be used to block vi-sual impulses of one eye when the patient has diplopia (double vision). Prism glasses may be helpful for the bedridden patient who is having difficulty reading in the supine position. People unable to read regular-print materials are eligible for the free talk-ing book services of the Library of Congress or may obtain large-type books from local libraries.
Cognitive impairment and emotional lability may occur early in MS in some patients and may impose numerous stresses on the patient and family. Some patients with MS are forgetful and easily distracted and may exhibit emotional lability.
Patients adapt to illness in a variety of ways, which may in-clude denial, depression, withdrawal, and hostility. Emotional support assists patients and their families to adapt to the changes and uncertainties associated with MS and to cope with the dis-ruption in their lives. The patient is assisted to set meaningful and realistic goals to achieve a sense of purpose, to remain as active as possible, and to keep up social interests and activities. Hobbies may help the patient’s morale and provide satisfying interests if the disease progresses to the stage in which formerly enjoyed ac-tivities can no longer be pursued.
The family should be made aware of the nature and degree of cognitive impairment. The environment is kept structured, and lists and other memory aids are used to help the patient with cog-nitive changes to maintain a daily routine. The occupational ther-apist can be helpful in formulating a structured daily routine.
The diagnosis of MS is always distressing to the patient and fam-ily. They need to know that no two patients with MS have iden-tical symptoms or courses of illness. Although some patients do experience significant disability early, others have a near-normal life span with minimal disability. Some families, however, face overwhelming frustrations and problems. MS affects people who are often in a productive stage of life and concerned about career and family responsibilities. Family conflict, disintegration, sepa-ration, and divorce are not uncommon. Often, very young family members assume the responsibility of caring for a parent with MS. Nursing interventions in this area include alleviating stress and making appropriate referrals for counseling and support to min-imize the adverse effects of dealing with chronic illness.
The nurse, mindful of these complex problems, initiates home care and coordinates a network of services, including social ser-vices, speech therapy, physical therapy, and homemaker services. To strengthen the patient’s coping skills, as much information as possible is provided. People who live with chronic illness need an updated list of the assistive devices, services, and resources that are available.
Coping through problem solving involves helping the patient define the problem and develop alternatives for its management. Careful planning and maintaining flexibility and a hopeful atti-tude are useful for psychological and physical adaptation.
MS can affect every facet of daily living. After certain abilities are lost, they are often impossible to regain. Physical function may vary from day to day. Modifications that allow independence in self-care should be implemented (eg, assistive eating devices, raised toilet seat, bathing aids, telephone modifications, long-handled comb, tongs, modified clothing). Physical and emotional stresses should be avoided as much as possible because these may worsen symptoms and impair performance. Exposure to heat in-creases fatigue and muscle weakness, so air conditioning in at least one room is recommended. Exposure to extreme cold may in-crease spasticity.
Patients with MS and their partners face problems that interfere with sexual activity, arising not only as a direct consequence of nerve damage but also from psychological reactions to the disease. Easy fatigability, conflicts arising from dependency and depres-sion, emotional lability, loss of self-esteem, and feelings of low self-worth compound the problem. Erectile and ejaculatory dis-orders in men and orgasmic dysfunction and adductor spasms of the thigh muscles in women can make sexual intercourse difficult or impossible. Bladder and bowel incontinence and urinary tract infections add to the difficulties.
An experienced sexual counselor helps bring into focus the patient’s or partner’s sexual resources and suggests relevant in-formation and supportive therapy (Sipski & Alexander, 1997). Sharing and communicating feelings, planning for sexual activ-ity (to minimize the effects of fatigue), and exploring alternative methods of sexual expression may open up a wide range of sexual enjoyment and experiences.
As the disease progresses, the patient and family need to learn new strategies to maintain optimal independence. Teaching of new self-care techniques may be initiated in the hospital or clinic set-ting and reinforced in the home. Teaching about self-care may address the use of assistive devices, self-catheterization, and ad-ministration of medications that affect the course of the disease or treat complications. Although the disease-modifying medica-tions (the “ABC and R medications”) may slow the progression of disease and disability in many persons with MS, they are not effective in all patients. Patients who receive these medications will require teaching and support, while those unable to take them or for whom the medications have not been effective need continued support and assistance in coping with this reality. Exercises that enable the patient to continue some form of activ-ity or that maintain or improve swallowing, speech, or respiratory function may be taught to the patient and family (Chart 64-3).
After discharge, the home care nurse often provides teaching and reinforcement of these new techniques in the patient’s home.
Nurses in the home setting assess for changes in the patient’s physical and emotional status, provide physical care to the patient if required, coordinate outpatient services and resources, and en-courage health promotion, appropriate health screenings, and adaptation. If changes in the disease or its course are noted, the home care nurse encourages the patient to contact the primary care provider because treatment of an acute exacerbation or new problem may be indicated. Continuing health care and follow-up are recommended.
The patient with MS is encouraged to contact the local c hapter of the National Multiple Sclerosis Society for services, publica-tions, and contact with others with MS. Local c-hapters also pro-vide direct services to patients. Through group participation, the patient has an opportunity to meet others with similar problems, to share experiences, and to learn self-help methods in a social environment.
Expected patient outcomes may include:
1) Improved physical mobility
a) Participates in gait-training and rehabilitation program
b) Establishes a balanced program of rest and exercise
c) Uses assistive devices correctly and safely
2) Is free of injury
a) Uses visual cues to compensate for decreased sense of touch or position
b) Asks for assistance when necessary
3) Attains or maintains control of bladder and bowel patterns
a) Monitors self for urine retention and employs intermit-tent self-catheterization technique, if indicated
b. Identifies the signs and symptoms of urinary tract infection
Maintains adequate fluid and fiber intake
4) Participates in strategies to improve speech and swallowing
a) Practices exercises recommended by speech therapist
b) Maintains adequate nutritional intake without aspiration
5) Compensates for altered thought processes
a) Uses lists and other aids to compensate for memory losses
b) Discusses problems with trusted advisor or friend
c) Substitutes new activities for those that are no longer possible
6) Demonstrates effective coping strategies
a) Maintains sense of control
b) Modifies lifestyle to fit goals and limitations
c) Verbalizes desire to pursue goals and developmental tasks of adulthood
d) Adheres to plan for home maintenance management
e) Uses appropriate self-care techniques to maintain in-dependence
f) Engages in health promotion activities and health screen-ings as appropriate
7) Adapts to changes in sexual function
a) Is able to discuss problem with partner and appropriate health professional
b) Identifies alternate means of sexual expression
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