Multiple sclerosis p.pdf

Multiple Sclerosis (MS) Multiple Sclerosis - Chronic disease caused by immune, genetic and/or infectious factors. ○ One of leading causes of neurologic disability for young and middle aged Pathophysiology: ○ Affects myelin and nerve fibers of the brain and spinal cord. ○ Immune system eats away at t...

Multiple Sclerosis (MS) Multiple Sclerosis - Chronic disease caused by immune, genetic and/or infectious factors. ○ One of leading causes of neurologic disability for young and middle aged Pathophysiology: ○ Affects myelin and nerve fibers of the brain and spinal cord. ○ Immune system eats away at the protective covering of nerves (myelin) Risk Factors: A POW ○ Age (usually between age 20-50) ○ People living away from: the Equator or tropical climates ○ Often Caucasians of European ancestry ○ Women (3 or 4 more times affected than men) Concepts Affected: ○ Mobility ○ Impaired immunity ○ Visual acuity/cognition Impact on People: ○ Limitations such as vision problems ○ Affects childbearing → Trouble caring for baby ○ Affects families with caregiving Types of MS Relapsing Remitting Secondary Progressive Primary Progressive Progressive Relapsing Signs and Symptoms ○ Relapsing Remitting - Unpredictable attacks which may or may not leave permanent deficits followed by periods of remission. ○ Secondary Progressive - Initial relapsing-remitting multiple sclerosis that suddenly begins to have increase in disability without periods of remission ○ Primary Progressive - Steady increase in disability without attacks ○ Progressive Relapsing - Steady increase in disability since onset with superimposed attacks. ○ Early Signs: I miss (MS) IDA Intentional tremor - hand starts shaking when you reach for something. Double vision (Diplopia) Ataxic gait / spastic Ataxia - without coordination ○ Late Signs: same as late Parkinson’s IUD Unable to walk Impaired cognition Difficulty swallowing/speaking ○ Other Symptoms: BEN FPS Bowel or bladder dysfunction → later symptom Euphoria/depression Nystagmus - involuntary eye movement ○ Eye rapidly moves up and down, side to side, in a circle, etc. ○ Fatigue, muscle weakness, muscle spasms and pain ○ Paresthesia(s) - numbness and tingling. “Pins and needles”. ○ Sensitivity to temperature (avoid heat) Interventions: IG, CBC, CSF, (MRI)VER | PHACE ○ Subjective questions to ask: Has your vision changed? Since when? What does it look like? What type of sensations are you feeling? Where? For how long? Are you having difficulty walking? Are you having tremors? Did this happen before? Did it go away and return? Are you having mood changes? Do symptoms get progressively worse? Does stress, heat, and a hot bath make symptoms worse? Family history of MS? IG, CBC, CSF, (MRI)VER ○ Secondary Preventions: Neuro exam/history Immunoglobulin (antibody) blood test CBC CSF shows: Elevated proteins (oligoclonal bands) ○ Oligoclonal bands = immunoglobulins = antibodies Increase in WBC Increase in myelin protein Increased immunoglobulins (antibodies) MRI - Plaques in two areas of brain and spinal cord considered diagnostic VER (Visual Evoked Response) - measures the electrical signal generated at the visual cortex in response to visual stimulation. Can show impaired transmission along optic nerve pathway ○ Tertiary Preventions: PHACE Physical/Occupational Therapy Physical therapist - work with gross motor movements (moving around) Occupational therapist - work with fine motor movements (using hands) Purpose = reduce spasticity, tremor, pain, fatigue, maintain functional ability ROM exercises / strengthening, stretching Home/environmental assessment Avoid activities that elevate body temperature. Keep the patient cool. Complementary/Alternative therapies (acupuncture, massage, yoga, aromatherapy, etc.) Eye patch alternating eyes for diplopia (double vision). Pharmacology (see below) Medications for MS ○ Immunomodulators and/or anti-inflammatory drugs Immunomodulators - medicines that change your immune system so it works more effectively. Includes treatments that increase/decrease immune response. Be concerned about secondary infection ○ Interferon-beta/immunomodulators - modify course of disease/antiviral effects Most common treatment Examples: ○ Interferon Beta 1A [Avonex, Rebif] ○ Glatiramer acetate ○ Interferon Beta 1A [Avonex, Rebif] - Immunomodulator that modifies the course of the disease and binds to receptors on the cell IM and taken weekly DEATH AM Side Effects: Diarrhea Elevated creatinine (kidney) and liver (ALT, AST, ASP) enzymes Anxiety, Depression Tachycardia Hypocalcemia Alopecia - hair loss. Myalgia - muscle pain Nursing Implications: Contraindicated in pregnancy or if breastfeeding Make sure blood work done periodically Discuss birth control/family planning Encourage high calcium foods ○ Vitamin D is needed for Calcium absorption ○ Glatiramer acetate - synthetic protein like a myelin based protein ○ Mitoxantrone - IV antineoplastic anti-inflammatory drug to stop relapses but risk of leukemia and cardiotoxicity Class: Antineoplastics - Chemo/Cancer medicines (Is the cure worse than the disease?) ○ Natalizumab - IV monoclonal antibody approved for MS that binds with WBC’s to prevent further damage to myelin (newer treatment with high risks) Class: Immunosuppressant Other Drugs ○ Corticosteroids - helps reduce recovery time by decreasing inflammation “-sone” and “-lone” Examples: Dexamethasone Prednisone Methylprednisolone Cortisone Typically given IV at first and may be followed by a tapered oral dose/can be intrathecal Intrathecal space (Subarachnoid space) - the area between the spinal cord and the thin, strong membranes that surround and protect it Adverse Effects: AHH PIGS Adrenal insufficiency Hyperglycemia Hypokalemia, Hypocalcemia and osteoporosis Psychosis/psychological disturbances (long term use) ○ Mild = insomnia, anxiety, agitation, irritability ○ Severe = delirium, hallucinations, depression, euphoria, mania. Iatrogenic Cushing’s Syndrome = Moon face, buffalo hump, truncal obesity GI irritation, peptic ulcer Sodium and fluid retention, weight gain, edema Implications: Clients taking Corticosteroids should: ○ Decrease sodium (corticosteroids caused salt/fluid retention) in their diets. ○ Increase both potassium and calcium in their diets. ○ Avoid grapefruit and grapefruit juice May increase serum levels of these medications. ○ Avoid receiving a "live" vaccine. Call their primary care practitioner if they are exposed to chickenpox or measles (since these conditions can be fatal in people who are using steroids.) Clients taking Glucocorticoids should: ○ Use with caution when combined with digoxin, thiazide or loop diuretics Hypokalemia increases the risk for digoxin-induced dysrhythmias. Potassium-depleting diuretics will increase the risk for hypokalemia. Take the medication in the morning (with food) to coincide with the body's normal secretion of cortisol. Contraindications/Cautions: Hypersensitivity, psychosis, fungal infection Caution with Diabetes Caution with infection → Mask signs of infection Can increase the potency of aspirin. NSAIDs and increases risk of GI bleeding. ○ Antispasmodics and muscle relaxants – treats muscle spasticity Baclofen [Lioresal, Gablofen] Cyclobenzaprine [Fexmid, formerly Flexeril] Dantrolene [Dantrium] ○ Antidepressants – depression or mood changes Fluoxetine [Prozac, Sarafem] Venlafaxine [Effexor] Imipramine [Tofranil] Phenelzine [Nardil] ○ GI medications ○ Sexual function medications Sildenafil [Viagra]. Other terms ○ Remissions - period with no symptoms. Client feels better ○ Exacerbations - symptoms come and attack and get worse. Hard to deal with because it is uncertain and they don't know when it’s coming. ○ MS patients may feel helpless, depressed, frustrated, scared.