21. Multiple sclerosis: progressive neurological disease, common in northern climates, characterized by demyelination of brain and spinal cord leading to degenerative neurological function; chronic remitting and relapsing disease; cause unknow Visual problems are often the first indication of multiple sclerosis. Classifications of multiple sclerosis: relapsing-remitting, primary-progressive, secondaryprogressive, and progressive-relapsin Exacerbations aggravated by fatigue, chilling, and emotional distress.
1. Pathophysiology: multiple foci (patches) of nerve degeneration throughout brain, spinal cord, optic nerve, and cerebrum cause nerve impulses to be interrupted (blocked) or distorted (slowed). Researchers suggest that in genetically susceptible people, the disease results from an abnormal autoimmune response to some agent, perhaps a virus or environmental trigger.
2. Risk factors:
1. Northern climate.
2. Onset age: 20-40 yr.
3. Two to three times more common in women than men.
3. Assessment:
1. Subjective data:
1. Extremities: weak, numb, decreased sensation.
2. Emotional instability, apathy, irritability, mood swings, fatigue.
3. Eyes: diplopia (double vision), spots before eyes (scotomas), potential blindness.
4. Difficulty in swallowing.
5. Pain.
2. Objective data:
1. Nystagmus (involuntary rhythmic movements of eyeball) and decreased visual acuity.
2. Inappropriate outbursts of laughing or crying (sometimes related to ingestion of hot food).
3. Disorders of speech.
4. Susceptible to infections.
5. Tremors to severe muscle spasms and contractures.
6. Changes in muscular coordination; gait: ataxic, spastic.
7. Changes in bowel habits, e.g., constipation.
8. Urinary frequency and urgency
9. Incontinence (urine and feces).
10. Sexual dysfunction.
11. Cognitive changes/depression.
12. Lab tests: cerebrospinal fluid has presence of gamma globulin IgG.
13. Diagnostic tests:
1. Neurological examination.
2. Positive Lhermitte’s sign (electric shock-like sensation along spine on flexion of the head).
3. Positive Babinski reflex.
4. MRI detects plaques.
4. Analysis/nursing diagnosis:
1. Impaired physical mobility related to changes in muscular coordination.
2. Self-esteem disturbance related to chronic, debilitating disease.
3. Altered health maintenance related to spasms and contractures.
4. Risk for impaired skin integrity related to contractures.
5. Constipation related to immobility.
6. Impaired swallowing related to tremors.
7. Visual sensory/perceptual alteration related to nystagmus and decreased visual acuity.
5. Nursing care plan/implementation:
1. Goal: maintain normal routine as long as possible.
1. Maintain mobility - encourage walking as tolerated; active and passive ROM; splints to decrease spasticity.
2. Avoid fatigue, infections.
3. Frequent position changes to prevent skin breakdown and contractures; position at night: prone to minimize flexor spasms of knees and hips.
4. Bowel/bladder training program to minimize incontinence.
5. Avoid stressful situations.
2. Goal: decrease symptoms - medications as ordered:
1. Methylprednisolone (high dose, IV) plus sodium succinate, followed by gradual tapering of steroids to treat at initial diagnosis.
2. Methylprednisolone (Solu-Medrol), prednisone (Deltasone), and dexamethasone (Decadron) used to treat acute relapses.
3. Methotrexate (Rheumatrex) (low dose) used to delay progression of impairment.
4. Interferon (3-lb (Betaseron) reduces number of lesions and frequency of relapses.
5. Glatiramer (Copaxone) to reduce number of relapses.
6. Baclofen (Lioresal) for alleviating spasticity 5 mg three times daily, increased by 5 mg every three days; not to exceed 80 mg/day (20 mg four times daily). Optimal effect between 40 and 80 mg; sudden withdrawal of medication may cause hallucinations and rebound spasticity.
7. Diazepam (Valium), dantrolene (Dantrium) to relieve muscle spasm.
8. Carbamazepine (Tegretol) or amitriptyline HC1 (Elavil) for dysesthesias or neuralgia.
9. Ciprofloxacin (Cipro) to treat bladder dysfunction.
10. Psyllium hydrophilic mucilloid (Metamucil) to treat bowel dysfunction.
11. Phenytoin (Dilantin) to treat sensory symptoms.
12. Analgesics to treat pain.
3. Goal: health teaching to prevent complications.
1. Signs and symptoms of disease; measures to prevent exacerbations.
2. Teach to monitor respiratory status to prevent infections.
3. Importance of physical therapy to prevent contractures.
4. Possible counseling or community support group for assistance in accepting long-term condition.
5. Teach special skin care to prevent decubitus ulcers.
6. Teach use of assistive devices to maintain independence.
4. Goal: provide psychosocial support.
1. Answer questions of patient and family members.
2. Provide referrals to appropriate agencies.
3. Monitor for signs of suicide (higher incidence of suicide in patients with MS than the general population).
4. Encourage communication.
6. Evaluation/outcome criteria:
1. Establishes daily routine; adjusts to altered lifestyle.
2. Injuries prevented; no falls.
3. Urinary and bowel routines established; incontinence decreased.
4. Infections avoided.
5. Symptoms minimized by medications.


22. Myasthenia gravis: Chronic neuromuscular disease characterized by weakness and easy fatigability of facial, oculomotor, pharyngeal, and respiratory muscles. The muscle weakness increases during periods of activity and improves after periods of rest.
1. Pathophysiology: inadequate acetylcholine or excessive or altered cholinesterase, leading to impaired transmission of nerve impulses to muscles at myoneural junction.
2. Risk factors:
1. Possible autoimmune reaction.
2. Thymus tumor.
3. Young women and older men, but can occur at any age.
3. Assessment:
1. Subjective data:
1. Diplopia (double vision).
2. Severe generalized fatigue.
2. Objective data:
1. Muscle weakness: hands and arms affected first.
2. Ptosis (drooping of eyelids), expressionless facies.
3. Hypersensitivity to narcotics, barbiturates, tranquilizers.
4. Abnormal speech pattern, with highpitched nasal voice.
5. Difficulty chewing/swallowing food.
6. Decreased ability to cough and deep breathe, vital capacity.
7. Positive Tensilon test (administration of edrophonium chloride, 10 mg IV, produces relief of symptoms within 30 sec).
8. Positive Prostigmin test (5 mg subcutaneous neostigmine methylsulfate, produces relief of symptoms within 15 min; increased muscle strength within 30 min).
4. Analysis/nursing diagnosis:
1. Ineffective breathing pattern related to weakness.
2. Risk for injury related to muscle weakness.
3. Activity intolerance related to severe fatigue.
4. Bathing/dressing self-care deficit related to progressive disease.
5. Impaired physical mobility related to decrease in strength.
6. Anxiety related to physical symptoms and disease progression.
7. Knowledge deficit related to medication administration and expected effectiveness.
5. Nursing care plan/implementation:
1. Goal: promote comfort.
   1. Passive and active ROM, as tolerated, to increase strength.
   2. Mouth care: before and after meals.
   3. Diet: as tolerated, soft, pureed, or tube feedings.
   4. Skin care to prevent decubiti.
   5. Eye care: remove crusts; patch affected eye prn.
   6. Monitor respiratory status - suction airway prn.
2. Goal: decrease symptoms.
   1. Administer medications as ordered:
      1. Anticholinesterase (neostigmine [Prostigmin], pyridostigmine [Mestinon]) to elevate concentration of acetylcholine at myoneural junction.
      2. Give before meals to aid in chewing, with milk or food to decrease GI symptoms; maybe given parenterally.
3. Goal: prevent complications.
   1. Respiratory assistance if breathing pattern not adequate.
   2. Monitor for choking/increased oral secretion.
   3. Avoid: narcotics, barbiturates, tranquilizers.
4. Goal: promote increased self-concept.
   1. Encourage independence when appropriate.
   2. Encourage communication; provide alternative methods when speech pattern impaired.
5. Goal: health teaching.
1. Medication information:
   1. Adjust dosage to maintain muscle strength.
   2. Medication must be taken at prescribed time to avoid:
   1. Myasthenic crisis (too little medication).
   2. Cholinergic crisis (too much medication).
2. Signs and symptoms of crisis: dyspnea, severe muscle weakness, respiratory distress, difficulty in swallowing.
3. Importance of avoiding upper respiratory infections.
4. Determine methods to conserve energy, to maintain independence as long as possible, while avoiding overexertion.
5. Refer to Myasthenia Gravis Foundation and other community agencies for assistance in reintegration into the community and plans for follow-up care.
6. Evaluation/outcome criteria:
1. Independence maintained as long as possible.
2. Respiratory arrest avoided.
3. Infection avoided.
4. Medication regimen followed and crisis avoided.