Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) characterized by chronic inflammation, demyelination, gliosis, and neuronal loss. Lesions in the CNS occur at different times and in different CNS locations. Approximately 400,000 individuals in the United States and 2.5 million individuals worldwide have multiple sclerosis. The disease is three-fold more common in females than in males. While the age of onset is usually between 20 to 40 years, the disease can present at any age.
Multiple sclerosis is an immune-mediated inflammatory disease that attacks myelinated axons in the central nervous system, destroying the myelin and the axon in variable degrees and producing significant physical disability within 20-25 years in more than 30% of clients. The hallmark of MS is symptomatic episodes that occur months or years apart and affect different anatomic locations.
MS is grouped into seven categories based on disease course:
- Relapsing-remitting (RR). RR is characterized by recurrent attacks in which neurologic deficits appear in different parts of the nervous system and resolve completely or almost completely over a short period of time, leaving little residual deficit. Clients diagnosed with a relapsing-remitting pattern account for approximately 85% of MS cases.
The following subgroups are sometimes included in RR:
- Clinically isolated syndrome (CIS). A single episode of neurologic symptoms or inflammatory CNS demyelination.
- Benign MS. MS with almost complete remission between relapses and little if any accumulation of physical disability over time.
- This is characterized by severe MS with multiple relapses and rapid progression towards disability.
- Primary progressive (PP). 15 to 20% of clients present with a gradual deterioration from the onset, with an absence of relapses.
- Secondary progressive (SP). This is characterized by a more gradual neurologic deterioration after an initial RR course. Unlike RR. SP without relapses does not seem to be responsive to currently available disease-modifying agents.
- Progressive-relapsing (PR). In 5% of clients, a gradual deterioration with superimposed relapses occurs.
The cause of MS is unknown, but it is likely that multiple factors act in concert to trigger or perpetuate the disease. Factors involved in pathogenesis are broadly grouped into three categories.
- Immune factors. Dysimmunity with an autoimmune attack on the CNS is the leading hypothesized etiology of MS. Although there are various proposed hypothetical mechanisms, the postulated “out-side-in” mechanism involves CD+4 proinflammatory T cells. Researchers hypothesize that an unknown antigen triggers and activates both TH1 and Th17, leading to CNS endothelium attachment, the crossing of the blood-brain barrier, and subsequent immune attack through cross-reactivity.
- Environmental factors. Geography is clearly an important factor in the etiology of MS. The incidence of the disease is lower in the equatorial regions of the world than in the southernmost and northernmost regions. Whatever environmental factor is involved must exert its effect in early childhood. If an individual lives in an area with a low incidence of MS until 15 years of age, that person’s risk remains low even if the individual subsequently moves to an area of high incidence.
- Genetic factors. There is a high risk of MS clients with biological relatives with MS. Heritability is estimated to be between 35 and 75%. Monozygotic twins have a concordance rate of 5%. There is a 2% concordance in parents and children, and this is still a 10 to 20-fold higher risk than in the general population.
Multiple sclerosis is an inflammatory, demyelinating disease of the CNS. In pathologic specimens, the demyelinating lesions of MS called plaques, appear as indurated areas—thus the term sclerosis. Two fundamental processes constitute the general pathological processes seen in MS clients: focal inflammation resulting in macroscopic plaques and injury to the blood-brain barrier; and neurodegeneration with a microscopic injury involving different components of the CNS. Together, these two primary processes result in microscopic and macroscopic injury. Lesions referred to as plaques occur in waves throughout the disease course and result from focal inflammation. MS plaques predominantly center around small veins and venules and show sharp margins. Myelin loss, edema, and axonal injury are the chief components of plaque pathology. The blood-brain barrier disruption during active plaque inflammation corresponds to the enhancement seen on MRI. Over time, the inflammatory process subsides, resulting in an astrocytic scar.
The most widely accepted clinical rating scale on the basis of findings from the history and physical examination is the 10-point Kurtzke Expanded Disability Status Scale (EDSS). The EDSS assigns a severity score to the client’s clinical status that ranges from 0–10 in increments of 0.5. The scores from 0-to 4 are determined using functional systems (FS) scales that evaluate dysfunction in eight neurologic systems.
Cognitive changes are common among clients diagnosed with MS. Interventions from the nurse must focus on assessment, measurement, and advice on lifestyle management. MS nurse specialists can also plan appointments and education sessions, and provide access for a client diagnosed with MS to seek unplanned support via nurse advice lines or digital services. The following are nursing diagnoses associated with multiple sclerosis.
- Impaired Physical Mobility
- Self-care Deficit
- Impaired Urinary Elimination
Multiple Sclerosis Nursing Care Plan
Below are sample nursing care plans for the problems identified above.
Impaired Physical Mobility
Mobility impairment, especially related to difficulty walking, is probably the most visible sign of MS. Several studies have provided insight into the prevalence of impaired mobility among clients diagnosed with MS, with a reported prevalence that ranges from almost 50% to >90% of clients. Limited data suggests that mobility impacts coping ability, participation in activities of daily living (ADL), health-related quality of life (HRQOL), and productivity, with outcomes reported among clients with mobility impairment being worse than those among clients without such impairment. A more focused evaluation of the effects of mobility, and its underlying components, including lower and upper extremity impairment, as contributing factors to employment, ADL, and HRQOL may provide guidance on managing MS clients in a manner that addresses their immediate priorities and long-term concerns.
- Impaired physical mobility
- Pain and discomfort
- CNS injury
- Demyelinating process
- Muscle cramping
- Increased muscle tone
- Resistance to movement
- Poor posture and balance
- Burning, gnawing, or shooting pain
- Wide-based gait
After implementation of nursing interventions, the client is expected to:
- Verbalize understanding of the situation, risk factors, and individual treatment regimen.
- Be free of complications
- Demonstrate techniques and behaviors that enable the resumption of activities.
- Maintain or increase strength and function of the affected or compensatory body part.
|Evaluate the degree of mobility impairment using clinical assessment tools.||The client may be rated according to several clinical disability scales, on the basis of findings on the history and physical examination. The most widely accepted of these is the 10-point Kurtzke Expanded Disability Status Scale (EDSS). Other scales include the Ambulation Index and the Multiple Sclerosis Functional Composite (MSFC).|
|Evaluate the need for mobility aids.||Clients diagnosed with MS may benefit from assessment in appropriate assistive devices to improve their mobility, strengthen muscles, and improve their range of motion.|
|Perform passive range of motion (ROM) exercises and assist with active exercises.||ROM exercises and good body mechanics strengthen the muscles of the lower extremities.|
|Encourage lower extremity exercises.||These exercises stimulate venous return and decrease venous stasis.|
|Provide good skin care and gently massage pressure points after a position change.||Gentle massage and frequent repositioning reduce the risk of skin irritation and breakdown. Frequent skin assessments and prompt interventions afford early detection of skin breakdown.|
|Note emotional and behavioral responses to immobility. Provide diversional activities.||The client’s immobility or difficulty in mobility may heighten restlessness and irritability. Diversional activity aids in refocusing attention and enhances coping with actual and perceived limitations.|
|Assist with activity, progressive ambulation, and therapeutic exercises.||Activity depends on the individual situation. It should begin as early as possible and usually progresses slowly, based on client tolerance.|
|Demonstrate the use of adjunctive devices, such as a walker or cane.||The appropriate use of adjunctive devices provides stability and support by compensating for altered muscle tone, strength, balance, and gait.|
|Provide means to summon help, such as a special sensitive call light.||This promotes the client’s sense of control and reduces the fear of being left alone.|
|Administer baclofen as prescribed.||Baclofen is particularly useful for the relief of flexor spasms and concomitant pain, clonus, and muscular rigidity in MS clients. It is effective in most cases, is inexpensive, and is titrated easily from 10-140 mg/day in divided doses.|
|Administer second-line agents including benzodiazepines, dantrolene sodium, and anticonvulsants as appropriate.||Benzodiazepines can be sedating and habit-forming, however, for clients who also have sleep disorders, the sedative effects can be beneficial, allowing the clinician to manage the spasticity and the sleep problem with a single medication. Dantrolene sodium acts directly on skeletal muscle to decrease spasticity. The anticonvulsant drug gabapentin is particularly useful in clients who experience spasticity and neuropathic pain.|
|Administer dalfampridine as prescribed.||Oral, sustained dalfampridine has been shown to improve walking ability in clients diagnosed with MS. It is the only medication approved by the FDA for this indication for MS clients. Fourteen weeks of treatment was found to improve walking ability in a significant percentage of clients in a randomized, multicenter, double-blind, phase III trial.|
|Arrange referral to a physical therapist.||Physical therapists evaluate and train the clients in appropriate exercise programs to decrease spasticity, maintain range of motion, strengthen muscles, and improve coordination. Physical therapy for spasticity in clients diagnosed with MS includes the establishment of a stretching program in which joints are moved slowly to positions that stretch the spastic muscles.|
|Refer the client to an occupational therapist, as indicated.||Occupational therapists are skilled in assessing the client’s functional abilities in completing activities of daily living, assessing fine motor skills, and evaluating adaptive equipment and assistive technology needs.|
|Caution the client regarding adverse effects of pharmacologic treatments.||An increased risk of seizures has been observed in clients taking dalfampridine; therefore, it is contraindicated in clients with a history of seizures. The FDA recommends that the kidney function of a client must be checked before starting the drug. Adverse effects of baclofen include fatigue and weakness; benzodiazepine is contraindicated to clients diagnosed with cognitive impairment due to their adverse CNS effects.|
Multiple sclerosis is an incapacitating disease that gradually affects the client’s self-care capacity and causes functional decline, evidenced by the evaluation of basic, instrumental, and advanced activities of daily living. Such activities, if compromised, may have an impact not only on self-care but also on the quality of life, and social interaction, and may contribute to the isolation of the individual. Nurses have a fundamental role in integrating the multidisciplinary team and ensuring the promotion, protection, and rehabilitation of health, focusing on the maintenance of self-care and on the functionality of the client.
- Self-care deficit
- Neuromuscular or perceptual impairment
- Activity intolerance
- Decreased strength and endurance
- Pain and discomfort
- Memory loss
- Inability to perform tasks of self-care
- Poor personal hygiene
After implementation of nursing interventions, the client is expected to:
- Perform self-care activities within the level of own ability.
- Identify individual areas of weakness and needs.
- Identify personal and community resources that provide assistance.
- Demonstrate techniques and lifestyle changes to meet self-care needs.
|Assess the degree of functional impairment using a scale of 0 to 4. Determine the current activity level or physical condition.||A functional assessment provides information to develop a plan for rehabilitation. One useful scale is the Multiple Sclerosis Functional Composite (MSFC), which includes the Ambulalation Index, which is based solely on the ability to walk 25 feet.|
|Note the presence of and accommodate fatigue.||Fatigue can be very debilitating and greatly impacts the ability to participate in ADLs. The subjective nature of reports of fatigue can easily be misinterpreted as manipulative or a form of secondary gain. An estimated 50-60% of persons diagnosed with MS describe fatigue as one of their most bothersome symptoms, and it is the major reason for unemployment among MS clients.|
|Assess the client’s level of understanding.||As the treatment schemes for MS can be complex, clients with low levels of literacy may have greater difficulty understanding and complying with the treatment. This may pose a challenge to care and lead to self-care impairment and cause functional disability.|
|Encourage the client to perform at the optimal level of function but do not pressure them.||Encouragement promotes independence and a sense of control. It may also decrease feelings of helplessness. Self-management is part of self-care in order to facilitate better adaptation to the disease, reduce the likelihood of secondary complications, contribute to the quality of life, reduce disability, and improve outcomes with treatment.|
|Encourage client input in planning schedule.||The client’s quality of life is enhanced when preferences are considered in daily activities. The planning of care, as well as its implementation, must be consistent with the needs observed since it has a crucial role in functional decline.|
|Provide assistance with physical limitations. Allow as much autonomy as possible.||Client participation in self-care can ease the frustration over perceived loss of independence. Clients with greater clinical compromise and with longer symptoms onset time and/or diagnosis time showed higher levels of dependence. In a study conducted in Turkey, researchers confirmed that in the first 10 years of the disease, clients tend to be slightly more dependent to perform ADLs and with a greater need for self-care.|
|Encourage scheduling activities early in the day or during peak energy levels.||Completing ADLs requires high energy expenditure. Poor planning of activities can cause early fatigue, persisting through the rest of the day.|
|Allow sufficient time to perform tasks. Display patience when movements are slow.||Decreased motor skills and spasticity may interfere with the ability to manage simple activities. The muscle stiffness greatly increases the energy expended to perform ADLs, which in turn contributes to fatigue.|
|Anticipate hygiene and grooming needs. Assist with the care of nails, skin, hair, and mouth and with shaving, as necessary.||The care provider can model a matter-of-fact attitude toward assistance with toileting and grooming activities. This facilitates the client and family members to accept changing roles and abilities.|
|Provide assistive devices as indicated.||Assistive devices such as shower chairs, elevated toilet seats with arm supports, and others, may reduce fatigue and enhance participation in care.|
|Reposition the client frequently and provide skin care to pressure points.||Repositioning reduces pressure on susceptible areas and prevents skin breakdown. It minimizes flexor spasms at the knees and hips.|
|Assist with active or passive range of motion and stretching and toning exercises on a regular schedule.||These maneuvers prevent problems associated with muscle pain, dysfunction, and disuse. They help maintain muscle tone, muscle strength, joint mobility, and proper body alignment. They decrease spasticity and the risk of calcium loss from bones.|
|Provide strategies to promote independent feeding.||Wrap the fork handle with tape, cut the client’s food, and show them how to hold a cup with both hands. These strategies promote independence and adequate nutritional intake.|
|Provide emotional support to the client, as appropriate.||Nurses should act by providing emotional support to the client, especially during the onset of first clinical manifestations, because the client may possibly be shaken due to possible disabilities and the changes that will occur not only in the body but also in lifestyle. This may be conducted through motivation to preserve self-care activities.|
|Arrange consultations with physical and occupational therapists.||Interdisciplinary consultations provide appropriate interventions that relieve spastic muscles, improve motor functioning, prevent or reduce muscle atrophy and contractures, and promote an optimal level of function, independence, and self-worth.|
|Administer amantadine as prescribed.||Amantadine is perhaps the first-line drug for the treatment of fatigue in MS, although this is an off-label use. Approximately 40% of MS clients experience some fatigue relief with amantadine .|
|Administer modafinil as indicated.||Modafinil, a drug approved for narcolepsy, has demonstrated some success in MS clients at doses of 200 mg/day.|
Impaired Urinary Elimination
Urinary incontinence in clients diagnosed with multiple sclerosis is one of the most important problems having a negative impact on the quality of life of clients. Central nervous system demyelination in MS causes many symptoms to appear. Among these symptoms, bladder problems occupy an important place. In the majority of clients diagnosed with MS, the sensory, motor, and sphincter functions of the bladder are affected and often cause sudden urination, frequent urination, and urinary incontinence problems. In studies, it was reported that the frequency of urinary incontinence in clients diagnosed with MS is at a rate of 52-97%. Urinary incontinence reduces the quality of life by having a negative impact on the social, professional, and sexual life of the individuals.
- Impaired urinary elimination
- Neuromuscular impairment
- Spinal cord lesions
- Neurogenic bladder
- Retention with overflow
- Recurrent UTIs
- Urinary frequency
After implementation of nursing interventions, the client is expected to:
- Verbalize understanding of the condition.
- Empty bladder completely and regularly, voluntarily or by catheter.
- Be free of urine leakage between voiding.
- Demonstrate behaviors and techniques to prevent or minimize infection.
|Assess for reports on urinary frequency, urgency, incontinence, nocturia, burning sensation, and the size and force of the urinary stream.||Urinary incontinence is an expected symptom in women diagnosed with MS due to the fact that the sensory, motor and sphincter functions of the bladder are affected.|
|Palpate the client’s bladder after voiding.||Bladder fullness after voiding indicates inadequate emptying or retention and requires further evaluation and intervention.|
|Assess the client’s drug regimen, including prescribed, OTC, and street drug use.||A number of medications, including antispasmodics, antidepressants, opioid analgesics; OTC medications with anticholinergic or alpha-agonist properties; or recreational drugs such as cannabis, may interfere with bladder emptying.|
|Start a bladder training program or timed voiding, as appropriate.||A bladder training program helps restore bladder functioning and reduces incontinence and bladder infection.|
|Instruct the client on performing pelvic floor muscle exercises.||During the filling phase of the voiding cycle, the pelvic floor muscles (PFM) help maintain urine retention by gradually increasing the capacity. A similar thing occurs when abdominal pressure increases. PFM contractions also prevent detrusor contraction. PFM contraction may be associated with perineal-detrusor reflex activation and may promote relaxation in the detrusor musculature.|
|Encourage adequate fluid intake. Instruct on avoiding caffeine, the use of aspartame, and limiting intake during late evening and at bedtime.||Sufficient hydration promotes urinary output and aids in preventing infection. When the client is taking sulfa drugs, sufficient fluids are necessary to ensure adequate excretion of the drug. Aspartame, a sugar substitute, may cause bladder irritation leading to bladder dysfunction .|
|Recommend the use of cranberry juice and vitamin C.||MS clients are susceptible to urinary tract colonization (UTC) and urinary tract infections (UTI), as a result of the bladder dysfunction in MS. It has been reported that cranberry can inhibit Escherichia coli adherence to the urethra.|
|Promote continued ambulation and mobility.||Continued mobility promotes bladder emptying, thus decreasing the risk of developing UTIs.|
|Promote proper hand hygiene and perineal care.||Perineal care reduces skin irritation and the risk of ascending infection. Urinary incontinence may distinctly cause disruption of skin integrity and hospitalizations related to urinary infections.|
|Administer medications as prescribed.||For storage problems, antimuscarinics are the first-line option, and more recently, beta-3 receptor agonists have become available and can be useful either as an add-on or stand-alone treatment. Antimuscarinics can be a good choice for clients diagnosed with MS. For voiding problems, only alpha-blockers are currently considered for medical therapy.|
|Administer antibiotics, as necessary.||Bacteriostatic agents inhibit bacterial growth and destroy susceptible bacteria. Prompt treatment of infection is necessary to prevent serious complications of ascending urinary infection, sepsis, and shock.|
|Perform catheterization, as indicated.||Depending on the pattern and extent of dysfunction and the client’s disability level, intermittent or indwelling catheterization may be offered to address the problem of incomplete bladder emptying. Since the introduction of clean intermittent catheterization in a client diagnosed with MS, it has become the gold standard in the treatment of voiding dysfunction.|
|Teach self-catheterization. Instruct in the use and care of the indwelling catheter.||Self-catheterization helps maintain the client’s autonomy and encourages self-care. An indwelling catheter may be required, depending on the client’s abilities ad the degree of the urinary problem.|
|Obtain periodic urinalysis and urine culture and sensitivity, as indicated.||As recommended by international guidelines, the gold standard for UTI diagnosis is urine culture. Microscopy reveals the type and count of cells found in the urine. Samples can be collected either from a clean-catch midstream sample, an indwelling urethral catheter, or a suprapubic aspiration from a suprapubic catheter.|
- Altunan, B., Gundogdu, A. A., Ozcaglayan, T. I. K., Unal, A., & Turgut, N. (2021, February 23). The effect of pelvic floor exercise program on incontinence and sexual dysfunction in multiple sclerosis patients. International Urology and Nephrology, 53, 1059-1065. https://doi.org/10.1007/s11255-021-02804-y
- de Medeiros Junior, W. L. G., Demore, C. C., Mazaro, L. P., de Souza, M. F. n., Parolin, L. F., Melo, L. H., Werka Junior, C. R., & Goncalves, M. V. M. (2020, November). Urinary tract infection in patients with multiple sclerosis: An overview. Multiple Sclerosis and Related Disorders, 46. https://doi.org/10.1016/j.msard.2020.102462
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.
- Jarrett, L. (2022, January 28). A multiple sclerosis nurse specialist narrative, focusing on supporting people to manage cognitive changes. British Journal of Neuroscience Nursing, 18(Sup1). https://doi.org/10.12968/bjnn.2022.18.Sup1.S32
- Luzzio, C., & Chawla, J. (2022, January 3). Multiple Sclerosis: Practice Essentials, Background, Pathophysiology. Medscape Reference. Retrieved May 24, 2022, from https://emedicine.medscape.com/article/1146199-overview#a5
- Mojaverrostami, S., Bojnordi, M. N., Ghasemi-Kasman, M., Ebrahimzadeh, M. A., & Hamidabadi, H. g. (2018, November 29). A Review of Herbal Therapy in Multiple Sclerosis. Advanced Pharmaceutical Bulletin, 8(4), 575-590. 10.15171/apb.2018.066
- Oliveira-Kumakura, A. R. d. S., Bezutti, L. M., Silva, J. L. G., & Gasparino, R. C. (2019). Functional and self-care capacity of people with multiple sclerosis. Revista Latino-Americana de Enfermagem, 27(e3183). https://doi.org/10.1590/1518-8345.3068.3183
- Soysal, O. Y., & Mollaoglu, M. (2022, January-April). Urinary Incontinence and the Quality of Life in Women with Multiple Sclerosis. International Journal of Caring Sciences, 15(1), 444.
- Sutliff, M. H. (2010). Contribution of impaired mobility to patient burden in multiple sclerosis. Current Medical Research and Opinion, 26(1), 109-119. 10.1185/03007990903433528
- Tafti, D., Ehsan, M., & Xixis, K. L. (2022, February 5). Multiple Sclerosis – StatPearls. NCBI. Retrieved May 24, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK499849/