Multiple Sclerosis MS Nursing Diagnosis and Nursing Care Plan

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Multiple Sclerosis MS Nursing Care Plans Diagnosis and Interventions

Multiple Sclerosis MS NCLEX Review and Nursing Care Plans

Multiple sclerosis (MS) is a chronic condition involving the central nervous system. It is an autoimmune disease characterized by the demyelination or degeneration of myelin sheaths which are protective covering of nerve cells.

The damage causes problems in the communication between the brain and the rest of the body.

There are three types of multiple sclerosis, namely: relapsing MS, secondary progressive MS, and primary progressive MS.

  1. Relapsing MS – the most common type, accounting for about 85% of all the MS cases. Relapsing MS is characterized by a relapsing and remitting cycle.
  2. Secondary progressive MS – starts off as relapsing MS but symptoms get steadily worse.
  3. Primary progressive MS – described as the gradual worsening of MS symptoms over time.

Signs and Symptoms of Multiple Sclerosis MS

Multiple sclerosis involves a range of different signs and symptoms.

These symptoms may vary depending on the location of affected nerve fibers, and may include:

  • Numbness or weakness on one or both sides of the body
  • Lhermitte sign – sensations of electric shocks when moving the neck
  • Tremors and unsteady gait
  • Partial/complete vision loss – typically occurs one eye at a time
  • Prolonged double vision
  • Blurred vision
  • Slurring of speech
  • Fatigue
  • Dizziness
  • Tingling sensation
  • Issues with sexual, bowel, and bladder function

Causes of Multiple Sclerosis MS

Multiple sclerosis is considered an autoimmune condition although the exact etiology of the disease is still unknown.

In the case of MS, the body attacks the protective covering of nerve fibers of the brain and spinal cord called myelin sheaths.

The risk factors for developing the condition are as follows:

  • Age – the onset of MS commonly occurs between 20-40 years of age. However, all ages can develop the condition
  • Sex – women are reported to be more susceptible to the disease
  • Family history – having immediate family members diagnosed with MS increases the risk of developing the condition
  • Some infections – there are infections associated with the development of MS such as Epstein-Barr infection
  • Race – those with Northern European descent are at higher risk of developing MS
  • Climate – MS is more common in countries with a temperate climate such as the US, New Zealand, and Europe
  • Vitamin D – low level of vitamin D is linked with the development of MS
  • Autoimmune diseases – those with pre-existing autoimmune diseases are slightly at risk of developing MS
  • Smoking

Complications of Multiple Sclerosis MS

  1. Muscle spasms
  2. Paralysis
  3. Problems related to bladder, bowel, and sexual functions
  4. Mental changes
  5. Depression
  6. Epilepsy

Diagnosis of Multiple Sclerosis MS

A neurologist typically makes the diagnosis of multiple sclerosis. The diagnosis for this condition may not be straightforward and may require a series of tests, which may include:

  • Neurological exam – questions about health problems at present and in the past may be asked as part of the assessment. The medical history may help explain the symptoms and rule out other possible diagnoses. A neurological exam may include physical tests to assess for changes and weaknesses in movement, vision, balance, sensation, speech, and reflexes.
  • Magnetic resonance imaging (MRI) – an MRI of the brain and spinal cord is performed to identify the exact location of damage to the nerve tissues. MRI has been successful in providing a definite diagnosis in 90% of cases.
  • Evoked potential test – this procedure involves the attachment of electrodes on the head to record brain patterns while stimuli are presented.
  • Spinal tap – also known as lumbar puncture, this test involves the insertion of a needle into the space surrounding the spinal cord to take a small sample of the spinal fluid. In people with MS, the fluid will show the presence of antibodies.
  • Blood tests – blood tests are performed to help rule out other conditions that are similar to MS.

Treatment for Multiple Sclerosis MS

Multiple sclerosis has no cure; however, several therapies and treatment options are available to help manage the disease.

  1. Disease-Modifying Therapies (DMTs). DMTs are known to be effective in relapsing MS. They work by slowing down the progression of symptoms and damage caused by the condition. There are a variety of DMTs available in the market in the form of tablets, injections, and infusions.
  2. Hematopoietic Stem Cell Transplantation (HSCT). HSCT is an intensive treatment involving the use of chemotherapy to wipe out and regrow the immune system with the use of stem cells. It is most effective in the early stages of the disease.
  3. Physiotherapy. Physiotherapists can help deal with physical difficulties associated with the disease. They can advise on movements and exercises to deal with the problematic area of the body.
  4. Complementary and Alternative Therapies. Also known as complementary and alternative medicine (CAMs), this therapy option involves the use of a variety of “natural” medicine such as acupuncture, yoga, and aromatherapy.

Nursing Diagnosis for Multiple Sclerosis MS

Nursing Care Plan for Multiple Sclerosis 1

Impaired physical mobility related to neurological impairment secondary to multiple sclerosis, as evidenced by numbness or weakness on one or both sides of the body, Lhermitte sign, tremors, and unsteady gait

Desired Outcome: The patient will be able to perform activities of daily living within the limits of the disease.

Multiple Sclerosis Nursing InterventionsRationales
Assess the patient’s level of functional mobility and ability to perform ADLs.To assist in creating an accurate diagnosis and monitor effectiveness of treatment and therapy.
Assist the patient during exercises and when performing activities of daily living.To encourage the patient to perform muscle-strengthening exercises and promote dignity by allowing the patient to perform their ADLs while maintaining safety.
Ensure the safety of the environment. Check that the call bell is within reach, the bed rails are up when the patient is on the bed, the bed is in the lowest level, the room is well-lit, the floor is not slippery, and that important things like phone and eyeglasses are easy to reach.To maintain patient safety and reduce the risk of falls.      
Encourage the patient to perform range of motion (ROM) exercises in all extremities.To improve venous return, muscle strength, and stamina while preventing stiffness and contracture deformation.
Refer to the physiotherapy and occupational therapy team.To provide a specialized care for the patient to gain physical and mental support in performing ADLs and mobilizing.

Nursing Care Plan for Multiple Sclerosis 2

Nursing Diagnosis: Fatigue related to body weakness secondary to multiple sclerosis as evidenced by numbness and weakness on one side of the body or both, inability to do activities of daily living (ADLs) as normal, and verbalization of overwhelming tiredness

Desired Outcome: The patient will demonstrate active participation in necessary and desired activities and demonstrate increase in activity levels.

Multiple Sclerosis Nursing InterventionsRationales
Assess the patient’s degree of fatigability by asking to rate his/her fatigue level (mild, moderate, or severe). Explore activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.To create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance.
Encourage activity through self-care and exercise as tolerated Alternate periods of physical activity with rest and sleep.    Encourage enough rest and sleep, and provide comfort measures.To help the patient balance his/her physical activity and rest periods.   To reserve energy levels and provide optimal comfort and relaxation.
Teach deep breathing exercises and relaxation techniques.   Provide adequate ventilation in the room.To allow the patient to relax while at rest. To allow enough oxygenation in the room.
Refer the patient to physiotherapy / occupational therapy team as required.To provide a more specialized care for the patient in terms of helping him/her build confidence in balancing daily physical activity and rest periods.

Nursing Care Plan for Multiple Sclerosis 3

Nursing Diagnosis: Disturbed Sensory Perception (Visual) related to visual impairment secondary to multiple sclerosis as evidenced by verbal complaint of vision problems such as blurry vision, prolonged double vision, or partial/total loss of vision

Desired Outcome: The patient will regain optimal vision while being able to cope with and accept permanent vision changes.

Multiple Sclerosis Nursing InterventionsRationale
Assess the vision ability of the patient using an eye chart.To establish a baseline assessment in terms of vision capacity.
Encourage the patient to have regular checkups with an ophthalmologist at least once a year.To monitor worsening of vision loss and treat accordingly.
Encourage the patient to promote sufficient lighting at home.The patient may not be able to perform activities of daily living as normal if he/she cannot see properly. Sufficient lighting also reduces the risk for injury.
Administer eye medications as prescribed.Eye drops prescribed by the ophthalmologist can help the patient cope with vision problems.  
Encourage the patient to use vision aides.Lenses or devices that enlarge images are helpful in addressing difficulties such as blurry vision.
Assess the need for a carer for the patient.To ensure patient’s safety considering that he/she is experiencing visual problems and other symptoms of multiple sclerosis such as unsteady gait and body weakness.
Encourage the patient to add foods containing vitamins C, E, beta-carotene, zinc, and copper in his/her diet in accordance to daily recommended intake.Foods containing vitamins C, E, beta-carotene, zinc, and copper are beneficial to eyesight when introduced to the patient’s diet.
Encourage the patient to inform the ophthalmologist if there is any worsening of symptoms.To monitor if vision is worsening and if there is a need for further investigation and treatment.

More Multiple Sclerosis Nursing Diagnosis

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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