NCM 112 – Medical Surgical (MS)

Mr. Lito Felices | Inflammatory and Immunologic Response

PATHOPHYSIOLOGY
Topic Outline:
● Multiple Sclerosis
 Etiology GENETIC AND ENVIRONMENTAL FACTORS
 Basic Anatomy
 Pathophysiology
 Signs and Symptoms Trigger the activation of the body’s own immune cells
 Medical Management
 Diagnostic Procedures
 Nursing Management That enter the CNS
 Surgical Procedure target the myelin and cause widespread inflammation
 Patient Discharge Management

As inflammation progresses, it gradually damages the axons

MUTIPLE SCLEROSIS as well.
Autoimmune degenerative nerve disorder

That causes demyelination of the nerve fibers of neurons in the: This impairs the transmission of nerve impulses leading to
all sorts of sensory, motor, and cognitive problems.
1. Brain
2. Spinal cord
any condition that causes damage to the
protective covering that surrounds nerve SIGNS AND SYMPTOMS
fibers. (MYELIN SHEAT)

This demyelination occurs when the body's own immune  The ONSET of Multiple Sclerosis is very slow and gradual
system: Inappropriately attacks + Gradually destroys the myelin  So specific signs and symptoms vary a lot from clients to
sheath = slowing down the communication between neurons. clients depending on the severity of the disease.

ETIOLOGY One common trio of signs is called Charcot’s neurologic triad,

including:
 Exact CAUSE of Multiple Sclerosis is unknown  Dysarthria, which is difficult or unclear speech
 Typically affects clients between the ages of 20 and 40  Nystagmus, which is involuntary rapid eye movement
 Intention tremor
It is linked to both:
1. Genetic Factors Other symptoms include:
 Family history of Multiple Sclerosis  Double vision or blurred vision
 Clients assigned female at birth,  Hearing loss
 HLA-DR2 – genes that encode a specific type of immune  Short term memory loss
molecule which is used to identify and bind to foreign  Fatigue
molecules  Generalized weakness
2. Environmental factors  Impaired swallowing
 Infections  Loss of sensation and coordination
 Smoking  Impaired bowel and bladder function
 Living in a colder climate,  Clients may also develop anxiety, and depression.
 Vitamin D deficiency – It might help explain why the rates
of multiple sclerosis are higher among the clients living at FOUR MAIN TYPES OF MULTIPLE SCLEROSIS
higher latitudes, compared to the clients living closer to the
equator where there’s a lot more sunlight. MS is classified into four main types:

BASIC ANATOMY 1. Relapsing-remitting – symptoms develop but resolve within

a few weeks or months and the client returns to partial or
complete remission
2. Primary-progressive – steady neurologic deterioration
occurs without any remission
3. Secondary-progressive – a relapsing-remitting course later
becomes a steady progression of symptoms
4. Progressive-relapsing – the disease continues to progress,
and there are frequent relapses with only partial recovery, but
no full return to normal.

NEURONS – are the cells of the brain and spinal cord that MEDICAL MANAGEMENT
transmit electrical signals throughout the central nervous system
and the body. Unfortunately, there is NO CURE FOR MULTIPLE SCLEROSIS

These signals are transmitted as nerve impulses, which move But there are medications which are particularly effective in
across a branch of the neuron called AXON, which is covered treating the relapsing-remitting type:
by a protective MYELIN SHEATH.  Immunomodulators
 Corticosteroids
 Cyclophosphamides
The role of this sheath is to speed up the transmission of electric  Cell cycle inhibitor
impulses, allowing information to travel quickly from one neuron  Intravenous immunoglobulin (can be used to help blunt the
to another in order for us to perceive sensations and perform autoimmune process)
movements.  Monoclonal antibodies, interferons or fumarate
Alba, Linea P. – GROUP 5 BSN 3D | 1
In addition  Checking their abdomen for distention,
 Plasmapheresis – when the plasma is filtered to remove  Prescribed stool softener to promote bowel elimination.
disease-causing autoantibodies, can be effective. 11. Emotional support
 Chronic treatment for multiple sclerosis includes
 Share their feelings about their disease progression and
immunosuppressants.
changes in quality of life.
 The following can be utilized in improving the sensory, motor,  Mobilize resources, including counseling services and
and cognitive symptom: local support groups.
 Physical therapy like water exercise
 Occupational therapy SURGICAL PRODEDURE (if there is any)
 Speech therapy
 Deep brain stimulation Surgical intervention is generally not a standard treatment for
 Dorsal-column electrical stimulation
Multiple Sclerosis

 New research on stem cell therapy has been going on to
manage aggressive or treatment-resistant forms of MS. PATIENT DISCHARGE MANAGEMENT

DIAGNOSTIC PROCEDURE GENERAL CLIENT AND FAMILY TEACHING

 There are NO definitive diagnostic tests available as of now  Review the causes of multiple sclerosis
for MS.  How their own immune system gradually destroys the
myelin sheath around the nerve fibers of neurons in the
 Multiple sclerosis is typically suspected when clients give a brain and the spinal cord.
history of multiple neurologic symptoms separated in space  Prescribed medications
and time.  Teach them to take them exactly as prescribed.
 Teach them about ways they can decrease the risk of an
 The diagnosis of multiple sclerosis is supported by an: exacerbation.
A. MRI of the brain and spinal cord  Frequent hand hygiene
B. CSF analysis can be done, which might show high levels  Avoiding large crowds and people who are sick.
of antibodies, indicating an autoimmune process  Stress reduction techniques they can use in stressful
C. VEP (Visual evoked potential) can be helpful as well, situations.
measuring the nervous system’s response to visual stimuli  Moderate activity
 Decrease muscle spasticity
NURSING MANAGEMENT  Improve coordination
 Too much physical activity
GOALS OF CARE: (Multiple Sclerosis Exacerbation)  Fatigue
 To provide symptom relief  Trigger an exacerbation
 Prevent complications  Alternate their daily activities with periods of rest
 Provide emotional support  Encourage them to get enough sleep each night
 Be sure to let them know that starting a new medication can
1. Symptom relief also trigger an exacerbation, so remind them to talk to their
 by assessing their current level of neuromuscular function. healthcare providers before taking any new over the counter
2. Institute fall precautions and administer the prescribed IV medication or supplement
corticosteroids  Avoid extremes of heat and cold
3. Monitor your client’s response to treatment, and report if
 Identify their individual triggers so they can be avoided
symptoms such as:
 Instruct your client to contact their healthcare provider right
 Extreme weakness
away
 Loss of balance
 Sudden onset of fatigue
 Dysarthria
 Any new pain
 Dysphagia  Numbness
 Loss of vision continue in spite of corticosteroids.
 Tremors
 Trouble emptying their bowels or bladder
As ordered, prepare your client for plasmapheresis.
 To seek immediate medical care
 Cannot move
4. Prevent complications from the exacerbation
 Double vision or loss of vision
5. Institute fall precautions and collaborate with the
physical therapist to provide:  Confused
 Range of motion  Depressed
 Stretching  Thoughts of harming themselves or others
 Muscle strengthening exercises.
6. Change position
 At least every two hours
 Take pressure off bony prominences such as heels, hips,
and elbows.
7. To prevent choking and aspiration, implement swallow
precautions and reach out to the speech-language
pathologist for:
 Swallowing assessment
 Individualized
 Dysphagia diet.
8. Keep a close eye on their bowel and bladder function
9. Monitor their intake and output
 Assess if they are able to completely empty their bladder
 Urinary retention? Perform a bladder scan and report to the
healthcare provider if post-void urine residual is present;
and perform a straight urinary catheterization, as ordered.
10. Monitor them for constipation
 Auscultating bowel sounds
Alba, Linea P. – GROUP 5 BSN 3D | 2
 IN SUMMARY: 4. Progressive-Relapsing – Continuous progression with
frequent relapses, but no full recovery.
Etiology
Medical Management
Multiple Sclerosis (MS) – An autoimmune degenerative nerve
disorder that causes demyelination of neurons in the brain and Medications:
spinal cord.  Immunomodulator
 Corticosteroids
 Exact cause unknown; linked to genetic and environmental  Cyclophosphamide
factors.  Intravenous immunoglobulin
 Genetic Risk Factors:  Other Options: Monoclonal antibodies, interferons, fumarates.
 Family history
 Female gender Additional Treatments:
 Specific immune molecule (HLA-DR2).  Plasmapheresis (to remove disease-causing antibodies),
 Environmental Risk Factors: immunosuppressants for chronic treatment.
 Infections  Therapies:
 Smoking  Physical therapy
 Colder climates  Water exercises
 Vitamin D deficiency  Occupational therapy
 Speech therapy
Basic Anatomy  Newer treatments: Stem cell therapy for treatment-resistant
 Neurons – Nerve cells that transmit electrical signals cases.
throughout the central nervous system (CNS).
 Axon – Part of the neuron that carries impulses, protected by Diagnostic Procedures
a myelin sheath.  Clinical History – Neurological symptoms separated in time
 Myelin Sheath – Insulating layer that speeds up nerve impulse and location.
transmission between neurons, enabling sensation and  MRI – Brain and spinal cord imaging for demyelination signs.
movement.  CSF Analysis – Elevated antibody levels indicate an
autoimmune process.
Pathophysiology  Visual Evoked Potential (VEP) – Measures CNS response to
visual stimuli.

Demyelination Nursing Management

The immune system inappropriately attacks and destroys
the myelin sheath, slowing nerve impulse transmission.
Goals of Care:
 Symptom relief
 Complication prevention
Inflammation  Emotional support.
Inflammation in the CNS damages myelin and axons,
impairing nerve function.
Interventions:
 Assess neuromuscular function, initiate fall precautions, and
administer prescribed IV corticosteroids.
 Monitor response to treatment, prepare for plasmapheresis if
Progressive Symptoms: indicated.
Leads to sensory, motor, and cognitive dysfunction.  Collaborate with physical therapy, provide positioning every
two hours, implement swallow precautions, monitor
bladder/bowel function, and catheterize if necessary.
Signs and Symptoms
 Provide emotional support by encouraging expression and
mobilizing counseling resources.
Charcot’s Neurologic Triad (the combination of nystagmus,
intention tremor, and scanning or staccato speech.)
Surgical Procedure (if there is any)
Surgical intervention is generally not a standard treatment for
 Dysarthria – Difficult or unclear speech.
MS.
 Nystagmus – Involuntary rapid eye movements.
 Intention Tremor – Tremors during intentional movements.
Patient Discharge Management

Other Symptoms:
Education:
 Double or blurred vision
 Review Multiple Sclerosis causes and mechanisms
 hearing loss
 Medication adherence and infection prevention techniques
 Memory loss (e.g., hand hygiene, avoiding sick contacts).
 Fatigue  Stress reduction methods, moderate physical activity, rest,
 Generalized weakness and avoiding temperature extremes.
 Impaired swallowing  Identify triggers and avoid them, seek guidance before
 Loss of sensation and coordination starting new medications or supplements.
 Impaired bowel/bladder function  When to Seek Medical Care? – New onset fatigue, pain,
 Anxiety numbness, tremors, urinary/bowel issues, visual changes,
 Depression confusion, or thoughts of self-harm.

Types of Multiple Sclerosis:

1. Relapsing-Remitting – Symptoms develop and resolve, with
partial or complete remission.
2. Primary-Progressive – Steady deterioration with no
remission.
3. Secondary-Progressive – Initially relapsing-remitting, but
becomes progressively worse.

Alba, Linea P. – GROUP 5 BSN 3D | 3

 SAMPLE QUESTIONS:

1. The nurse has educated a newly diagnosed multiple 4. A client newly diagnosed with multiple sclerosis (MS)
sclerosis (MS) patient. Which statement made by the asks the nurse what causes the condition. Which topic(s)
client indicates an understanding of the teaching? Select should the nurse include in the teaching? Select all that
all that apply. apply.

A. “I will make sure that I engage in moderate activity.” A. Smoking.

B. “I will sit in my sauna to relax my muscles.” B. Living in a colder climate.
C. “I will keep an aggressive schedule with my daily C. Vitamin E deficiency.
activities.” D. Family history of multiple sclerosis.
D. “I will avoid large crowds.” E. Clients assigned female at birth.
E. “I will check with my doctor before I take any new F. Ages between 40 and 60.
medications.”
5. The nurse reviews the medication administration record
2. The nurse reviews systems with a client newly diagnosed (MAR) of a client admitted to the hospital with an
with multiple sclerosis (MS). Which statement(s) made by exacerbation of relapse-remitting multiple sclerosis (MS).
the client correlates with the diagnosis? Select all that Which prescription(s) should the nurse plan to
apply. administer to treat the client’s condition? Select all that
apply.
A. “I am experiencing blurred vision.”
B. “When I try to drink or eat, my hand shakes.” A. Methylprednisolone 1 g IV daily for three days
C. “I have trouble remembering what I did the day before.” B. Albuterol 0.083% 2.5 mg per 3 mL via nebulizer every 6
D. “I feel tired all of the time.” hours as needed
E. “I have been experiencing nausea and vomiting.” C. Fosfomycin 3 g PO once
F. “I have difficulty swallowing sometimes.” D. Intravenous Immunoglobulin G (IVIG) 0.4 g/kg daily for five
days
3. A client presents to the clinic with a history of several E. Glipizide15 mg PO daily
neurological symptoms and is suspected of having F. Enalapril 5 mg PO daily
multiple sclerosis (MS). To confirm the diagnosis, which
diagnostic testing should the nurse prepare the client? 6. The nurse has admitted a client to the hospital with
Select all that apply. primary progressive multiple sclerosis. Which is the
nurse’s priority intervention?
A. Electrocardiogram (EEG) A. Obtain a physical therapy consultation.
B. Magnetic resonance imaging (MRI) B. Prepare the client for plasmapheresis.
C. Electroencephalogram (EEG) C. Monitor intake and output.
D. Visual evoked potential (VEP) D. Implement fall precautions.
E. Lumbar

Alba, Linea P. – GROUP 5 BSN 3D | 4