Multiple Sclerosis Once the neuron is stimulated, the outside of

neuron is sodium (+) and inside is sodium

IMMUNE-MEDIATED PROGRESSIVE (-) , the membrane will be open so that the
DEMYELINATING DISEASE OF THE sodium will go inside to the open gated and
CNS there will be an action potential which we
called as Depolarization.
Progressive - Chronic (refers to myelin
which covers the axon) When the combined sodium will go inside,
the potassium (+) will move until the
Autoimmune in nature impulses will reach the destination

• Familial Predisposition ⁃ Sodium

GENDER: 2-3X >.WOMEN FAMILY ⁃ Potassium
HISTORY OF MS RACE > CAUCASIANS ⁃ Calcium
• Autoimmune
• SOCIOECOMIC STATUS: Myelin sheath
< rural, lower class ⁃ fatty-protein coating provides
• MIGRATION protective
< 15 yrs – risk: country – moved insulation
> 15 yr- - risk: stays fixed from country ⁃ allows electrical impulses to travel
quickly & efficiently
Diseases associated with Epstein-Barr Virus ⁃ maintains strength of the impulse
message as it travels down the axon.
Epstein-Barr virus (EBV) ---human
herpesvirus 4, is a member of the herpes SENSITIZED T- CELLS, B
virus family -- LYMPHOCYTES CROSS THE BB
one of the most common human viruses ▼
REMAINS IN CNS, PROMOTE
INFILTRATION – INFLAMMATION
▼
PRODUCTION OF INFLAMMATORY
CYTOKINES & REACTIVE O2 SPECIES
▼
DEMYELINATION, DESTRUCTION OF
OLIGODENDROCYTES
▼
FORMATION OF PLAQUES
▼
SCARRING, DESTRUCTION OF
SHEATH
▼
SCATTERED IRREGULARLY
THROUGHOUT CNS
Characteristics Excitability Conductivity ▼
Ability to influence other neurons INTERRUPTION OF NERVE IMPULSES
▼
MULTIPLE SCLEROSIS
• POSTERIOR COLUMNS OF Spinal
Central nervous system Chord
(brain and spinal cord) • MEDIAL LONGITUDINAL
FASCICULUS
In multiple sclerosis the myelin sheath, • CEREBELLAR
which is a single cell whose membrane
wraps around the axon, is destroyed with  Cerebellum – little brain which
inflammation and scarring responsible for balance and
coordination
Multiple Sclerosis: Damaged Myelin
• SPINO CEREBELLAR
1. SEQUENTIAL DEVELOPMENT OF  From spinal going to cerebellum
SMALL INFLAMMATORY PATCHES

2. LESIONS EXTEND & CONSOLIDATE Cerebellum – little brain, which responsible

of your balance and coordination
CRANIAL NERVES Brain stem – consist of pons and medulla
pons - 5 to 9 oblangata
Medulla oblangata - 5,9 10 11 and 12 Insula – floor of the brain, just below of
temporal lobe consider as social lobe, which
AREAS AFFECTED desire smoking and alcohols etc.
• OPTIC Thalamus – where the motor and sensory
• CORTICO SPINAL pathway

 Upper motor neuron and it will

attach to the spinal cord which called
the lower spinal cord.
 Will cross at the level of the medulla
oblangata, it was known as
pyramidal
 Carry voluntary motor movement
 It will go down to the cerebral, 5
thoracic 12 lumbar and 5 sacral

• CORTICO BULBAR

- (Cortico means from cerebral Optic chiasm – optic tract will cross
cortex and bulbar means end in the brain
stem)
- descending tract coming from
cerebral cortex and it will end at the cranial
nerves in the brain stem

Pyramidal tract – (means cross in the mid

brain) from left to right and right to left
 crossing in medulla oblangata, after crossing
it will descend to the spinal cord

Corticosteroid – upper neuron

The cerebellum is for making postural

adjustments to maintain balance.

Corticobulbar
tract carries upper motor neuron input to
motor nuclei of trigeminal, facial,
glossopharyngeal, vagus, accessory, and
hypoglossal nerves.

The cerebellum is for making postural

adjustments to maintain balance.

Corticospinal tract pyramidal tract

- carry movement-related information from
the cerebral cortex to the spinal cord.

If demyelinated, it will result paralysis or spinocerebellar tracts

plegia carry unconscious proprioceptive
information gleaned from muscle spindles,
Hemi plegia- paralysis in one side of the Golgi tendon organs, and joint capsules to
body the cerebellum.

Paralysis mean weakness of spasticity - Ascending Tract

If there is spasticity, there will a hypertonic

Contralateral- damage is on the right but the

manifestation is on the left due to the Dorsal column pathway
 Scotoma – (blindspot)
Function
 Carries fine touch, vibration and Throat:
conscious proprioception signals  Dysphagia
(deep sensations) (CN IX and X , cause problem is
Three order neuron swallowing, gagging or coughing)
 1st order neuron enters spinal cord
through dorsal root; Musculoskeletal:
Ascends to medulla (brain stem)  Weakness
 2nd order neuron crosses over in  Spasms
medulla; ascends to thalamus  Ataxia
 3rd order neuron projects to
somatosensory cortex Sensation;
 Pain
 Hypoesthesias
medial longitudinal fasciculus - found in  Paranesthesias
brainstem is a set of crossed fibers with
ascending and descending fibers. links the 3 LHERMITTE’S SYMPTOM - Annoying
CN which control EOM, & CN VIII sensation which describes as Electrical like
sensation will travel down to the extremities
Clinical manifestation of Multiple sclerosis from the neck whenever multiple sclerosis
is fatigue will flex its neck
 Related to a lot of ATP to transmit
impulses in the axon Bowel:
 Incontinence
ATP – adenosine triphosphate (energy)  Diarrhea or constipation
 It requires a lot of ATP
(Sexual Impotence in the male)
White matter due to a lot of axon.
Urinary:
Main Symptoms of Multiple Sclerosis  Incontinence
 Frequency or retention (bladder did
Central: not contract)
 Fatigue
 Cognitive
 Impairment
 Depression
 Unstable mood
Visual:
 Nystagmus
 Optic neuritis
 Diplopia
(3 mentions are classic manifestation
of multiple sclerosis)
  Scanning Speech

DIAGNOTIC TESTS:

 MRI – detect the presence of

multiple plaques

 CT Scan – increased density of

white matter of the brain

 Protein electrophoresis - uses an

electrical current on a CSF
sample to separate out types of
Lifespan : 5 -20 years protein called immunoglobulins.
1. As you see on the graph, at first there  Presence of antibodies
was no problem and then there is a
spike and the pattern continue. This  Only be seen an increased amount of
is consider benign where you have IGM (Immunoglobulins)
no disability.
2. There are no new disability; there is
 Usually it punctured in between the
an attack but there was no difference
space of lumbar 3 and 4
3. Multiple sclerosis is progressive and
these graph is from the #2, at first
 Clear fluid indicates the CSF, the
there was no new disability but later
first drop is not collected only after
on the graph increase
several drops to be collected
4. A steady and increase stability
without attacks but there is a
continuation increase.  Visual Evoked response
determined by EEG: delayed
 There are medication that could treat
the multiple sclerosis but there was  visual evoked potential (VEP)
no cure due to multiple sclerosis is measures electrical response of the
autoimmune brain's primary visual cortex to a
visual stimulus. To measure the
CHARCOT’S Triad electrical response place 3 electrodes
Coined by Dr. Jean Martin Charcot on the scalp.

 Nystagmus – rapid jerky movement  The patient made to watch and there
of the eyes will be a record for the response of
the patient. There will be a graphing
 Classic sign and one of the
intermitted by the neurology
manifestation

 Intention Tremor
 Whenever the patient move
TREATMENT
 1. DISEASE-MODIFYING agents 3. FOR TREATMENT OF
Pharmacologic therapy SYMPTOMS
• A VONEX (Beta Interferon 1a, IM)
• B ETASERON (Beta Interferon1b) For spasticity:
• C OPAXONE (Glatiramer Acetate)  Damage to your corticospinal tract
 Not an interferon but works like an
interferon (These are the medication for spasticity)
• R EBIF (Beta Interferon 1a) • Baclofen (Lioresal),
 Latest • Benzodiazepine Valium)
- Relaxation of the muscle
IMMUNE ENHANCERS • Dantrolene (Dantrium)
• Tizanidine ( Zanaflex)
2. FOR ACUTE EXACERBATIONS:
• Corticosteroids (anti-inflammatory, For fatigue:
it will suppressed the function of • Amantadine ( Symmetryl)
flammatory cells) - Anti-viral medication
NSG Consideration for steroids: - It will help to relax the patient
 If there is more than 2 weeks of • Fluoxetine (Prozac)
using, there is a moon face and there - Anti-depressant drug, for patient
is a presence of buffalo hump experiencing fatigue
 Monitor blood sugar and vital signs
since this is the combination of For ataxia:
sodium and water • Beta adrenergic blockers – Inderal
Ex. Propanolol
Example: • Antiseizure agents – Neurontin
(Methylprednisolone) • Benzodiazepines – Klonopin

• ACTH For bladder problems:

 To destroy the myelin sheath • Ascorbic acid (vit C)
• Plasmapheresis • Anticholinergics
 Works like a hemodialysis, it remove
the plasma out of the body and get For secondary progressive:
antibodies from the plasma called • Novantrone – reduces frequency of
immunoglobulin and filter outside. relapses
Temporarily the plasma was being
replace by normal saline. Throughout
the filtration of the plasma, it will be
back again to the patient’s body.

Plasmapheresis
plasma, is separated from the blood cells
plasma is replaced with another solution NURSING INTERVENTION
such as saline or albumin,
or the plasma is treated and returned to Promote Optimum Mobility
body.
 A. MUSCLE-STRETCHING & • Test bath water with thermometer
STRENGTHENING EXERCISES • Avoid heating pads, hot water bottles
B. WALKING EXERCISES TO • Frequent position changes
IMPROVE GAIT USE WIDE – • Inspect body parts for injury
BASED GAIT
C. ASSISTIVE DEVICES: CANES,
WALKER, RAILS, WHEELCHAIR
AS NEEDED
D. MINIMIZE SPASTICITY &
CONTRACTURES
•Administer medication as ordered
•Exercises
E. ACTIVITY & REST
• Frequent rest periods
• Fatigue exacerbates symptoms
- Fatigue is one that can exacerbate the
symptom
F. ENCOURAGE INDEPENDENCE
ENHANCE BLADDER & BOWEL
IN SELF CARE
CONTROL
G. PREVENT COMPLICATIONS OF
1. Force fluids 3000 ml/day 2. use of acid-
IMMOBILITY
ash foods (cranberry, grape juice)
 Pressure Ulcer
3. URINARY RETENTION:
Nursing Management:
intermittent catheterization bethanecol
1. We have to move patient, as
chloride
often as every 2 hrs.
- cholinergic agent, promote the contraction
2. Skin care. Prevent breakdown of
of the bladder
the skin, patient should be free
from moisture. Use highly
4. URINARY INCONTINENCE: Establish
moisturize soap and put lotion
voiding schedule
and massage if there is no
- continuation of bladder to contract
breakdown
- may cause UTI
- Dress every day.
3. No contractures.
Anticholinergic: propantheline bromide,
4. Deep vein Thrombosis
tolterodine (Detrol)
- could cause a problem in circulation
- possibility will go up to the lungs
5. BOWEL – demyelinated of sacral nerves
5. Pulmonary embolism (fatal)
- Clot from extremities, will travel to
* ADEQUATE FLUIDS
the heart and to the lungs
* DIETARY FIBER
6. Pneumonia
* BOWEL TRAINING PROGRAM
- The lungs are unable to expand very
well. Mobility of secretion will
ENHANCE COMMUNICATION &
decrease. Phlegm should be excreted.
MANAGING SWALLOWING
7. Urinary and Bladder retention
DIFFICULTIES
PREVENT INJURY
 REFER FOR SPEECH THERAPY
/SWALLOWING PROBLEMS PROVIDE TEACHING & DISCHARGE
- No Thin liquids PLANNING
- No milk or dairy products
- Make the food as the consistency of an 1. Well-balance diet
oatmeal 2. Fresh air & sunshine
- Sitting position 3. Avoid fatigue, overheating,
- Teach patient to swallow effectively chilling, stress, infection
4. Regular exercise – walking,
 PREVENT ASPIRATION swimming, biking
5. Balance between activity & rest
6. Use of energy conservation
Improve Sensory and Cognitive function techniques
7. Regular exercise – walking,
swimming, biking

Encourage – realistic goal for the patient,

must be performing activities in daily living
such as self-care activities.

PROMOTING SEXUAL
FUNCTIONING

• USE OF ALTERNATIVE
METHODS FOR SEXUAL
GRATIFICATION
• REFER FOR SEXUAL
COUNSELLING