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Multiple sclerosis- Sushila [Autosaved].ppt
- 1. Multiple Sclerosis Sushila Hamal M.Sc.Nursing (B-2023) BPKIHS
- 2. General objective • Atthe end of this session, the participant will be able to explain about the Multiple Sclerosis.
- 3. Specific objectives At theend of this session the participant will be able to: • Anatomy and physiology of Nervous System • Introduction of Multiple Sclerosis • Definition of Multiple Sclerosis • Incidence of Multiple Sclerosis • Etiology and Risk factors of Multiple Sclerosis • Pathophysiology of Multiple Sclerosis
- 4. Specific objectives Contd… •Clinical Manifestations of Multiple Sclerosis • Diagnostic Evaluation of Multiple Sclerosis • Management of Multiple Sclerosis • Complications • Research Article • References
- 6. Terminology • Disseminated Sclerosis:a chronic progressive nervous disorder involving loss of myelin sheath around certain nerve fibers. • Encephalomyelitis disseminate: is a neurological disorder characterized by brief but widespread attacks of inflammation (swelling) in the brain and spinal cord that damages myelin. • Immune mediated disease: is a condition that results from an abnormal immune system response. In these diseases, the immune system mistakenly targets the body. This creates an inflammatory response that causes damage.
- 7. Terminology Contd… • Anautoimmune disease: is a condition arising from an abnormal immune response to a normal body part. • T- cells: A type of white blood cell. T cells are part of the immune system and develop from stem cells in the bone marrow. They help protect the body from infection and may help fight cancer. Also called T lymphocyte and thymocyte. • B- cells: A type of white blood cell that makes antibodies. B cells are part of the immune system and develop from stem cells in the bone marrow. Also called B lymphocyte
- 8. Terminology Contd… • Macrophages:A type of white blood cell that surrounds and kills microorganisms, removes dead cells, and stimulates the action of other immune system cells • Oligodendrocytes: A cell that forms the myelin sheath (a layer that covers and protects nerve cells) in the brain and spinal cord. • Spasticity: is a condition in which there is an abnormal increase in muscle tone or stiffness of muscle, which might interfere with movement, speech, or be associated with discomfort or pain.
- 10.
- 11. Myelin Myelin is aninsulating layer, or sheath that forms around nerves, including those in the brain and spinal cord. It is made up of protein and fatty substances. • This myelin sheath allows electrical impulses to transmit quickly and efficiently along the nerve cells. If myelin is damaged, these impulses slow down. This can cause diseases such as multiple sclerosis.
- 12. There are twotypes of myelin: • Central nervous system myelin: coats the nerve fibers of the "white matter" in the brain and is produced by oligodendrocytes. • Peripheral nervous system myelin: coats the motor neuron fibers and is produced by Schwann cells
- 14. Introduction of MS •MS is a chronic demyelinating disease that affects the myelin sheath of neurons in the central nervous system • Multiple sclerosis occurs as a result of destruction of myelin sheath resulting in impaired transmission of nerve impulses. • It is also known as "disseminated sclerosis" or "encephalomyelitis disseminata”.
- 15. • Although MSis thought to be an autoimmune disease, the specific target of the immune attack in MS has not yet been identified. So, MS is referred to as an immune-mediated disease. • As part of the immune attack on the CNS, myelin is damaged, along with the nerve fibers themselves. The damaged myelin forms scar tissue (sclerosis), which gives the disease its name. • It is a disease of white matter. Introduction of MS Contd…
- 16. Definition • Multiple sclerosisis a chronic demyelinating disease that affects the myelin sheath of neurons in the CNS.
- 17.
- 19. Epidemiology (WHO 2020) •The latest estimation of the total number of people with multiple sclerosis was 2.8 million globally, with a prevalence of 36 per 100,000 people. In Africa, there are 5 people per 100, 000 diagnosed with MS, compared to South East Asia where the prevalence in 9 per 100,000, 112 per 100,000 in the America and 133 per 100,000 in Europe.
- 20. Epidemiology (WHO 2020)Contd… • Most people are diagnosed between 20 to 50 yrs. • In Nepal death rate reached 38% or 0.02% of total death. • Women are more affected the man (3:1). • White people are more affected than Hispanics, black or Asian. • Most prevalent in colder climates of North America and Europe.
- 21.
- 22. Causes of MSContd… While the cause (etiology) of MS is still not known, scientists believe that a combination of several factors may be involved. • Immunologic • Environmental • Infectious • Genetic
- 23. Causes: Immunologic Factor •The body’s own immune cells attack the CNS and ultimately destroy nerve condition. • Many different cells are involved in the abnormal immune response. Two important types of immune cells are T cells and B cells. • In MS, the immune system is responsible for the demyelination. The removal of the protective myelin sheath of the nerve cells in the CNS.
- 24. Causes: Environmental • Variationsin geography, demographics, genetics, infectious causes and migration patterns are being studied. • Climate, sunlight and low vitamin D have been investigated as influences of the disease.
- 25. Causes: Infectious • Measles,human herpes virus-6, Epstein- Barr, and Chlamydia pneumonia. • Initial exposure to numerous viruses, bacteria and other microbes occurs during childhood and since viruses are well recognized as causes of demyelination and inflammation.
- 26. Causes: Genetic • Havinga first-degree relative such as a parent or sibling with MS increases an individual's risk of developing the disease • Some researchers theorize that MS develops because a person is born with a genetic predisposition to react to some environmental agent that upon exposure, triggers an autoimmune response.
- 27. Pathophysiology Due to etiologicalfactors Activated T-cells expressed in CNS and Macrophages (B- cells) enter the brain from peripheral circulation Production of inflammatory cytokines and reactive O2 species Inflammation Then activated T-cells and B-cells cause demyelination and destruction of oligodendrocytes
- 28. Pathophysiology Contd… Formation ofplaque Causes scarring and destruction of sheath Compensatory system starts causing subsidation of edema and inflammation After that some remyelination process occurs which is often incomplete Multiple Sclerosis
- 29. Types of MultipleSclerosis • Relapsing-Remitting MS • Primary-Progressive MS • Secondary-Progressive MS • Progressive-Relapsing MS
- 30. 1. Relapsing-remitting MS(RR-MS) • More than 80% of the cases • Followed by complete or incomplete remission during which the person full or partially recovers from the deficits acquired during relapse
- 31. 2. Primary-progressive MS(PP-MS) • 10 to 20% of individuals with MS are diagnosed with PP-MS • Gradual progression of the disease from its onset • No overlapping relapses and remissions
- 32. 3. Progressive-relapsing MS(PR-MS) • Steady progression of clinical neurological damage with superimposed relapses and remissions.
- 33. 4. Secondary ProgressiveMS (SP-MS) • SP-MS is characterized by a steady progression of neurological damage with or without superimposed relapses and minor remissions
- 34. Most Common Symptoms •Fatigue • Numbness • Paresthesia • Gait, Coordination, Balance Problems • Bladder Dysfunction • Bowel Dysfunction • Ataxia • Vision Problems • Dizziness & Vertigo • Sexual Dysfunction • Urgency, Frequency • Cognitive Dysfunction • Pain • Dysphagia • Emotional Changes • Depression • Spasticity
- 35. Less Common Symptoms •Speech Disorders • Swallowing Problems • Paralysis • Headache • Hearing Loss • Seizures • Tremor • Respiration / Breathing Problems • Itching
- 36.
- 38. Diagnostic evaluation • Historytaking and physical examination • No definitive test for MS • CSF analysis for the presence of oligoclonal banding, proteins and electrolytes. • MRI brain and spinal cord for presence of MS plaques • CSF Electrophoresis: presence of Immunoglobulin G (normal protein is 15-45mg /dl) elevated 10 mg/dl ) • Evoked potentials of the optic pathways and auditory system to assess the presence of slowed nerve conduction
- 39. • MRI brainand spinal cord for presence of MS plaques
- 40. Treatment Although there isstill no cure for MS, effective strategies are available to: • Modifying the Disease Course • Treating exacerbations • Managing Symptoms • Promoting Function through Rehabilitation
- 41. Modifying the DiseaseCourse • Novantrone (mitoxantrone) • Copaxone (glatiramer acetate) • Extavia (interferon beta-1b) • Aubagio (teriflunomide) • Avonex (interferon beta-1a) • Betaseron (interferon beta-1b) • Gilenya (fingolimod) • Rebif (interferon beta-1a) • Tecfidera (dimethyl fumarate)
- 42.
- 43. Treating exacerbations • Severeexacerbations are most commonly treated with high-dose corticosteroids to reduce the inflammation. • Plasmapheresis (Is a blood purification procedure used to treat several autoimmune disease. It is also known as therapeutic plasma exchange) is considered for 10% who do not respond well to corticosteroids.
- 44. Managing symptoms Spasticity: Baclofen,Dantrolene, Diazepam Fatigue: Amantadine Depression: Antidepressants Bladder symptoms: Anticholinergics, prophylactic Abx Dystonia: Carbamazepine Pain syndrome: Carbamazepine, phenytoin, amitriptyline
- 45. Promoting function throughRehabilitation Besides medication, self-care techniques and the use of assistive devices, rehabilitation includes: • Physical Therapy • Occupational Therapy • Therapy for Speech and Swallowing Problems • Cognitive Rehabilitation • Vocational Rehabilitation
- 46.
- 47. Assessment • Observe motorstrength, coordination and gait • Perform cranial nerve assessment • Evaluate elimination function • Explore coping, effect on activity and sexual function, emotional adjustment • Assess patient and family coping, support system and available resources.
- 48. Nursing diagnosis • Impairedphysical mobility related to muscle weakness, spasticity and incoordination. • Self care deficit related to intolerance to activity. • Fatigue related to increased energy requirements to perform activities and stress of coping • Disturbed sensory perception related to disease process. • Impaired urinary elimination related to neuromuscular impairment. • Interrupted family process related to disease process.
- 49. Nursing diagnosis Contd… •Sexual dysfunction related to disease process. • Low self esteem related to change in structure and function. • Powerlessness related to lifestyle of helplessness • Risk for ineffective coping related to multiple life changes. • Risk for caregiver role strain related to complexity and amount of caregiving tasks. • Deficient knowledge related to cognitive limitation.
- 50. Interventions Promoting motor function •Perform muscle stretching and strengthening exercises. • Apply ice packs before stretching to reduce spasticity. • Avoid muscle fatigue and take frequent rests. • Encourage ambulation and activity and teach patients how to use supportive devices. • Avoid sudden changes position which may cause falls • Frequent position change while immobilized to avoid pressure sores
- 51. Interventions Contd… Minimizing fatigue •Understand fatigue is an integral part of MS. • Plan and prioritize activities • Avoid overheating, overexertion and infection • Encourage energy conservation techniques • Develop healthy lifestyle
- 52. Interventions Contd… Optimizing sensoryfunctions • Use eye patch or frosted lens for double vision • Encourage ophthalmic consultations • Provide safe environment: Orientation to environment, arrangement of furniture, clear floor, use of all senses to maintain awareness to environment.
- 53. Interventions Contd… Maintaining urinaryelimination • Ensure adequate fluid intake to prevent infection and stone formation • Assess urinary retention and catheterize for residual urine • Set up bladder training program to reduce incontinence
- 54. Interventions Contd… Promoting sexualfunction • Encourage open communication between partners • Discuss birth control options if appropriate • Suggest sexual activity when patient is most rested • Suggest consultation with sexual therapist to help obtain greatest sexual satisfaction.
- 55. Interventions Contd… Normalizing familyprocess • Encourage verbalization of feelings of each family member • Encourage counseling and use of community resources • Divide household duties and child care responsibilities • Expand treatment efforts to include whole family • Explore adaptation of some roles so patient can still function in family unit.
- 56. Complications 1. Respiratory dysfunction 2.Infections: bladder, respiratory, sepsis 3. Complications with immobility 4. Speech, voice and language disorders such as dysarthria
- 57. Research Article Rising Prevalenceof MS Worldwide: Insight from the Atlas of MS Abstract • Background: High-quality epidemiologic data worldwide are needed to improve our understanding of disease risk, support health policy to meet the diverse needs of people with multiple sclerosis (MS) and support advocacy efforts.
- 58. Research Article Contd… •Objectives: The Atlas of MS is an open-source global compendium of data regarding the epidemiology of MS and the availability of resources for people with MS reported at country, regional and global levels. • Methods: Country representatives reported epidemiologic data and their sources via survey between September 2019 and March 2020, covering prevalence and incidence in males, females, children, and age and MS type at diagnosis. Regional analyses and comparisons with 2013 data were conducted.
- 59. Research Article Contd… •Results: A total of 2.8 million people are estimated to live with MS worldwide (35.9 per 100,000 population). MS prevalence has increased in every world region since 2013 but gaps in prevalence estimates persist. The pooled incidence rate across 75 reporting countries is 2.1 per 100,000 persons/year, and the mean age of diagnosis is 32 years. Females are twice as likely to live with MS as males. • Conclusions: The global prevalence of MS has risen since 2013, but good surveillance data is not universal. Action is needed by multiple stakeholders to close knowledge gaps
- 60. REFERENCES 1. Sharma S.,Madhavi S., Hinkle, J. L. &Cheever, K.H. Brunner & Suddarth’s. Textbook of Medical-Surgical nursing. 2nd ed. New Delhi: Wolters Kluwer (India) Pvt. Ltd; 2019: 1775-1782. 2. Chugh S N. Textbook of Medical Surgical Nursing. 1st ed. New Delhi: Avichal Publishing Company; 2013: 1141-1144. 3. Sharma M., Kalpana P., Gautam R. Essential Textbook of Medical Surgical Nursing. 2nd ed. Ghattekulo Rautahadevi Marga, Kathmandu: Samiksha Publication Pvt. Ltd; 2017: 362-368.
- 61. REFERENCES Contd… 4. WaltonC, King R, Rechtman L, Kaye W, Leray E, Marrie RA, et al. Rising prevalence of multiple sclerosis worldwide: Insights from the Atlas of MS, third edition. Mult Scler. 2020 Dec;26(14):1816-1821. doi: 10.1177/1352458520970841. Epub 2020 Nov 11. PMID: 33174475; PMCID: PMC7720355. 5. https://en.wikipedia.org/wiki/Multiple_sclerosis 6. https://www.physiopedia.com/Multiple_Sclerosis_(MS)