Care of Patients With MS
-
Upload
hardeep-singh-bali -
Category
Documents
-
view
216 -
download
0
Transcript of Care of Patients With MS
-
8/11/2019 Care of Patients With MS
1/14
CONTINUING EDUCATION
Special Needs Populations:
Care of Patients WithMultiple SclerosisCLARE RUTO, MSN, RN 2.0
www.aorn.org/CE
Continuing Education Contact Hours
indicates that continuing education (CE) contact hours
are available for this activity. Earn the CE contact hours by
reading this article, reviewing the purpose/goal and objectives,
and completing the online Examination and Learner Evaluation
at http://www.aorn.org/CE. A score of 70% correct on the
examination is required for credit. Participants receive feedback
on incorrect answers. Each applicant who successfully completes
this program can immediately print a certificate of completion.
Event:#13527
Session: #0001
Fee: Members $12, Nonmembers $24
The CE contact hours for this article expire September 30,
2016.
Purpose/GoalTo enable the learner to provide appropriate perioperative care
for the patient with multiple sclerosis (MS) who is undergoing
surgery.
Objectives
1. Explain the pathophysiology of MS.
2. Describe the symptoms of MS.
3. Discuss the causes of MS.
4. Identify tests used to diagnose MS.
5. Identify medications that patients with MS may be taking.
6. Discuss perioperative care of the patient with MS under-
going surgery.
Accreditation
AORN is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Centers
Commission on Accreditation.
Approvals
This program meets criteria for CNOR and CRNFA recertifi-
cation, as well as other CE requirements.
AORN is provider-approved by the California Board of
Registered Nursing, Provider Number CEP 13019. Check with
your state board of nursing for acceptance of this activity for
relicensure.
Conflict of Interest Disclosures
Ms Ruto has no declared affiliation that could be perceived as
posing a potential conflict of interest in the publication of this
article.
The behavioral objectives for this program were created
by Rebecca Holm, MSN, RN, CNOR, clinical editor, with
consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative Education. Ms Holm and Ms Bakewell have
no declared affiliations that could be perceived as posing
potential conflicts of interest in the publication of this
article.
Sponsorship or Commercial Support
No sponsorship or commercial support was received for this
article.
DisclaimerAORN recognizes these activities as CE for registered nurses.
This recognition does not imply that AORN or the American
Nurses Credentialing Center approves or endorses products
mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2013.07.002
AORN, Inc, 2013 September 2013 Vol 98 No 3 AORN Journal j 281
http://www.aornjournal.org/http://www.aorn.org/CEhttp://dx.doi.org/10.1016/j.aorn.2013.07.002http://dx.doi.org/10.1016/j.aorn.2013.07.002http://www.aorn.org/CEhttp://www.aornjournal.org/ -
8/11/2019 Care of Patients With MS
2/14
-
8/11/2019 Care of Patients With MS
3/14
PATHOPHYSIOLOGY
Multiple sclerosis is characterized by inflammation,
demyelination, and axonal damage in the brain
and spinal cord with a loss of myelin that covers
the axons. As the myelin sheath regenerates, scar
tissue forms, which looks like plaques on magnetic
resonance imaging scans. Multiple sclerosis arises
when immune-mediated inflammation activates T
cells and causes the T cells and immune mediators
to cross the blood-brain barriers into the CNS and
attack oligodendrocytes (ie, a type of neuroglial
cell with dendritic projections that coil around axons
of neural cells). When the oligodendrocytes are
attacked, the myelin sheath is replaced by scar
tissue, which forms throughout the CNS. As a result
of damage to the myelin sheath, the ability to tran-
smit and conduct nerve impulses along the spinal
cord and in the brain is interrupted, leading to muscle
weakness, fatigue, loss of coordination, balance
impairment, and cognitive and visual disturbance.
This disease is characterized by unpredictable
remissions that occur over several years. During
periods of remission, the myelin sheath usually
regenerates and symptoms may resolve, but the
myelin cannot be completely repaired. As the dis-
ease progresses, the myelin sheath is destroyedand nerve impulses become much slower or ab-
sent and symptoms worsen.6 When degeneration
exceeds self-repair ability, permanent disability
results.7(p630) There are four defined clinical types
of MS: relapsing-remitting, primary-progressive,
secondary-progressive, and progressive-relapsing.7
n Relapsing-remitting MS is the most common
type, affecting about 90% of people with a
diagnosis of MS. Exacerbations occur withfull recovery and remission of symptoms. Bet-
ween attacks, there is no progression of the
disease. The exacerbations last between one
and three months and are followed by remis-
sions that can last as long as a year.
n Primary-progressive MS usually shows a steady
progression or worsening of the disease from
onset, with occasional plateaus or minor re-
covery. Worsening symptoms may occur with
or without relapses.
n Secondary-progressive MS begins with a pat-
tern of clear-cut relapses and recovery but
becomes steadily progressive over time, with
continued worsening between acute attacks.
This type of MS eventually develops in about
two-thirds of people with MS.
n Progressive-relapsing MS is a rare type of MS.
It usually progresses steadily from onset.
CLINICAL MANIFESTATIONS
Multiple sclerosis usually involves more than one
body system. The symptoms and clinical manifes-
tations of the disease process reflect a variety of
sites in the CNS that have been affected by de-
myelination of the myelin sheath. The symptoms
seen in MS are different from one person to another
because MS can affect any part of the CNS. Ac-
cording to Callahan,2 the first symptoms of MS
often affect the patients vision.
Approximately 15% of patients initially develop
optic or retrobulbar neuritis. This causes a decrease
in visual acuity, hyperemia, and edema of the optic
disc. The person also experiences pain in the af-fected eye with diplopia and blind spots. In addition
to ophthalmic symptoms, MS can cause symp-
toms and manifestations in other body systems
as well (Table 1).
As the disease progresses, remission after an
exacerbation usually becomes less complete, and
the myelin sheath cannot regenerate itself. With
time, the disease becomes incapacitating, which
is almost always characterized by muscle weak-
ness; approximately 50% of affected people requirehelp walking within 15 years of diagnosis.6
DIAGNOSIS
All other possible causes of a patients symptoms
must be ruled out and eliminated before a person
is diagnosed with MS. The diagnostic criteria for
MS are known as the McDonald criteria. The
AORN Journal j 283
SPECIAL NEEDS POPULATIONS www.aornjournal.org
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://www.aornjournal.org/http://www.aornjournal.org/http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?- -
8/11/2019 Care of Patients With MS
4/14
McDonald criteria require confirmation of MS
by diagnostic testing.
n Magnetic resonance imaging and computed
tomography scanning are used to identify bothactive and demyelinated plaques.
n Visual and somatosensory evoked potential is
used to help detect decreased or slowed con-
duction velocity in visual, auditory, and so-
matosensory pathways.
n Lumbar puncture is used to analyze the presence
of elevated immunoglobulin G, which appears
as oligoclonal bands in cerebrospinal fluid.7
CURRENT TREATMENT
Currently, there is no known cure for MS. The
treatment goal of MS is prevention of permanent
neurological damage. Acute relapses are treated
with corticosteroids to help improve symptomsand to speed recovery by restoring the blood-brain
barrier and improving axonal nerve conduction.
Studies indicate that glatiramer acetate, IV immu-
noglobulins, and azathioprine help reduce relapses
in relapsing-remitting MS.7,8 An overview of phar-
macologic treatment of MS is presented inTable 2.
Management of symptoms (eg, ataxia, bladder and
bowel dysfunction, cognitive difficulties, depression,
TABLE 1. Symptoms and Manifestations of Multiple Sclerosis by Body System1
System Symptom and manifestation
Ophthalmic n Visual disturbances including temporary or unilateral loss of vision, diplopia, blurred vision, scotoma,
red-green distortion, and optic neuritis manifesting as retro-orbital pain
Neurological n Cerebellar symptoms including ataxia, nystagmus, dysarthria, slurred speech, intentional tremors, and
vertigo
n Sensory symptoms including numbness and paresthesias in the face and the extremities and impaired
vibration, temperature, and depth perceptions
n Paroxysmal symptoms including localized and generalized seizures, trigeminal neuralgia, and painful
spasms of the hands and feet
n Headaches
Urological n Bladder dysfunction manifesting as increased urinary urgency and frequency, nocturia, overow
incontinence, hesitancy, and a feeling that the bladder has not been emptied after voiding
Gastrointestinal n
Bowel dysfunction manifested as diarrhea, incontinence, or constipation
Musculoskeletal n Paroxysmal limb pain manifesting as burning, itching, and aching
n Spasticity common in the calf, thigh, back, and groin muscles that results in pain
n Motor disorder manifesting as gait dysfunction and muscle weakness of the lower extremities that may
progress to paralysis and decreased proprioception
Psychological n Hopelessness, loss of control, fear, and uncertainty, which lead to further deterioration of physical
function
n Mood disorders manifesting as emotional lability, euphoria, or depression
n Cognitive impairment manifesting as difculty concentrating, planning, or maintaining attention and
decits in judgment and problem solving
Other n Fatigue that increases the severity and intensity of other symptoms
n Sexual dysfunction manifesting in women as difculty achieving orgasm and in men as erectile
dysfunction and difculty ejaculating
1. Schneider KM. AANA Journal course: update for nurse anesthetistsdan overview of multiple sclerosis and implications for anesthesia. AANA J.
2005;73(3):217-224.
284 j AORN Journal
September 2013 Vol 98 No 3 RUTO
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?- -
8/11/2019 Care of Patients With MS
5/14
TABLE 2. Pharmacologic Treatment of Multiple Sclerosis (MS)
Classification Medication Usage
Corticosteroids Methylprednisolone
(eg, Solu-Medrol)
n The principal treatment for relapses used to shorten the duration of
attacks of MS.n Anti-inammatory effects restore the blood-brain barrier, decrease
edema, and improve axonal nerve conduction.
n Concerns involve immunosuppression and the risk of opportunistic
infections.
n Side effects of long-term use include hypertension, diabetes, osteo-
porosis, cataracts, and ulcers.
n Side effects may outweigh possible benets of long-term use.
Immunotherapeutic
agents
Interferon beta-la
(eg, Avonex, Rebif)
n These agents reduce inammation and inhibit the immune response;
they may reduce the frequency of relapses by as much as 30%.
n Avonex: An immune system modulator with antiviral properties that
is administered intramuscularly; side effects include u-like symp-
toms and headaches.
n Rebif: An immune system modulator with antiretroviral properties;
administered subcutaneously; side effects include u-like symp-
toms, reactions around the injection site, and abnormal blood cell
count and liver function test results.
Interferon beta-lb
(eg, Betaseron)
n An immune system modulator with antiviral properties; administered
subcutaneously; side effects include u-like symptoms, reactions
around the injection site, and abnormal blood cell count and liver
function test results.
Glatiramer acetate
(eg, Copaxone)
n An immune system modulator blocking the destruction of myelin;
administered subcutaneously; side effects include reactions around
the injection site and a systemic reaction 5 to 15 minutes after injection
manifesting as anxiety, ushing, chest tightness, palpitations, and
shortness of breath; symptoms last a few minutes and do not require
treatment.
Immunosuppressants Azathioprine
(eg, Imuran)
n A purine analogue that depresses cell-mediated and humoral immu-
nity; decreases the rate of relapses but does not affect progression of
MS.
n This type of medication is considered when there is no response to
treatment with immunotherapy drugs.
Antineoplastics Mitoxantrone
(eg, Novantrone)
n An immune system modulator and suppressor; administered as an IV
infusion every 3 months; side effects include nausea, thinning hair,
loss of menstrual periods, bladder infections, mouth sores, and bluish
discoloration of urine and sclera.
Methotrexate
(eg, amethopterin)
n An immunosuppressant used to reduce relapse rates and delay
disease progression; it also may be used to halt worsening progres-
sion of MS; there is a risk of cardiotoxic effects that require routine
cardiac testing, white blood cell counts, and liver function tests; may
not be used longer than 2 to 3 years because of cardiotoxic effects.
Cyclophosphamide
(eg, Cytoxan)
n A folic acid antagonist and antineoplastic with anti-inammatory
effects inhibiting cell-mediated and humoral immunity; attempts to
slow progression of MS.
(table continued)
AORN Journal j 285
SPECIAL NEEDS POPULATIONS www.aornjournal.org
http://www.aornjournal.org/http://www.aornjournal.org/ -
8/11/2019 Care of Patients With MS
6/14
fatigue, heat intolerance, pain, psychosocial issues,
sexual dysfunction, spasticity, tremor, vertigo,
weakness) is essential in helping an individual cope
with this chronic condition. Some of the most
common symptoms are usually cognitive difficul-
ties, visual disturbances, and fatigue.
Cognitive Difficulties
Cognition means knowing or perceiving; no matter
what a person is doing, his or her nervous system
continuously tries to provide the most complete andaccurate picture of reality. It is important for
patients with MS to be aware of any cognitive
symptoms because it may serve as an effective
signal of an upcoming exacerbation. Being aware
of this also may help the patient slow down or
readjust his or her activities of daily living before
symptoms begin to appear or intensify.
The most common cognitive difficulty in people
with MS is mild to moderate impairment of short-
term and working memory. People who usuallyhave good memories may find themselves forget-
ting things, such as appointments. Attention span
and ability to concentrate also may be diminished.
Sometimes, the person may find it hard to keep
track of what he or she was doing before being
interrupted. For example, the person may have
difficulty getting back on track if the phone rings
while sorting mail. Although these problems may
be subtle, they can be extremely frustrating and
upsetting.
Some people with MS experience more serious
cognitive problems. They have difficulty planning
and problem-solving and tend to become over-
whelmed and inflexible when a task is too complex.
They may lack the flexibility to generate alternative
solutions. They may even be unaware of their dif-
ficulties and have problems monitoring their own
behavior, and they may not comprehend how their
behavior affects others.9 Some of the strategies to
maximize cognitive function in daily living are for
the person to
n respect the complexity of everyday tasks;
n stay conscious of how well or poorly he or she
is functioning;
n use sticky notes in areas where he or she is
likely to see them (eg, mirrors, television sets,
telephones, the refrigerator);
n
arrange the environment where he or she per-forms tasks (eg, always put things back where
they belong, keep items of importance within
reach);
n make a daily list, write down things that come to
mind, and refer to the list frequently during the
day; and
n most importantly, rest and relax before starting
a new task.9
TABLE 2. (continued) Pharmacologic Treatment of Multiple Sclerosis (MS)
Classification Medication Usage
Other Carbamazepine
(eg, Tegretol)
n Used to treat paroxysmal symptoms.
Tricyclic antidepressants n Used to treat depression.
Bethanechol n Used to treat urinary retention.
Baclofen, benzodiazepines,
and dantrolene
n Used to treat muscle spasticity.
Anticholinergics n Used to treat urinary incontinence.
Solu-Medrol is a registered trademark of Pharmacia & UpJohn Co LLC, Kalamazoo, MI. Avonex is a registered trademark of Biogen Idec MA Inc, Weston,
MA. Rebif is a registered trademark of Ares Trading SA, Aubonne, Switzerland. Betaseron is a registered trademark of Bayer Schering Pharma, Berlin,
Germany. Copaxone is a registered trademark of Teva Pharmaceutical Industries Ltd, Tiqva, Israel. Imuran is a registered trademark of Burroughs Wellcome
& Co Inc, Tuckahoe, NY. Novantrone is a registered trademark of American Cyanamid Co, Wayne, NJ. Cytoxan is a registered trademark of Baxter
International Inc, Deereld, IL. Tegretol is a registered trademark of Geigy Chemical Corp, Ardsley, NY.
286 j AORN Journal
September 2013 Vol 98 No 3 RUTO
http://-/?-http://-/?-http://-/?-http://-/?- -
8/11/2019 Care of Patients With MS
7/14
Visual Disturbances
Optic neuritis is blurry vision or hazy vision that
affects one eye. Usually, it is associated with some
eye pain or discomfort, especially with eye move-
ment. When the person looks from side to side or
up and down, he or she may feel an ache or sticking
sensation behind the eye. According to Atkins,10
at disease onset, although individuals with MS
might experience a variety of symptoms such as
pain, weakness, and fatigue, 50% of the time
visual symptoms are the presenting symptom.
During the course of the disease, 100% of indi-
viduals with MS will have some visual problem,
such as optic neuritis including visual loss.10 As
with other neurological symptoms in MS, these
visual problems can come and go or fluctuate in
severity according to exacerbations.
The best acute treatment option for demyelin-
ating optic neuritis is a three-day course of high-
dose (1 g/day) IV corticosteroid treatment (eg,
methylprednisolone) followed by a tapering dose
of oral prednisone. This mode of treatment helps
speed up visual recovery. Intravenous methylpred-
nisolone is also well toler-
ated, but mild corticosteroid-
related side effects arecommon, including
insomnia, weight gain,
stomach upset, and
mood alteration.10
Fatigue
In addition to experiencing
cognitive and visual symp-
toms, patients with MS
commonly have fatigue;70% to 90% of patients
with MS note fatigue as
the most common symp-
tom.11(p26) Although fatigue
can greatly decrease a
patients quality of life,
it can be managed with
proper treatment.
To live positively with fatigue, the person with
MS should
n alternate periods of activity with naps and rest,
n create a calm environment,
n assess and minimize personal stress levels,
n assess sleep patterns and seek opportunities to
encourage uninterrupted sleep, and
n seek assistance with minimizing stress and
decreasing work requirements.
Health care providers treating patients with MS
who are experiencing fatigue should consider pre-
scribing sleeping aids that help facilitate uninter-
rupted sleep at night as well as medications that
treat fatigue.
The most common medication prescribed forfatigue is the stimulant amantadine. Amantadine
affects cholinergic, dopaminergic, adrenergic, and
glutamatergic neurotransmission. Although the
mechanism of action in treating fatigue in patients
with MS is unknown, this medication has been used
to treat fatigue in patients with MS since the early
1980s; 20%e40% of patients with MS experience
Online Resources
n American Academy of Family Physicians.http://familydoctor
.org/familydoctor/en/diseases-conditions/multiple-sclerosis
.printerview.all.html.
n American Academy of Neurology. http://patients.aan.com/
disorders/index.cfm?eventview&disorder_id998.
n MedlinePlus. http://www.nlm.nih.gov/medlineplus/multiple
sclerosis.html.
n Multiple Sclerosis Foundation. http://www.msfocus.org/.
n The Multiple Sclerosis Association of America. http://www
.msaa.com.
n National Institute of Neurological Disorders and Stroke.http://
www.ninds.nih.gov/disorders/multiple_sclerosis/multiple_
sclerosis.htm.
n National Multiple Sclerosis Society.http://www.nationalms
society.org/about-multiple-sclerosis/index.aspx.
Web site access verified May 22, 2013.
AORN Journal j 287
SPECIAL NEEDS POPULATIONS www.aornjournal.org
http://-/?-http://-/?-http://-/?-http://-/?-http://familydoctor.org/familydoctor/en/diseases-conditions/multiple-sclerosis.printerview.all.htmlhttp://familydoctor.org/familydoctor/en/diseases-conditions/multiple-sclerosis.printerview.all.htmlhttp://familydoctor.org/familydoctor/en/diseases-conditions/multiple-sclerosis.printerview.all.htmlhttp://patients.aan.com/disorders/index.cfm?event=view%26disorder_id=998http://patients.aan.com/disorders/index.cfm?event=view%26disorder_id=998http://patients.aan.com/disorders/index.cfm?event=view%26disorder_id=998http://patients.aan.com/disorders/index.cfm?event=view%26disorder_id=998http://www.nlm.nih.gov/medlineplus/multiplesclerosis.htmlhttp://www.nlm.nih.gov/medlineplus/multiplesclerosis.htmlhttp://www.msfocus.org/http://www.msaa.com/http://www.msaa.com/http://www.ninds.nih.gov/disorders/multiple_sclerosis/multiple_sclerosis.htmhttp://www.ninds.nih.gov/disorders/multiple_sclerosis/multiple_sclerosis.htmhttp://www.ninds.nih.gov/disorders/multiple_sclerosis/multiple_sclerosis.htmhttp://www.nationalmssociety.org/about-multiple-sclerosis/index.aspxhttp://www.nationalmssociety.org/about-multiple-sclerosis/index.aspxhttp://www.aornjournal.org/http://www.aornjournal.org/http://www.nationalmssociety.org/about-multiple-sclerosis/index.aspxhttp://www.nationalmssociety.org/about-multiple-sclerosis/index.aspxhttp://www.ninds.nih.gov/disorders/multiple_sclerosis/multiple_sclerosis.htmhttp://www.ninds.nih.gov/disorders/multiple_sclerosis/multiple_sclerosis.htmhttp://www.ninds.nih.gov/disorders/multiple_sclerosis/multiple_sclerosis.htmhttp://www.msaa.com/http://www.msaa.com/http://www.msfocus.org/http://www.nlm.nih.gov/medlineplus/multiplesclerosis.htmlhttp://www.nlm.nih.gov/medlineplus/multiplesclerosis.htmlhttp://patients.aan.com/disorders/index.cfm?event=view%26disorder_id=998http://patients.aan.com/disorders/index.cfm?event=view%26disorder_id=998http://patients.aan.com/disorders/index.cfm?event=view%26disorder_id=998http://patients.aan.com/disorders/index.cfm?event=view%26disorder_id=998http://familydoctor.org/familydoctor/en/diseases-conditions/multiple-sclerosis.printerview.all.htmlhttp://familydoctor.org/familydoctor/en/diseases-conditions/multiple-sclerosis.printerview.all.htmlhttp://familydoctor.org/familydoctor/en/diseases-conditions/multiple-sclerosis.printerview.all.htmlhttp://-/?-http://-/?-http://-/?-http://-/?- -
8/11/2019 Care of Patients With MS
8/14
a reduction in fatigue symptoms while taking the
medication amantadine.11(p26)
PERIOPERATIVE CONSIDERATIONS
When patients with MS present in the periopera-
tive area, health care providers should take special
consideration in planning their care. The stress of
surgery usually does not exacerbate symptoms of
MS; however, complications of surgery (ie, infec-
tion, fever) may aggravate the symptoms.12 The
effect of surgery and anesthesia on MS is related
to the severity of the disease process. Patients withmuscle weakness or those who are confined to
bed may have difficulty recovering from surgery
and may require physical therapy to recover.12 A
patient with MS who has respiratory problems
should consider the
n nature of the surgery,
n potential risks,
TABLE 3. Perioperative Nursing Implications: Care of the Patient With Multiple Sclerosis (MS)
Preoperative care
n Conrm with the patient and document a diagnosis of MS.
n Document any signs or symptoms of neurological decit in the patient.
n Assess for fall risks and initiate fall precaution guidelines.n Document the patients current medications, including date and time of the last dose, paying particular attention to corti-
costeroids and muscle relaxers.
n Conrm that preoperative antibiotics were administered if ordered.
n Ask the patient about medication restrictions before surgery.
n Check the patients white blood cell count for indications of infection.
n Implement preoperative warming with temperature-regulating blankets or forced-air warming units to prevent hypothermia.
n Provide preoperative teaching, focusing especially on postoperative mobilization and signs and symptoms of infection.
n Help decrease the patients anxiety by encouraging verbalization of concerns.
Intraoperative care
n Ensure that all members of the surgical care team are aware of the patients MS diagnosis.
n Continue using temperature-regulating blankets or forced-air warming units intraoperatively to prevent hypothermia.
n Position the patients body carefully, making sure to protect the joints and prevent hyperextension.
n Minimize hyperextension of the neck during intubation.
n Reduce intraoperative time to prevent the patient from being in one position for an extended time.
n Monitor intake and output.
n Prepare for the use of local anesthetic injections around the surgical sites to minimize postoperative pain.
Postoperative care
n Perform a thorough admission assessment with a focus on respiratory, temperature, cardiac, musculoskeletal, and peripheral
vascular status.
n Monitor the patients vital signs, oxygen, and blood glucose.
n Continue using temperature-regulating blankets or forced-air warming units postoperatively to prevent hypothermia.
n Monitor intake and output.
n Place an eye patch on the patients eye for diplopia if visual changes are apparent.
n Assess for pain and medicate as needed to provide relief.
n Resume the patients home medications as needed.
n Initiate physical and speech therapy as needed.
n Promote regular elimination by bladder and bowel training as needed.
n Instruct the patient to avoid fatigue, stress, infection, overheating, and chilling.
n Instruct the patient in safety measures related to sensory loss (eg, regulating the temperature of bath water, avoiding heating
pads).
n Instruct the patient in safety measures related to preventing falls.
288 j AORN Journal
September 2013 Vol 98 No 3 RUTO
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?- -
8/11/2019 Care of Patients With MS
9/14
n need for prolonged respiratory support, and
n possible need for mechanical ventilation.
These patients should be informed in advance of
these possibilities so they can make an informed
decision of whether they want to proceed withsurgery. Strictly elective surgical procedures should
be considered with caution and should not be rec-
ommended for patients with MS if possible.
Just as with any patient undergoing surgery, the
perioperative nurse should formulate an individu-
alized plan of care for the patient with MS to in-
clude individualized teaching dependent on the
patients specific manifestations of MS. Details on
perioperative considerations for patients with MS,
including during the preoperative, intraoperative,and postoperative phases, are provided in Table 3.
Preoperative Considerations
Patients with MS are sensitive to cold temperatures,
so preoperative nurses should assess the patients
baseline body temperature and implement measures
to maintain normothermia in an effort to prevent
exacerbation of symptoms. As a result of the in-
herent muscle weakness, muscle imbalance, and
possible muscle spasms or paralysis that patientswith MS experience, it is imperative that the pre-
operative nurse assess the patients risk for falls and
initiate fall precautions as needed. The preoperative
nurse should assess the patients respiratory status
and notify the RN circulator if additional respira-
tory equipment and supplies are needed for trans-
port from the preoperative area to the OR. If the
patient would like a family member present, the
preoperative nurse should endeavor to acquiesce
given the potential for visual deficits and cognitivedecline related to the stage of the patients MS.
During the hand-off communication with the RN
circulator, the preoperative nurse should commu-
nicate the patients
n vital signs, particularly his or her temperature;
n musculoskeletal status;
n respiratory condition;
n status of pain management; and
n level of impaired communication ability (eg,
visual deficits, cognitive decline).
Intraoperative Considerations
Given the patients sensitivity to cold tempera-tures, the RN circulator should initiate appropriate
warming measures as soon as the patient is trans-
ferred into the OR. The RN circulator also should
assess the patients MS-related pain, numbness, and
tingling before the procedure and pay particular
attention to positioning the patient to avoid exac-
erbating any preexisting problems. As the proce-
dure comes to a close, the RN circulator should
discuss the patients respiratory status with the
anesthesia professional and, if necessary, notifythe postanesthesia care unit (PACU) nurse of the
potential for prolonged respiratory support and
possible need for mechanical ventilation.
Postoperative Considerations
As the patient enters the postoperative phase, the
PACU nurse should frequently assess the patient
for symptoms of exacerbation. The PACU nurse
should monitor the patients temperature and
continue warming techniques as needed to maintainnormothermia. Patients with MS who had respira-
tory issues or were immobilized before surgery
may need respiratory therapy to help prevent atel-
ectasis, pneumonia, or aspiration issues.2
Patients who have been on corticosteroid therapy
before surgery may require supplementation in the
postoperative period, particularly to decrease
edema. Patients on baclofen should not be with-
drawn from this therapy in the postoperative period
because of the possibility of seizures or hallucina-tions. The PACU nurse should consider use of an
eye patch if the patient is experiencing visual
impairment. Before discharge from the PACU, the
nurse should involve the patient and his or her
family members in discharge instructions (eg, fall
prevention, initiating physical therapy if needed,
avoiding stress and fatigue, preventing post-
operative wound infections, pain management).
AORN Journal j 289
SPECIAL NEEDS POPULATIONS www.aornjournal.org
http://-/?-http://-/?-http://www.aornjournal.org/http://www.aornjournal.org/http://-/?-http://-/?- -
8/11/2019 Care of Patients With MS
10/14
CONCLUSION
The care and treatment of patients with MS has
improved significantly and is improving the quality
of care being provided to this patient population.
To help provide excellent care and ensure that best
perioperative patient outcomes are met, perioper-
ative nurses should seek out learning opportunities
to remain current regarding the needs and care of
patients with MS.
References
1. National Collaborating Centre for Chronic Conditions
(UK).Multiple Sclerosis: National Clinical Guideline for
Diagnosis and Management in Primary and Secondary
Care. United Kingdom: Royal College of Physicians;
2004.http://www.ncbi.nlm.nih.gov/books/NBK48919.
Accessed May 22, 2013.
2. Callahan L. Perioperative care of the patient withmultiple sclerosis. Curr Rev Post Anesth Care Nurs.
1995;17(1):2-8.
3. Swann J. What is multiple sclerosis? Br J Healthc
Assistants.2008;2(4):168-170.
4. Causes of multiple sclerosis. Multiple Sclerosis Trust.
http://www.mstrust.org.uk/atoz/cause.jsp. Accessed May
22, 2013.
5. Miller DH, Weinshenker BG, Filippi M, et al. Differen-
tial diagnosis of suspected multiple sclerosis: a consensus
approach. Mult Scler. 2008;14(9):1157-1174.
6. Schneider KM. AANA Journal course: update for
nurse anesthetistsdan overview of multiple sclerosis
and implications for anesthesia. AANA J. 2005;73(3):
217-224.
7. McCance KL, Huether SE, Brashers VL, Rote NS, eds.
Pathophysiology: The Biologic Basis for Disease in
Adults and Children. 6th ed. Maryland Heights, MO:
Mosby Elsevier; 2010.
8. Weinstock-Guttman B, Jacobs LD. What is new in the
treatment of multiple sclerosis?Drugs.2000;59(3):401-410.9. Lou JQ, Tischenkel C, DeLange L. Cognitive deficits in
multiple sclerosis. Multiple Sclerosis Foundation. http://
www.msfocus.org/article-details.aspx?articleID46. Ac-cessed June 15, 2013.
10. Atkins JE. Optic neuritis and MS. Multiple Sclerosis
Foundation.http://www.msfocus.org/article-details.aspx?
articleID380. Accessed June 15, 2013.11. Johnson CM. Managing fatigue in patients with multiple
sclerosis. Nursing. 2012;42(6):26-29.
12. Anesthesia and surgery. National Multiple Sclerosis So-
ciety. http://www.nationalmssociety.org/living-with
-multiple-sclerosis/getting-the-care-you-need/doctors-visit/
anesthesia-and-surgery/index.aspx. Accessed May 22,
2013.
Clare Ruto, MSN, RN, is an RN in the neuro-
science intermediate intensive care unit at
Kennestone Regional Medical Center, Marietta,
GA. Ms Ruto has no declared affiliation that
could be perceived as posing a potential conflict
of interest in the publication of this article.
290 j AORN Journal
September 2013 Vol 98 No 3 RUTO
http://www.ncbi.nlm.nih.gov/books/NBK48919http://refhub.elsevier.com/S0001-2092(13)00722-9/sref2http://refhub.elsevier.com/S0001-2092(13)00722-9/sref2http://refhub.elsevier.com/S0001-2092(13)00722-9/sref2http://refhub.elsevier.com/S0001-2092(13)00722-9/sref2http://refhub.elsevier.com/S0001-2092(13)00722-9/sref3http://refhub.elsevier.com/S0001-2092(13)00722-9/sref3http://refhub.elsevier.com/S0001-2092(13)00722-9/sref3http://refhub.elsevier.com/S0001-2092(13)00722-9/sref3http://www.mstrust.org.uk/atoz/cause.jsphttp://refhub.elsevier.com/S0001-2092(13)00722-9/sref4http://refhub.elsevier.com/S0001-2092(13)00722-9/sref4http://refhub.elsevier.com/S0001-2092(13)00722-9/sref4http://refhub.elsevier.com/S0001-2092(13)00722-9/sref4http://refhub.elsevier.com/S0001-2092(13)00722-9/sref4http://refhub.elsevier.com/S0001-2092(13)00722-9/sref5http://refhub.elsevier.com/S0001-2092(13)00722-9/sref5http://refhub.elsevier.com/S0001-2092(13)00722-9/sref5http://refhub.elsevier.com/S0001-2092(13)00722-9/sref5http://refhub.elsevier.com/S0001-2092(13)00722-9/sref5http://refhub.elsevier.com/S0001-2092(13)00722-9/sref5http://refhub.elsevier.com/S0001-2092(13)00722-9/sref5http://refhub.elsevier.com/S0001-2092(13)00722-9/sref6http://refhub.elsevier.com/S0001-2092(13)00722-9/sref6http://refhub.elsevier.com/S0001-2092(13)00722-9/sref6http://refhub.elsevier.com/S0001-2092(13)00722-9/sref6http://refhub.elsevier.com/S0001-2092(13)00722-9/sref6http://refhub.elsevier.com/S0001-2092(13)00722-9/sref7http://refhub.elsevier.com/S0001-2092(13)00722-9/sref7http://refhub.elsevier.com/S0001-2092(13)00722-9/sref7http://refhub.elsevier.com/S0001-2092(13)00722-9/sref7http://www.msfocus.org/article-details.aspx?articleID=46http://www.msfocus.org/article-details.aspx?articleID=46http://www.msfocus.org/article-details.aspx?articleID=46http://www.msfocus.org/article-details.aspx?articleID=380http://www.msfocus.org/article-details.aspx?articleID=380http://www.msfocus.org/article-details.aspx?articleID=380http://refhub.elsevier.com/S0001-2092(13)00722-9/sref8http://refhub.elsevier.com/S0001-2092(13)00722-9/sref8http://refhub.elsevier.com/S0001-2092(13)00722-9/sref8http://refhub.elsevier.com/S0001-2092(13)00722-9/sref8http://www.nationalmssociety.org/living-with-multiple-sclerosis/getting-the-care-you-need/doctors-visit/anesthesia-and-surgery/index.aspxhttp://www.nationalmssociety.org/living-with-multiple-sclerosis/getting-the-care-you-need/doctors-visit/anesthesia-and-surgery/index.aspxhttp://www.nationalmssociety.org/living-with-multiple-sclerosis/getting-the-care-you-need/doctors-visit/anesthesia-and-surgery/index.aspxhttp://www.nationalmssociety.org/living-with-multiple-sclerosis/getting-the-care-you-need/doctors-visit/anesthesia-and-surgery/index.aspxhttp://www.nationalmssociety.org/living-with-multiple-sclerosis/getting-the-care-you-need/doctors-visit/anesthesia-and-surgery/index.aspxhttp://www.nationalmssociety.org/living-with-multiple-sclerosis/getting-the-care-you-need/doctors-visit/anesthesia-and-surgery/index.aspxhttp://refhub.elsevier.com/S0001-2092(13)00722-9/sref8http://refhub.elsevier.com/S0001-2092(13)00722-9/sref8http://www.msfocus.org/article-details.aspx?articleID=380http://www.msfocus.org/article-details.aspx?articleID=380http://www.msfocus.org/article-details.aspx?articleID=380http://www.msfocus.org/article-details.aspx?articleID=46http://www.msfocus.org/article-details.aspx?articleID=46http://www.msfocus.org/article-details.aspx?articleID=46http://refhub.elsevier.com/S0001-2092(13)00722-9/sref7http://refhub.elsevier.com/S0001-2092(13)00722-9/sref7http://refhub.elsevier.com/S0001-2092(13)00722-9/sref6http://refhub.elsevier.com/S0001-2092(13)00722-9/sref6http://refhub.elsevier.com/S0001-2092(13)00722-9/sref6http://refhub.elsevier.com/S0001-2092(13)00722-9/sref6http://refhub.elsevier.com/S0001-2092(13)00722-9/sref5http://refhub.elsevier.com/S0001-2092(13)00722-9/sref5http://refhub.elsevier.com/S0001-2092(13)00722-9/sref5http://refhub.elsevier.com/S0001-2092(13)00722-9/sref5http://refhub.elsevier.com/S0001-2092(13)00722-9/sref5http://refhub.elsevier.com/S0001-2092(13)00722-9/sref4http://refhub.elsevier.com/S0001-2092(13)00722-9/sref4http://refhub.elsevier.com/S0001-2092(13)00722-9/sref4http://www.mstrust.org.uk/atoz/cause.jsphttp://refhub.elsevier.com/S0001-2092(13)00722-9/sref3http://refhub.elsevier.com/S0001-2092(13)00722-9/sref3http://refhub.elsevier.com/S0001-2092(13)00722-9/sref2http://refhub.elsevier.com/S0001-2092(13)00722-9/sref2http://refhub.elsevier.com/S0001-2092(13)00722-9/sref2http://www.ncbi.nlm.nih.gov/books/NBK48919 -
8/11/2019 Care of Patients With MS
11/14
EXAMINATIONCONTINUING EDUCATION PROGRAM
2.0
www.aorn.org/CESpecial Needs Populations: Careof Patients With Multiple Sclerosis
PURPOSE/GOAL
To enable the learner to provide appropriate perioperative care for the patient with
multiple sclerosis (MS) who is undergoing surgery.
OBJECTIVES
1. Explain the pathophysiology of MS.
2. Describe the symptoms of MS.
3. Discuss the causes of MS.
4. Identify tests used to diagnose MS.
5. Identify medications that patients with MS may be taking.
6. Discuss perioperative care of the patient with MS undergoing surgery.
The Examination and Learner Evaluation are printed here for your conven-
ience. To receive continuing education credit, you must complete the Exami-
nation and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS
1. Multiple sclerosis is a progressive, neurodegen-
erative disease of the
a. central nervous system.
b. brain neurons.
c. nerve cells in the spinal cord.
d. nerve cells in the cerebrum.
2. In MS,
1. the myelin sheath is damaged and eventually
degenerates.
2. plaques or lesions occur anywhere randomly
on the myelin sheath.
3. nerve conductivity is impaired, which inter-
feres with message transmission.
4. psychiatric problems occur in conjunction
with demyelination.
a. 1 and 3 b. 2 and 4
c. 1, 2, and 3 d. 1, 2, 3, and 4
3. As a result of demyelination and the resulting
impairments, patients with MS may experience
1. learning disabilities and mental retardation.
2. muscle imbalance.
3. muscle weakness.
4. pain, numbness, or tingling sensations.5. possible muscle spasms with partial or
complete paralysis.
6. visual impairment and alteration of cognitive
abilities.
a. 1, 3, and 5 b. 2, 4, and 6
c. 2, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6
4. The cause of MS is unknown, but current theories
to explain it include
AORN, Inc, 2013 September 2013 Vol 98 No 3 AORN Journal j 291
http://www.aornjournal.org/http://www.aorn.org/CEhttp://www.aorn.org/CEhttp://www.aornjournal.org/ -
8/11/2019 Care of Patients With MS
12/14
1. autoimmunity.
2. genetic composition.
3. pathogen mediation.
4. immune repression.
a. 1 and 4 b. 1, 2, and 3
c. 2, 3, and 4 d. 1, 2, 3, and 4
5. Hormones may play a vital role in determining an
individuals susceptibility to acquiring MS.
a. true b. false
6. The clinical type of MS that usually shows
a steady progression or worsening of the disease
from onset with occasional plateaus or minor
recovery is
a. primary-progressive.
b. progressive-relapsing.
c. relapsing-remitting.
d. secondary-progressive.
7. A diagnosis of MS is confirmed by
1. lumbar puncture.
2. magnetic resonance imaging and computed
tomography scanning.
3. serum human chorionic gonadotropin.
4. visual and somatosensory evoked potential.
5. genetic testing.
a. 4 and 5 b. 1, 2, and 4
c. 1, 2, 3, and 5 d. 1, 2, 3, 4, and 5
8. Corticosteroids are used to treat MS because they
a. modulate the immune system and block the
destruction of myelin.
b. inhibit cell immunity and shorten the duration
of attacks of MS.
c. restore the blood-brain barrier and improve
axonal nerve conduction.
d. suppress the immune system and decrease the
rate of relapse.
9. The stress of surgery usually exacerbates symp-
toms of MS.
a. true b. false
10. Intraoperative nursing care of the patient with MS
who is undergoing surgery includes
1. initiating warming measures to prevent
hypothermia.
2. ensuring careful positioning of the patientsbody to protect joints and prevent
hyperextension.
3. reducing intraoperative time to prevent the
patient from being in one position for an
extended time.
4. preparing for use of local anesthetic injec-
tions around surgical sites to minimize post-
operative pain.
a. 1 and 3 b. 2 and 4
c. 1, 2, and 4 d. 1, 2, 3, and 4
292 j AORN Journal
September 2013 Vol 98 No 3 CE EXAMINATION
-
8/11/2019 Care of Patients With MS
13/14
-
8/11/2019 Care of Patients With MS
14/14
C o p y r i g h t o f A O R N J o u r n a l i s t h e p r o p e r t y o f E l s e v i e r I n c . a n d i t s c o n t e n t m a y n o t b e c o p i e d
o r e m a i l e d t o m u l t i p l e s i t e s o r p o s t e d t o a l i s t s e r v w i t h o u t t h e c o p y r i g h t h o l d e r ' s e x p r e s s
w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s m a y p r i n t , d o w n l o a d , o r e m a i l a r t i c l e s f o r i n d i v i d u a l u s e .