9 Multiple Sclerosis Nursing Care Plans

Fatigue

Fatigue is a common symptom in patients with multiple sclerosis due to the disease’s impact on the central nervous system, which can lead to disruptions in nerve signals and cause the body to use more energy to complete simple tasks. Additionally, the immune system’s constant attack on myelin, the protective coating around nerve fibers, may also contribute to the development of fatigue.

Nursing Diagnosis

• Fatigue

May be related to

• Decreased energy production, increased energy requirements to perform activities
• Psychological/emotional demands
• Pain/discomfort
• Medication side effects

Possibly evidenced by

• Verbalization of overwhelming lack of energy
• Inability to maintain usual routines; decreased performance
• Impaired ability to concentrate; disinterest in surroundings
• Increase in physical complaints

Desired Outcomes

• The patient will identify risk factors and individual actions affecting fatigue.
• The patient will identify alternatives to help maintain desired activity level.
• The patient will participate in the recommended treatment program.
• The patient will report an improved sense of energy.

Nursing Assessment and Rationales

1. Note and accept the presence of fatigue.
Fatigue is the most persistent and common symptom of MS. Studies indicate that the fatigue encountered by patients with MS occurs with the expenditure of minimal energy, is more frequent and severe than “normal” fatigue, has a disproportionate impact on ADLs, has a slower recovery time, and may show no direct relationship between fatigue severity and patient’s clinical neurological status.

2. Identify and review factors affecting the ability to be active: temperature extremes, inadequate food intake, insomnia, use of medications, and time of day.
Provides an opportunity to problem-solve to maintain or improve mobility.

3. Investigate the appropriateness of obtaining a service dog.
Service dogs can increase a patient’s level of independence. They can also assist in energy conservation by carrying items in “saddle” bags and retrieving or performing tasks.

Nursing Interventions and Rationales

1. Accept when the patient is unable to do activities.
Ability can vary from moment to moment. Nonjudgmental acceptance of patients’ evaluation of day-to-day variations in capabilities provides the opportunity to promote independence while supporting fluctuations in the level of required care.

2. Determine the need for walking aids. Provide braces, walkers, or wheelchairs. Review safety considerations.
Mobility aids can decrease fatigue, enhancing independence and comfort, as well as safety. However, individuals may display poor judgment about the ability to safely engage in an activity.

3. Schedule ADLs in the morning if appropriate. Investigate the use of a cooling vest.
Fatigue commonly worsens in the late afternoon (when body temperature rises). Some patients report a lessening of fatigue with stabilization of body temperature.

4. Plan care consistent rest periods between activities. Encourage afternoon naps.
Reduces fatigue, and aggravation of muscle weakness.

5. Assist with physical therapy. Increase patient comfort with massages and relaxing baths.
Reduces fatigue and promotes a sense of wellness.

6. Stress the need for stopping exercise or activity just short of fatigue.
Pushing self beyond individual physical limits can result in excessive or prolonged fatigue and discouragement. In time, the patient can become very adept at knowing limitations.

7. Recommend participation in groups involved in fitness or exercise and/or the Multiple Sclerosis Society.
Can help the patient to stay motivated to remain active within the limits of the disability or condition. Group activities need to be selected carefully to meet the patient’s needs and prevent discouragement or anxiety.

8. Administer medications as indicated: 

• 8.1. Amantadine (Symmetrel); pemoline (Cylert)
  Useful in the treatment of fatigue. Positive antiviral drug effect in 30%–50% of patients. Use may be limited by side effects of increased spasticity, insomnia, and paresthesias of hands and feet.

• 8.2. Methylphenidate (Ritalin), modafinil (Provigil)
  CNS stimulants may reduce fatigue but may also cause side effects of nervousness, restlessness, and insomnia.

• 8.3. Sertraline (Zoloft), fluoxetine (Prozac)
  Antidepressants useful in lifting the mood, and “energizing” a patient (especially when depression is a factor) and when the patient is free of anticholinergic side effects.

• 8.4. Tricyclic antidepressants: amitriptyline (Elavil), nortriptyline (Pamelor)
  Useful in treating emotional lability, neurogenic pain, and associated sleep disorders to enhance willingness to be more active.

• 8.5. Anticonvulsants: carbamazepine (Tegretol), gabapentin (Neurontin), lamotrigine (Lamictal)
  Used to treat neurogenic pain and sudden intermittent spasms related to spinal cord irritation.

• 8.6. Steroids: prednisone (Deltasone), dexamethasone (Decadron), methylprednisolone (Solu-Medrol)
  May be used during acute exacerbations to reduce and prevent edema formation at the sclerotic plaques. Note: Long-term therapy seems to have little effect on the progression of symptoms.

• 8.7. Vitamin B
  Supports nerve-cell replication, enhances metabolic functions and may increase a sense of well-being and energy level.

• 8.8. Immuno-modulating agents: cyclophosphamide (Cytoxan), azathioprine (Imuran), methotrexate (Mexate), interferon [beta]-1B (Betaseron); interferon [beta]-1A (Avonex, Rebif), glatiramer (Copaxone); mitoxantrone (Novantrone)
  May be used to treat acute relapses, reduce the frequency of relapses, and promote remission. Interferon [beta]-1B (Betaseron) has been approved for use by ambulatory patients with remitting relapsing MS and is the first drug found to alter the course of the disease. Current research indicates early treatment with drugs that reduce inflammation and lesion formation may limit permanent damage. Therapy of choice is “A, B, C” drugs: Avonex, Betaseron, and Copaxone. Therapeutic benefits have been reported in patients at all stages of disability with a reduction in both steroid use and hospital days. (Copaxone chemically resembles a component of myelin and may act as a decoy, diverting immune cells away from myelin target.) Note: Novantrone may be used if other medications are not effective but are contraindicated in patients with primary progressive MS.

9. Prepare for plasma exchange treatment as indicated.
Research suggests that individuals experiencing severe exacerbations not responding to standard therapy may benefit from a course of plasma exchange