Care of Patients With MS

8/11/2019 Care of Patients With MS

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CONTINUING EDUCATION

Special Needs Populations:

Care of Patients WithMultiple SclerosisCLARE RUTO, MSN, RN 2.0

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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

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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

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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.

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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

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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.

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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)

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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.

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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.

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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.

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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).

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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

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


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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
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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


13/14


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 .

Documents

Care of Patients With MS