Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations for multiple sclerosis and myasthenia gravis
- Describe the diagnostics and laboratory values in the diseases of multiple sclerosis and myasthenia gravis
- Apply nursing concepts and plan associated nursing care for the patient with multiple sclerosis and myasthenia gravis
- Evaluate the efficacy of nursing care for the patient with multiple sclerosis and myasthenia gravis
- Describe the medical therapies that apply to the care of multiple sclerosis and myasthenia gravis
Multiple sclerosis (MS) and myasthenia gravis (MG) are chronic neurological diseases and complex disorders that profoundly affect lives. Multiple sclerosis is more common and typically initially affects people between the ages of 20 and 40 years old (NINDS, 2019). Myasthenia gravis (MG) is an uncommon disorder that usually affects females under 40 and males older than 60 years of age (NINDS, 2024b).
The autoimmune condition of the central nervous system characterized by inflammation, demyelination, and neurodegeneration that manifests with diverse neurological symptoms, such as difficulties with coordination, slurred speech, and cognitive problems is called multiple sclerosis (MS). MS is an incurable illness.
The autoimmune neuromuscular condition that manifests due to the body’s production of hyperreactive antibodies that block acetylcholine receptors on muscle fibers, prohibiting communication to the nerves is called myasthenia gravis (MG). MG primarily affects the neuromuscular junction, which is the point where nerve impulses meet muscles to create movement. Fewer nerve signals make it to the muscles, resulting in muscles that do not contract and move. Once a patient develops MG, it is a chronic condition.
Multiple Sclerosis
MS has the potential to be disabling. Although the exact cause of MS is still unknown, various genetic and environmental elements are believed to play a part, including family history, certain infections, vitamin D deficiency, and smoking (NINDS, 2019). Females tend to be affected more frequently than males, with symptoms typically appearing in early adulthood (NINDS, 2019).
Pathophysiology
MS is a neurodegenerative disease that has no cure. It is caused by antibodies attacking and damaging the protective layer of myelin sheath covering nerve fibers in the brain and spinal cord. This process creates scar tissue called “sclerosis.” MS disrupts nerve signal transmissions, creating communication issues between the brain and other parts of the body.
Clinical Manifestations
MS manifests through a variety of symptoms, including the following:
- muscle weakness
- fatigue
- tingling and numbness
- lack of coordination
- a sensation that causes patients to feel dizzy, sometimes as if they are spinning or in motion while still, known as vertigo
- balance issues, which may include the inability to walk
- cardiovascular disease
- suppressed immune system
- eyesight issues, including blurred and/or double vision
- hearing loss
- difficulty breathing
- bladder, bowel, and sexual dysfunction, including infertility
- speech disorders as well as difficulty with swallowing
- cognitive issues, including confusion, memory problems, and difficulty concentrating
- personality and mood changes
The severity of MS symptoms varies among patients (Figure 17.7). Some patients go through periods of remission, when symptoms are minimized or even disappear, before facing exacerbation, a period when symptoms manifest again. Some patients do not have periods of remission and are continuously affected by MS symptoms. This may include symptoms so severe that patients are immobile, without the ability to walk independently.
Assessment and Diagnostics
MS is diagnosed by gathering a patient’s medical history to determine if they have risk factors for MS. Such factors include a family history of MS; autoimmune diseases, such as type 1 diabetes or thyroid disease; vitamin D deficiencies; infections, such as Epstein-Barr (the virus that causes mononucleosis); obesity; and smoking. The medical history should also determine if patients have symptoms of MS, such as lack of coordination, cognitive issues, and hearing loss.
Diagnostics and Laboratory Values
If patients have symptoms of MS along with risk factors, additional assessment can be done through diagnostic testing. Blood tests, lumbar punctures, evoked potential tests, and MRIs may be useful to confirm an MS diagnosis.
Blood test results cannot show if a patient has MS, but they may show if a patient has another condition, with symptoms that are similar to MS, such as Lyme disease. If blood tests determine that a patient has a condition other than MS, health-care professionals can rule out MS as a diagnosis for the patient. Blood tests can also show the patient has a problem that is a risk factor for MS, such as a vitamin D deficiency.
A lumbar puncture can rule out infections that may be causing symptoms that mimic MS, as well as show if a patient has antibody abnormalities typical in MS. Evoked potential tests show how quickly nerve signals travel through the body, and in patients with MS these signals are defective. An MRI may show lesions that indicate MS.
Nursing Care of the Patient with Multiple Sclerosis
MS is incurable, but treatment can help patients manage the disease. Nursing care for patients with MS focuses on empowering them to participate in their care while supporting them to maintain the maximum independence and functioning levels possible.
Recognizing Cues and Analyzing Cues
To recognize the cues for MS, nurses should assess the patient’s neurological status, with attention to motor functioning, coordination, and sensory perceptions. Nurses should be alert for muscle weakness, tremors, and gait issues, as well as problems with fine or gross motor skills. Other cues include sensory disturbances such as tingling or numbness, as well as problems such as fatigue, memory lapses, difficulty with concentration, and mood shifts. As part of this process, nurses should be aware that some patients with MS go through periods of remission and exacerbation, so some cues may be visible only part of the time. Nurses should also consider the results of blood tests, lumbar punctures, evoked potential tests, and/or MRIs performed on the patient. To analyze the cues of both symptoms and test results, nurses must evaluate how the findings deviate from normal ranges for both body functioning and test results.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
For patients with MS, prioritize health problems according to severity of symptoms, recognizing that some symptoms may be mild and require no treatment. Although there is no cure for MS, patients still need treatment to help them manage symptoms, recover from attacks, and slow the disease’s progression. Coordinate with each patient’s health-care team to generate solutions and develop the best plan of care to address the patient’s case. The appropriate nursing interventions may include the actions in Table 17.8.
| Nursing Care | Rationale |
|---|---|
| Complete focused neurological assessments. | Changes in the patient’s neurological symptoms, including cognitive issues such as memory and confusion, personality and mood changes, vertigo, muscle weakness, tingling, numbness, and lack of coordination may indicate MS. |
| Monitor vital signs. | Changes in the patient’s vital signs such as heart rate and blood pressure may indicate health issues. |
| If patient has an MS exacerbation, provide medications and monitor for side effects. | Patients may need corticosteroids to reduce nerve inflammation. Patients may experience side effects, such as elevated blood pressure, insomnia, and mood swings. |
| Monitor if patients receive a plasma exchange. | During the healing process after a plasma exchange, the plasmapheresis machine must be monitored and patients need care to prevent infections. This may include administering intravenous methylprednisolone. |
| Medication for ongoing MS management | Patients may need medication to manage ongoing MS symptoms, including injectable, infusion, or oral treatments of drugs such as monoclonal antibodies, interferons, and teriflunomide. |
| Administer other medications. | Patients may need additional medications to address problems such as fatigue and pain. Some patients may need muscle relaxants. |
| Assist with mental health support. | Patients may need consultation with a mental health professional to help them cope with the challenges of living with MS. Some patients may need prescription medications to help with issues such as anxiety and depression. |
| Collaborate with physical therapist. | Patients may need assistance with mobility, including exercises to strengthen muscles and help with coordination and balance problems. Coordinate with the physical therapist as needed. |
Evaluation of Nursing Care for the Patient with Multiple Sclerosis
Because MS is incurable, the desired outcome for patients with MS is symptom management that enables the patient to have a better quality of life. This should include improvement, and even abatement, of symptoms as much as possible. If symptoms cannot be abated, the goal should be to modify the disease and increase the amount of time that elapses between periods when symptoms occur. Patients should also have the support system needed to help them overcome any psychological challenges, such as anxiety and depression, that they may experience as they manage MS.
Medical Therapies and Related Care
See the medical therapies used for patients with MS in Table 17.9.
| Medical Therapy | Explanation of Care |
|---|---|
| MS exacerbations should first be treated with corticosteroids. | May include drugs, such as intravenous methylprednisolone and oral prednisone |
| If corticosteroids do not work, MS exacerbations may be treated with plasmapheresis. | The plasma exchange process should include removing the patient’s plasma, mixing it with a protein solution, and putting it back into the patient’s body. For some patients with MS, the protein solution can help treat MS symptoms. |
| Disease-modifying therapies may include injectable treatments. | Examples include monoclonal antibodies, interferons, and glatiramer acetate. |
| Disease-modifying therapies may include infusion treatments. | Examples include monoclonal antibodies such as natalizumab and alemtuzumab. |
| Disease-modifying therapies may include oral treatments | Examples include teriflunomide, monomethyl fumarate, siponimod, cladribine, ponesimod, and dimethyl fumarate. |
| Physical therapy | Should include exercises to help patients stretch and strengthen their muscles |
| Additional medications | Patients may need muscle relaxants and pain relievers to help with pain issues. Patients may also need medications, such as modafinil and methylphenidate, to help with fatigue. Other medications may be needed to help with problems such as constipation, sexual dysfunction, and insomnia. |
| Mental health support | Support may include counseling as well as medication to treat issues such as anxiety and depression |
Myasthenia Gravis
Myasthenia gravis (MG) is a chronic autoimmune disorder that occurs when the nerves and muscles fail to communicate. MG causes the skeletal muscles to become weak, affecting muscles that patients control voluntarily to do things such as swallow, make facial expressions, blink eyes, and move the arms and legs. MG generally affects females under age 40 and males over the age of 50 (Johns Hopkins Medicine, 2024c).
Pathophysiology
MG occurs when the immune system produces antibodies that target and block acetylcholine receptors at the neuromuscular junction. Acetylcholine is a key neurotransmitter essential in muscle contraction. When acetylcholine is blocked, it inhibits communication between nerves and muscles, hindering normal nerve-muscle connection, and leading to muscle fatigue and weakness.
Individuals with an autoimmune condition, such as lupus or rheumatoid arthritis, may be at risk for MG. Also, in some cases, MG may result when patients have a tumor in their thymus gland. The thymus gland produces and trains T cells, which are white blood cells that assist the immune system to fight infections and disease. The thymus gland can produce antibodies that block acetylcholine, so if the gland has a tumor and malfunctions, it may contribute to MG.
Clinical Manifestations
Typically, the symptoms of MG may include difficulty breathing, chewing, swallowing, and/or speaking; facial movement difficulties, including the inability to smile; vision problems, including double vision and drooping eyelids known as ptosis; neck, limb, and/or muscle weakness; and fatigue. Nurses should be aware that the symptoms of MG are likely to worsen when patients are tired. In particular, a repetitive activity such as working the jaw muscles and chewing a plate of coarse foods, such as a steak or crackers, can be wearisome for patients with MG if the disease affects their bulbar nerves, which hold the jaw in place and control swallowing, chewing, and speaking processes. The symptoms of MG are likely to lessen after periods of resting the affected muscles.
Assessment and Diagnostics
MG is assessed and diagnosed by conducting a physical examination focused on patients’ coordination, balance, reflexes, senses of sight and touch, and muscle strength. Neurological assessments may show that patients have symptoms, such as breathing difficulties, muscle weakness, balance and coordination problems, poor reflexes, and vision problems.
Diagnostics and Laboratory Values
Tests that can be used to identify MG include blood analysis, ice pack tests, single-fiber EMG, repetitive nerve stimulation, imaging, and pulmonary function tests. Blood tests may show the presence of antibodies that block acetylcholine receptors. Ice pack tests may show that droopy eyelids do not respond to cold therapy. EMGs may reveal limited electrical activity occurring between the patient’s brain and muscles. Repetitive nerve stimulation measurements may show that nerves have a limited ability to send signals to muscles. Imaging may illustrate a tumor in the patient’s thymus gland. Pulmonary functioning tests—which measure a patient’s lung capacity, volume, gas exchange, and flow rates—can determine whether MG affects a patient’s breathing.
Link to Learning
For patients with MG symptoms, the ice pack test is a useful bedside tool to help confirm a MG diagnosis.
Nursing Care of the Patient with Myasthenia Gravis
For patients with MG who are struggling to breathe, nurses should alert patients’ providers that they need medications and other inventions, such as mechanical assistance to restore breathing. Nursing care should focus on following providers’ orders to provide immediate medications and other assistance needed to restore breathing. Because MG is incurable, other nursing care for patients with MG should focus on alleviating symptoms as much as possible and helping patients manage the disease. For example, nurses can help patients conserve energy by modifying the way they eat meals and perform other tasks, such as learning to walk with a cane. Nurses should help patients identify which medications alleviate their symptoms and should provide education and support to ensure that patients understand the disease and the challenges that it poses for them.
Recognizing Cues and Analyzing Cues
To recognize the cues for MG, nurses should assess the patient’s neurological status, with focus on the patient’s coordination, balance, reflexes, senses of sight and touch, and muscle strength. Nurses should be alert for the symptoms of MG, such as shortness of breath, speaking difficulties, drooping eyelids, trouble swallowing, attempts to smile that appear as a scowl, fatigue, and muscle weakness, particularly in muscles that are used repetitively.
Nurses should consider whether patients have risk factors for MG, such as a thymus gland tumor or an autoimmune condition, such as lupus. To analyze the cues of the patient’s symptoms and test results, nurses must evaluate how the findings deviate from normal ranges for both body functioning and test results. For example, a patient’s blood test may reveal nontypical antibodies that disrupt communication between the patient’s nerves and muscles.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
MG can be life-threatening. Specifically, if MG affects the muscles that enable patients to breathe, patients may need immediate intervention to restore breathing. For other symptoms, because there is no cure for MG, treatment should focus on helping patients manage symptoms, and, as much as possible, slow the disease’s progression. Nursing interventions include those in Table 17.10.
| Nursing Care | Rationale |
|---|---|
| Complete focused neurological assessments. | Changes in the neurological symptoms of a patient with MG including muscle weakness, vision issues, difficulties with swallowing and speaking, facial movements, and particularly shortness of breath indicate health issues. |
| Monitor vital signs. | Changes in the vital signs of a patient with MG, such as heart rate and blood pressure, may indicate health issues. |
| Maintain breathing. | Patients with MG with breathing difficulties may need medications, such as inhaled bronchodilators and/or inhaled steroids, to restore breathing. They may also need a ventilator, using either endotracheal intubation or a BiPAP. |
| Assist with bed positioning. | Patients with MG with breathing difficulties should be placed in Fowler’s position while they are in bed. This is a semi-sitting position with the head of the bed elevated 45 to 60 degrees. |
| Administer medications for ongoing MG management. | For ongoing MG symptoms, patients may need medications such as corticosteroids, immunosuppressants, and cholinesterase inhibitors. |
| Administer intravenous therapy. | If patients with MG have symptoms that suddenly worsen, intravenous therapy may be useful. This includes therapies such as plasmapheresis, intravenous immunoglobulin (IVIG), and monoclonal antibodies that nurses administer by vein. |
| Assist with mental health support. | Patients with MG may need consultation with a mental health professional to help them cope with the challenges of living with MG. Some patients may need prescription medications to help with issues such as anxiety and depression. |
| Prepare for surgery and provide aftercare. | For patients with MG who have a thymus gland tumor, surgery may be warranted to remove the tumor. Nurses should help prepare patients for surgery and provide care after surgery. This may include wound care, as well as pain management. |
| Coordinate with occupational therapist. | Some patients with MG may benefit by learning how to use appliances, such as electrical toothbrushes and electric can openers, to conserve their body’s energy by reducing the use of voluntary muscles. Coordinate with the occupational therapist as needed. |
Evaluation of Nursing Care for the Patient with Myasthenia Gravis
For patients with MG who struggle to breathe, the desired outcome is maintaining the optimal quality of breathing, and abatement of the medical emergency caused by the patient’s breathing difficulties. Because MG is incurable, the desired outcome for all patients with MG is symptom management that helps patients manage the disease and have a better quality of life. An example includes, after consultation with a mental health professional does the patient appear they can cope with MG prognosis. Another evaluation includes if the bed is positioned to help the patient breathe easier, do they appear in respiratory distress after repositioning.
Medical Therapies and Related Care
The medical therapies used for patients with MG may include those in Table 17.11.
| Medical Therapy | Explanation of Care |
|---|---|
| MG exacerbations that cause breathing difficulties should be treated with medications and possibly ventilation | Medications may include inhaled bronchodilators and/or inhaled steroids. Ventilators may use either endotracheal intubation or a BiPAP. |
| Medication for ongoing symptoms | Medications to manage ongoing MG symptoms may include corticosteroids, immunosuppressants, and cholinesterase inhibitors. |
| Intravenous therapy | For some patients with MG, intravenous therapies such as plasmapheresis, intravenous immunoglobulin (IVIG), and monoclonal antibodies given by vein may be useful. |
| Surgery | For patients with MG who have a thymus gland tumor, surgery may be an option to remove the tumor. |
| Occupational therapy | Patients with MG may need to be taught to use appliances, such as electrical toothbrushes and electric can openers, to use their voluntary muscles less and conserve energy. |
| Mental health support | Support may include counseling, as well as medication, to treat issues such as anxiety and depression for patients who need mental health support to manage MG. |
Interdisciplinary Plan of Care
Interdisciplinary Care for Patients with MG
Patients with MG require an interdisciplinary approach to provide care that addresses all of their needs. For example, in addition to treatment from a primary provider, patients with MG typically need occupational therapy to learn how to use tools, such as electric toothbrushes, that can help patients with MG expend less energy to perform everyday tasks. Physical therapists can teach patients with MG about stretching and other exercises that can help them build and conserve physical energy. Mental health professionals can counsel patients with MG about mental health issues they may experience, such as anxiety and depression, and help them learn coping techniques. If needed, mental health professionals can prescribe medication to help patients with MG control issues such as anxiety. Nurses can help patients with MG by acting as the liaison among their care team and helping patients with MG coordinate with each member of their team to get the best possible treatment.