Objectives

On completion of this lecture, the student will be

able to:
1. Describe the multiple sclerosis, bell’s palsy and
epilepsy.
2. Describe factors, causes, S&S for multiple sclerosis,
bell’s palsy and epilepsy.
3. Explain the diagnostic investigations.
4.Identify appropriate medical interventions for
multiple sclerosis, bell’s palsy and epilepsy.
5. Use the nursing process as a framework for the
care of patients with multiple sclerosis, bell’s palsy
and epilepsy.
 Multiple Sclerosis
MS typically presents in young adults ages 20 to 40
and it affects women more frequently than men.
The cause of MS is an area of ongoing research.
Genetic factors may promote susceptibility to MS.
A specific virus capable of initiating the myelin
sheath nerve fiber.
 MS is an immune-mediated progressive
demyelinating disease of the CNS. Demyelination
refers to the destruction of myelin, the fatty and
protein material that surrounds certain nerve
fibers in the brain and spinal cord; it results in
impaired transmission of nerve impulses.
 Multiple Sclerosis
 Demyelination interrupts the flow of nerve
impulses and results in a variety of
manifestations, depending on which nerves are
affected.
 Plaques of sclerotic tissue appear on
demyelinated axons, further interrupting the
transmission of impulses, resulting in
permanent and irreversible damage.
The areas most frequently affected are the optic
nerves, the brain stem, cerebellum and the
spinal cord.
 Multiple Sclerosis
Clinical Manifestations
The S & S of MS are varied and multiple, reflecting the location
of the lesion (plaque) or combination of lesions.
The primary symptoms most commonly are fatigue,
depression, weakness, numbness, difficulty in
coordination, loss of balance, and pain (in 66% of
patients with MS).
Fatigue impairs optimal function of patient.
Depression may relate to the pathophysiology or may
occur as a reaction to the diagnosis. Suicide as the
cause of death occurs 7.5 times more frequently among
persons diagnosed with MS than among general
population. If suicide occurs, it is likely to occur within
the first 5 years of diagnosis.

 Multiple Sclerosis
Clinical Manifestations
 Visual disturbances due to lesions in the optic
nerves may include blurring of vision, diplopia
(double vision), patchy blindness (a partial loss of
vision) (scotoma), and total blindness.
 Spasticity muscle hypertonicity of extremities
and loss of the abdominal reflexes are due to
involvement of the main motor pathways of the
spinal cord.
 Cognitive changes (eg, memory loss, decreased
concentration) occurs in about half of patients due
to frontal or parietal lobe involvement but severe
cognitive changes with dementia are rare.
 Multiple Sclerosis
Clinical Manifestations
 Sensory dysfunction (paresthesias, pain).
 Involvement of the cerebellum or basal ganglia
can produce ataxia (impaired coordination of
movements) and tremor.
 Involvement of the the cortex and the basal
ganglia may cause emotional lability and
euphoria (a feeling or state of intense excitement
and happiness).
 Bladder, bowel, and sexual dysfunctions are
common.
 Multiple Sclerosis
Complications
 Urinary tract infections,
 Constipation
 Pressure ulcers
 Contracture deformities
 Decreased bone mass
 Dependent pedal edema
 Pneumonia
 Depression and emotional problems
 Multiple Sclerosis
Diagnostic Findings
MRI is the primary diagnostic tool for
visualizing plaques, documenting disease
activity, and evaluating the effect of treatment.
CSF identifies an immune system abnormality.
Underlying bladder dysfunction is diagnosed by
urodynamic studies.
Neuropsychological testing may be indicated to
assess cognitive impairment.
 Multiple Sclerosis
Medical Management
 No cure exists for MS.
 The goals of treatment are to:
 delay the progression of the disease,
 manage chronic symptoms, and
 treat acute exacerbations.
 Many patients with MS have stable disease.
 Symptoms requiring intervention.
 Management strategies target the various motor
and sensory symptoms and effects of immobility
that can occur.
 Multiple Sclerosis
Nursing Management
 Assessment
 Assess actual and potential problems associated
with the disease, including neurologic problems,
secondary complications, and the impact of the
disease on the patient and family.
 The patient’s movements and walking are observed
to determine if there is danger of falling.
 Assess when the patient is well rested and when
fatigued. The patient is assessed for weakness,
spasticity, visual impairment, incontinence, and
disorders of speech.
 Additional areas of assessment include the
following:
 How has MS affected the patient’s lifestyle?
 How well is the patient coping?
 Multiple Sclerosis
Nursing Management
Nursing Diagnosis
Impaired physical mobility related to weakness,
muscle paresis, spasticity.
Risk for injury related to sensory and visual
impairment.
Impaired urinary and bowel elimination
(urgency, frequency, incontinence, constipation)
related to nervous system dysfunction.
Impaired speech and swallowing related to
cranial nerve involvement.
 Multiple Sclerosis
Nursing Management
 Nursing Diagnosis
 Disturbed thought processes (loss of memory,
dementia, euphoria) related to cerebral
dysfunction.
 Ineffective individual coping related to MS
 Impaired home maintenance management
related to physical, psychological, and social
limits imposed by MS
 Potential for sexual dysfunction related to
spinal cord involvement or psychological
reactions to condition
 Multiple Sclerosis
Nursing Management
 Planning and Goals
The major goals for the patient may include:
 Promotion of physical mobility
 Avoidance of injury
 Achievement of bladder and bowel continence
 Promotion of speech and swallowing mechanisms
 Improvement of cognitive function
 Development of coping
 Improved home maintenance management
 Adaptation to sexual dysfunction.
 Multiple Sclerosis
Nursing Management
Nursing Care:
Promoting physical mobility
Encourage exercises
Minimizing spasticity and contractures
Encourage activity and rest
Minimizing effects of immobility
Preventing injury.
Enhancing bladder and bowel control
Managing speech and swallowing difficulties
Improving sensory and cognitive function
Strengthening coping mechanism

 Bell’s Palsy
Bell’s palsy (facial paralysis) is due to unilateral
inflammation of the seventh cranial nerve, which
results in weakness or paralysis of the facial muscles
on the affected side.

The cause is unknown, although possible causes may

include vascular ischemia, viral disease (herpes
simplex, herpes zoster), autoimmune disease, or a
combination of all of these factors.

The incidence is 13 to 34 cases per 100,000; it increases

with age and among pregnant women in the third
trimester.
 Bell’s Palsy:
S&S
Bell’s palsy is represent a type of pressure paralysis.
The inflamed, edematous nerve becomes compressed,
or its nutrient vessel is occluded, producing ischemic
necrosis of the nerve.
There is distortion of the face from paralysis of the
facial muscles.
Increased lacrimation (tearing), the eye does not
close completely and the blink reflex is diminished.
Painful sensations in the face, behind the ear, and in
the eye.
Speech and swallow difficulties, loss of taste and
unable to eat on the affected side because of weakness
or paralysis of the facial muscles.
 Bell’s Palsy:
Medical Management
The objectives of treatment are to maintain the muscle
tone of the face and to prevent / minimize denervation.
The patient should be reassured that no stroke has
occurred and that spontaneous recovery occurs within
3 to 5 weeks in most patients.
Early administration of corticosteroid therapy appears
to diminish the severity of the disease, reduce
inflammation and edema; this reduces vascular
compression and permits restoration of blood
circulation to the nerve, relieve the pain, and minimize
denervation.
 Bell’s Palsy:
Medical Management
Facial pain is controlled with analgesic agents.
Heat may be applied to the involved side of the face to
promote comfort and blood flow through the muscles.
Electrical stimulation may be applied to the face to
prevent muscle atrophy.
Surgical exploration of the facial nerve may be
indicated in patients who are suspected of having a
tumor or for surgical decompression of the facial nerve
and for surgical treatment of a paralyzed face.
 Bell’s Palsy:
Nursing Management
The involved eye must be protected during the day.
Frequently, the eye does not close completely and the
blink reflex is diminished, so the eye is vulnerable to
dust and foreign particles.
Corneal irritation and ulceration may occur if the eye
is unprotected. Distortion of the lower lid alters the
proper drainage of tears.
To prevent injury, the eye should be covered with a
protective shield at night.
The application of eye ointment at bedtime causes the
eyelids to adhere to one another and remain closed
during sleep.
 Bell’s Palsy:
Nursing Management
When the patient can tolerate touching the face, the
nurse can suggest massaging the face several times
daily, using a gentle upward motion, to maintain
muscle tone.
Facial exercises, such as wrinkling the forehead, and
blowing out the cheeks, may be performed to prevent
muscle atrophy.
Exposure of the face to cold is avoided.
Monitor for aspiration of food/fluids; diet education
for client.
Monitor intake to assure adequate nutrition.
 Epilepsies
Seizure defined as episodes of abnormal motor,
sensory, autonomic {involuntary}, or psychic
activity or combination of these that result from
sudden excessive discharge from cerebral
neurons.
The syndrome of recurrent, unprovoked seizures
is termed Epilepsy.
The onset of epilepsy occurs before the age of 20
years in greater than 75% of patients.
 Epilepsies
Causes
Epilepsy can be primary (idiopathic) or
secondary, when the cause is known and the
epilepsy is a symptom of another underlying
condition such as a brain tumor.
Epilepsy can follow birth trauma, head injuries,
some infectious diseases (bacterial, viral,
parasitic), toxicity (carbon monoxide and lead
poisoning), circulatory problems, fever,
metabolic and nutritional disorders, and drug or
alcohol intoxication.
It is also associated with brain tumors,
abscesses, and congenital malformations.
 Epilepsies
Clinical Manifestation:
Depending on the location of the discharging
neurons, seizures may range from a simple
episode to prolonged convulsive movements
with loss of consciousness.
In simple partial seizures, only a finger or hand
may shake, or the mouth may jerk
uncontrollably.
The person may talk unintelligibly, may be
dizzy, and may experience unusual or unpleasant
sights, sounds, odors, or tastes, but without loss
of consciousness.
 Epilepsies
Clinical Manifestation:
In complex partial seizures, the person may
experience excessive emotions of fear, anger or
irritability.
Whatever the manifestations, the person does
not remember the episode when it is over.
Alter state of consciousness after seizure usually
lasts 5-30 min
Patient may experience different symptoms such
as:
drowsiness, confusion, nausea, hypertension,
headache, fatigue and depression
 Epilepsies
Clinical Manifestation:
In generalized seizures there may be intense rigidity of the
entire body followed by alternating muscle relaxation and
contraction (generalized tonic–clonic contraction).
The tongue is often chewed.
The patient is incontinent of urine and stool.
After 1 or 2 minutes, the convulsive movements begin to
subside; the patient relaxes and lies in deep coma,
breathing noisily & chiefly abdominal.
After the seizure the patient is often confused and hard to
arouse and may sleep for hours.
Many patients complain of headache, fatigue, and
depression.
Tonic–Clonic Contraction
 Epilepsies
Diagnostic Investigation:
It include biochemical and hematologic studies.
MRI is used to detect lesions in the brain, focal
abnormalities, cerebrovascular abnormalities.
Electroencephalogram (EEG) aids in classifying
the type of seizure.
CT
Telemetry and computerized equipment are used
to monitor electrical brain activity and
determining the type of seizure as well as its
duration
Video recording of seizures taken with EEG.
 Epilepsies
Medical management
• Pharmacologic therapy: antiseizure
• Tegretol
• Phenoparbital
• Phenytoin ( Dilantin)
• Valporate (Topamax)
The objective is to achieve seizure control with
minimal side effects. Medication therapy
controls rather than cures seizures.
Medications are selected on the basis of the type
of seizure
 Epilepsies
Surgical management:
Surgery is indicated for patients whose epilepsy
results from intracranial tumors, abscess, cysts, or
vascular anomalies.
Some patients have intractable (severe) seizure
disorders that do not respond to medication. There
may be a focal atrophic process secondary to trauma,
inflammation, stroke, or anoxia (an absence of oxygen).
As an adjunct to medication and surgery in adults
with partial seizures, a generator may be implanted
under the clavicle. The device is connected to the
vagus nerve in the cervical area, where it delivers
electrical signals to the brain to control and reduce
seizure activity
 Epilepsies
Assessment :
The diagnostic assessment is aimed at
determining the type of seizures, their frequency
and severity, and the factors that precipitate them.
A developmental history is taken, including events
of pregnancy and childbirth, to seek evidence of
preexisting injury.
The patient is also questioned about head injuries
that may have affected the brain.
 Epilepsies
Nursing Care During a Seizure
Provide privacy and protect the patient from curious
on-lookers.
(The patient who has an aura [warning of an
impending seizure] may have time to seek a safe,
private place.)
Ease the patient to the floor, if possible.
Protect the head with a pad to prevent injury (from
striking a hard surface).
Loosen constrictive clothing and loosen tight clothes
around neck
Push aside any furniture that may injure the patient
during the seizure.
 Epilepsies
Nursing Care During a Seizure
Clear the area around patient from any hazard
If patient fall on the floor put something soft under
his head to prevent him from banging the floor.
If the patient is in bed, remove pillows and raise side
rails.
If an aura precedes the seizure, insert an oral airway
to reduce the possibility of the tongue or cheek being
bitten.
Do not attempt to pry open jaws that are clenched in
a spasm to insert anything. Broken teeth and injury to
the lips and tongue may result from such an action.
 Epilepsies
Nursing Care During a Seizure
If possible, place the patient on one side with
head flexed forward, which allows the tongue to
fall forward and facilitates drainage of saliva and
mucus.
Don’t try to remove secretion until seizure end
No attempt should be made to restrain the patient
during the seizure because muscular contractions
are strong and restraint can produce injury.
Don’t give any food, fluid or medications orally
 Epilepsies
Nursing Care After a Seizure
Keep the patient on one side to prevent aspiration. Make
sure the airway is patent.
There is usually a period of confusion after a grand mal
seizure.
A short apneic period may occur during or immediately
after a generalized seizure.
The patient, on awakening, should be reoriented to the
environment.
If the patient becomes agitated after a seizure, use gentle
restraint.
Check for any injuries and level of consciousness
Don’t give any fluid or food orally till you make sure patient
got back gag reflex
 Epilepsies
Nursing Diagnosis
Fear related to the possibility of seizures
Risk for injury related to seizure activity
Ineffective individual coping related to stresses
imposed by epilepsy
Deficient knowledge related to epilepsy and
its control
 Epilepsies
Nursing Intervention:
Reducing fear of seizures
Preventing injury
Improving coping mechanisms
Providing patient and family education
Monitoring and managing potential
complications
Teaching Patients Self-Care
 Status Epilepticus
Status Epilepticus: series of generalized seizure
that occur without full recovery of consciousness
between attacks.
The vigorous muscular contraction during the
series of seizure impose heavy metabolic demands
and interferes with respiration
May lead to brain damage because of brain
hypoxia .