The levels of recommendation (1-3) and the levels of evidence supporting the recommendations (I-IV) are defined at the end of the "Major Recommendations" field.
Definition, Natural History, and Epidemiology of Multiple Sclerosis (MS)
The model of nursing care in MS includes establishing, continuing, and sustaining care along the MS spectrum of new or probable MS, relapsing forms of MS, progressive MS, and advanced MS (Level 3). Nurses should facilitate treatment and symptom management, promote and enhance function, and support a quality of life (QOL) of adults with MS and their family-care partners that is wellness focused (Level 3). Nurses use evidence-based knowledge to determine an effective course of action for MS patients with specific needs (Level 2). Nurses act as advocates to ensure that patients and their family-care partners have access to needed care and assistance in using resources crucial to managing MS (Level 2). Nurses should help patients locate and develop appropriate resources and initiate contacts as needed (Level 2).
Classification of MS
Nurses caring for patients with MS need an understanding of the various types of MS and should be familiar with the typical clinical course of each type in order to:
- Provide explanations and initiate patient education and counseling for patients and their families
- Provide information and counseling to help patients and care partners develop a realistic picture of the disease, the benefits of treatment, and expectations related to its management
- Help patients and their families cope with a new diagnosis of MS, adopt a healthy lifestyle, and maintain a positive and hopeful perspective
- Emphasize health-promotion strategies and preventive health care and screening, including the importance of regular follow-up with their neurologist and other healthcare providers (Level 3).
Immunogenetics and Pathogenesis
Well-designed multidisciplinary research is needed for a more complete understanding of the pathophysiology of MS (Level 3).
Assessment and Diagnostic Process
A comprehensive assessment should be completed, including the following areas: physical, cognitive, sensory, and bowel and bladder function. The baseline functional assessment can be used to compare with future neurologic examinations (Level 2). For assessment of function, frequency of evaluation has not been extensively studied. Nurses should complete an initial assessment of function and monitor on an ongoing basis for any changes in condition (Level 3).
Nurses should familiarize themselves with published and ongoing research efforts in the area of biomarkers for MS disease diagnosis and progression to provide patient education regarding laboratory testing and respond to questions from patients (Level 3).
Management of MS
Nurses need to be aware of the mechanism of action of MS medications to educate and counsel patients about expected benefits and adverse effects of medication therapy (Level 3). Nurses need to be aware of the role of personal patient preference and drug regimen complexity related to tolerance of and willingness to adhere to treatment protocols (Level 2).
Nurses can serve as advocates for MS patients related to ensuring connection with medication support services (Level 2).
Immunotherapies Reveal Aspects of MS
Nurses must be aware of patient responsiveness to therapy and serve as advocates for follow-up with appropriate interdisciplinary team providers (Level 3). Nurses should monitor MS patients for medication-related side effects and use appropriate strategies to manage their manifestations (Level 2).
Clinical Features and Symptom Management
Clinical Features and Sensory Symptoms
The nurse should conduct intermittent assessment for pain, dysthesia, and spasticity (Level 2). Evaluate for the loss of neuroprotective sensation and the potential for pressure ulcer development (i.e., ensure full body assessment; Level 2). Evaluate the patient for triggering and alleviating factors (Level 2). Evaluate the effectiveness of pharmacologic therapies and advocate for evaluation by the interdisciplinary team (Level 1). Provide patient with emotional support and evaluate for anxiety (Level 2). Provide patient and family education related to availability of adjuvant treatment and possible surgical interventions; assess patient's willingness and readiness to incorporate alternative therapies into treatment regimen (Level 3).
Visual and Hearing Impairment
Encourage regular eye examinations (Level 3). Be aware of the potential for hearing changes and assess as needed (Level 3). Provide education regarding the patient’s particular visual and hearing symptom experience (Level 3). Support the patient as visual and hearing impairment may reduce overall function (Level 2). Promote safety through education and counseling related to effective lighting, scanning, and environmental modifications (Level 2).
Nurses should be aware of and assess for secondary causes of fatigue to include depression, medication side effects, pain, and sleep disorders (Level 2). Nurses should educate and counsel patients regarding energy conservation strategies, including the role of body temperature control (Level 2). The nurse should be aware of the optimal timing of medication administration to enhance energy level and to avoid interrupting sleep (Level 3).
Identify functional effect of impaired mobility and collaborate with interdisciplinary team members to promote optimal mobility within the patient’s limitations (Level 3). Evidence-based treatment interventions for mobility optimization include exercise promotion (Level 1). Educate patient and care partners regarding treatment, therapy recommendations, medications, and support adherence (Level 3). The nurse should encourage safety by reinforcing appropriate and safe use of adaptive equipment and aides (Level 2). Assess for the psychological effect of reduced mobility and/or increased disability (Level 2).
Bladder and Bowel Symptoms
Nurses should work with the patient, care partner, and other members of the interdisciplinary team to develop an appropriate bladder management program (Level 3). Assess all patients for urinary dysfunction and assess effectiveness of treatments or behavioral strategies over time (Level 3). Encourage discussion of symptoms and effect on QOL and role function and assist with coping strategies (Level 3). Assess for infection and assist in management strategies to reduce risk of infection, stone formation, or worsening of neurologic condition (Level 3).
Nurses should work with the patient, care partner, and other members of the interdisciplinary team to develop an appropriate bowel management program (Level 3). Assess all patients for disorders of bowel function and assess effectiveness of treatments or behavioral strategies over time (Level 3). Encourage discussion of symptoms and effect on QOL and role function and assist with coping strategies (Level 3). Assess for effectiveness of management strategies and effectiveness of medications, understanding that bowel interventions may take a long time to become effective and that worsening of symptoms without any relief from strategies may indicate disease progression (Level 3).
Sexual Dysfunction and Reproductive Issues
Nurses must consider MS patients' interest in sexuality and intimacy rather than assume that they are asexual or uninterested (Level 2). Nurses should provide information, education, counseling, and resources about issues related to sexuality, reproductive function, pregnancy, and parenting (Level 3).
Assess the patient regularly for swallowing difficulties (Level 2). Nurses should work with the patient, care partner, and other members of the interdisciplinary team to develop an appropriate dysphagia management program (Level 3). Monitor weight at each visit (Level 3). Educate and counsel the patient and care partner to reinforce safe swallowing practices (Level 3).
Nurses should work with the patient, care partner, and other members of the interdisciplinary team to develop an appropriate cognitive management program and reevaluate on an ongoing basis (Level 3). The nurse should screen for factors that could increase cognitive problems such as medications, sleep disturbance, inadequately treated pain, and other untreated symptoms (Level 2). Nurses need to recognize and acknowledge the distressing nature of cognitive deficits (Level 3). Patients should be provided with verbal and written instructions regarding the need to reduce distractions and implement safety measures (Level 3).
Nurses should work with the patient, care partner, and other members of the interdisciplinary team to manage depression appropriately (Level 2). Other roles are to assist patients and care partners to adjust to changes involved in living with MS (Level 2); identify the physical, emotional, spiritual, and educational needs of the patient and family (Level 2); reinforce the importance of medication regimen and be aware of medication side effects (Level 2); be alert to cues related to mood changes and treatment outcomes (Level 2); and encourage participation in a regular pattern of exercise to improve mood (Level 1).
Patient and Care Partner Education
Nurses should use an evidence-based and wellness-focused approach to education and counseling to assist patients with MS and their families to adhere to the treatment regimen, manage their symptoms, and cope with their chronic disease (Level 3). The nurse should screen for factors that could influence the ability to learn, such as cognitive difficulties and health literacy issues, and adapt teaching as appropriate (Level 2).
Levels of Evidence Supporting the Recommendations
Class I: Randomized controlled trial (RCT) without significant limitations or meta-analysis.
Class II: RCT with important limitations (e.g., methodological flaws or inconsistent results) or observational studies (e.g., cohort or case-control).
Class III: Qualitative studies, case study, or series.
Class IV: Evidence from reports of expert committees or expert opinion of the guideline panel, standards of care, and clinical protocols.
Levels of Recommendation
Level 1: Recommendations are supported by class I evidence.
Level 2: Recommendations are supported by class II evidence.
Level 3: Recommendations are supported by class III and IV evidence.