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Myasthenia gravis (MG) is an autoimmune disorder affecting the voluntary muscles. Like other autoimmune conditions, the body attacks its own by mistake. What happens in myasthenia gravis is that the immune system hinders the neuromuscular impulses that are necessary for muscular function.

Based on several researches, it occurs at any age, but it is common in young women and older men in their 50’s. Sad to say, there is no definitive reason for MG, aside from theories regarding depletion of hormone acetylcholine and the possibility for tumor growth in the thymus gland.

Management for myasthenia gravis can turn out to be supportive in nature since its symptoms may vary depending on certain factors. There could be remissions but exacerbations may also happen due to under or overdoses of medications. Up to now, there is no cure for it. But according to some experts, proper treatment can lead to longer remissions without any symptoms.

Assessment

     Nursing management on myasthenia gravis routinely requires assessment of muscular strength. It has to be accompanied with careful and individualized plan of care since muscle weakness is worsened when the body is put into exertion especially during its exacerbation state.

A healthcare provider can assess the following clinical manifestations:

– Ptosis (often the most common initial symptom)
– Diplopia
– Blank affect or expressionless face
– Facial drooping, facial paralysis
– Tendency of the mouth to hang open (often associated with saliva drooling)
– Dysphagia , also difficulty in chewing, swallowing, and gagging
Risk for choking
– Hoarseness or change in voice (phony or nasal)
– Increasing muscle weakness with sustained contractions
– Difficulty in maintaining steady gait, climbing stairs, lifting objects
– Easy fatigability
– Respiratory muscle involvement causing distress and dyspnic episodes

Common Nursing Diagnoses

– Fatigue
– High risk for aspiration
– High risk for ineffective airway clearance
– High risk for ineffective breathing pattern
– Impaired swallowing
– Risk for fluid volume deficit
– Risk for imbalanced nutrition less than body requirements
– Impaired physical mobility
– High risk for disuse syndrome
– Urinary incontinence
– Bowel incontinence
Diarrhea
– High risk for injury
Risk for infection
– Fear
– Hopelessness
– Caregiver role strain

Planning / Implementation

  • Assist in the conduct of Tensilon test. It is a procedure done to diagnosis the client for myasthenia gravis. Atropine is usually given prior to test to prevent the client from experiencing discomforts during the procedure. The drug edrophonium is injected intravenously and after a minute or two, if the client feels an improvement in his muscles or in some, the symptoms worsen especially if during cholinergic crisis, the result is then drawn.

Tensilon test helps differentiate MG from other neurologic conditions. It can be done repeatedly to confirm the diagnosis.

  • Strictly administer medications at the right dose and the right time to avoid exacerbations (under and over doses can both produce harmful scenario to the client).
  • Administer anticholinesterase drugs such as Mestinon and Neostigmine and corticosteroid medication.
  • Assist client during plasmapheresis.
  • Provide scheduled adequate resting periods for the client.
  • Limit (emotional or physical) stressful activities as it could aggravate the symptoms.
  • Expose client to a quiet and peaceful environment, free from extreme temperatures.
  • Assist client in her basic needs and daily activities; eating, moving around, etc.
  • Secure emergency cart or intubation set, suctioning machine and catheters at bedside.
  •  Educate client and family about the condition and compliance to treatments and necessary procedures.
  • Encourage the use of adaptive devices to prevent client from injury.
  • Assist client in daily supportive exercises.
  • Refer client to physical therapists for appropriate exercises regimen.
  • Encourage client to be involve in support groups and community dealing with myasthenia crisis.
  • Watch out for signs and symptoms of exacerbations:

Myasthenia Crisis

– Increase in vital signs: tachycardia, tachypnea, high blood pressure
– Cyanosis, restlessness
– Increased secretions
– Bowel and urinary incontinence

Cholinergic Crisis

– Hypotension
– Facial muscle twitching and blurring of vision
– Nausea and vomiting and excessive pulmonary secretion
– Dysphagia accompanied by difficulty in chewing, speaking and breathing

During myasthenia crisis, the nurse should:

– Administer anti-cholinergic medication as ordered.
– Assess and reassess respiratory status.
– Clear airway through thorough suctioning
– Administration of supplemental oxygen as advised
– Attach to ventilator assistance if necessary.

During cholinergic crisis, the nurse should:

–  Hold cholinergic drugs as it could exacerbate the situation.
–  Ensure airway clearance through prompt and thorough suctioning
–  Administer supplemental oxygen and ventilation assistance as needed
–  Strictly monitor hypotension

 

References:

A.D.A.M.S. Medical Encyclopedia. (June 2011). Myasthenia Gravis. Retrieved last August 28, 2012 from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001731/
Palandri, M. K. & Sorrentino, C.R. (1993). Pocket Companion for Luckman and Sorrentino’s Medical – Surgical Nursing: A Psychophysiologic Approach 4th Edition. W.B. Saunders Company.

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A dedicated registered nurse who loves to view life as a revolving conundrum with spectacles of light and an aspiring writer who wants to share her expertise and experience in the nursing profession. She had pursued continuing education specializing in Psychiatric Nursing but had her practice on MNCHN.