Watch More! Unlock the full videos with a FREE trial
Add to Study plan
Master
Included In This Lesson
Study Tools
Myasthenia Gravis Patho Chart (Cheat Sheet)
Example Care Plan_Myasthenia Gravis (MG) (Cheat Sheet)
Blank Nursing Care Plan_CS (Cheat Sheet)
Myasthenia Gravis (Image)
Access More! View the full outline and transcript with a FREE trial
Transcript
This is the care plan for my myasthenia gravis. So the pathophysiology behind myasthenia gravis is a chronic progressive disorder that is characterized by decreased acetylcholine activity in the synapses. This is due to insufficient acetylcholine from an excessive secretion of acetylcholinesterase, which is the enzyme that inactivates acetylcholine. This causes a decrease in effective transmission of the nerve impulses in the muscles. It causes weakness and fatigue, especially in the respiratory muscles. So nursing considerations, these are some things that we want to just be mindful of when we are taking care of these patients. First thing we want to do is to assess the airway. The airway is very important to have a grasp on. We want to make sure that we can differentiate between a cholinergic crisis and a myasthenic crisis. And we would like to take care of the aspiration risk because these patients are at risk for aspiration.
The desired outcome is we want these patients to have preserved functional ability. We want to protect the airway and prevent complications such as my student crisis or call an energy crisis on this slide. This slide is just giving you a little information about our cholinergic crisis versus myasthenic crisis. They look very similar, but they are different. The way we differentiate is we do something called a tensilon test. A tensilon test is when we give edrophonium. And if the symptoms improve temporarily the weakness, the muscle weakness, then the diagnosis for myasthenic is positive. If we give it and they get worse, if we give the edge of Folium and it gets worse than that means the patient does not have my stadia, they are in a cholinergic crisis. The antidote for the edrophonium is atropine. So just keep that in the back of your mind. Okay? So the subjective data, what are some things that the patient is going to present? How are they going to tell us, what are they seeing? How are they feeling? Well, this patient is going to have double vision. This patient is also going to complain of weakness or fatigue. This is going to be some dysphagia. So they're going to have some difficulty swallowing. So they're going to have some dysphasia, they're going to also have some difficulty breathing. They may have a cholinergic crisis. They are going to have some muscle cramps, nausea and a myasthenic crisis. They are going to have sudden severe weakness. Some objective data: they're going to have ptosis. And that is just droopy eyelids.
They are going to have some difficulty breathing, so their respirations are going to be up because the work of breathing is up. So they're going to have an increased respiratory rate. They're going to have an abnormal ABG. If you think about it, they're not able to get that full respiration. They're not able to expel all that air. So they're going to hold onto some of that CO2. The ABG is going to be a little off. They're going to have some diminished breath sounds or crackles. That'll be due to some atelectasis. Okay. If they are actually in a cholinergic crisis, there will be some vomiting and diarrhea. There's going to be bradycardia and hypotension. If they're in a myasthenic crisis, they're going to have increased heart rate. They're going to be tachycardic. Like I said, those respirations are going to be up and the BP is going to be up. The patient will have some hypoxia, low sats on the monitor. They're going to have some cyanosis, which is some bluing of the skin. They also will present with some bowel and bladder incontinence because those muscles are weak. They're not going to be able to control it.
The nursing interventions, what we want to do is we want to try to get this patient as close to their baseline before the symptoms of the myasthenia gravis has started to take effect. So in order to do that, we want to administer a cholinesterase inhibitor. Okay? The goal of this medication is to increase the net amount of acetylcholine activity at the nurse in absence. This is going to help improve conduction, and it's going to help the muscles have a little more strength. It's going to kind of combat some of that weakness. So that is a cholinesterase inhibitor. Okay. The next thing is we want to monitor respiratory status. So we want to monitor respiratory status. They are at high risk for respiratory distress due to muscle weakness and dysphagia. They can aspirate.
We are going to have a suction set up at bedside. Okay. We are going to make sure that these patients are prepared in the rooms in case of an emergency, because they are at a higher risk of aspiration and at a higher risk of respiratory distress. We're going to educate the patient on the signs and symptoms of cholinergic versus myasthenic crisis. Remember, we just went through those things and the cases can look very similar. Severe muscle weakness, respiratory depression, the most important thing is to protect the patient's airway. Intubation may be necessary.
They may require intubation. So we want to make sure that we're doing that. Okay. Here's the completed care plan. The path though, behind it on the key points is that this is a chronic progressive disorder. So progressive. It's going to continue to get worse, hopefully with the tensilon test, that we are going to be able to at least preserve some of that regular function. That's objective data that they are going to complain of. There's going to be sudden weakness. The weakness is going to be very sudden. They're going to have some dysphasia. They're going to have some difficulty swallowing. So you may hear some coughing when they take in liquids, dyspnea, some difficulty breathing because those muscles and the diaphragm that controls the lungs are going to be very weak. We're going to see on the monitor that they are going to have increased heart rate.
They're going to be tachycardic. The BP is going to be up there may also present with some droopy eyelids or ptosis, as well as some hypoxia. We're going to make sure we have suction at the bedside because this patient may go into V-fib and they may need some mechanical ventilation. I'm going to do a swallow evaluation because they are at high risk for aspiration due to their extreme muscle weakness. And we are going to evaluate this swallowing because they may need to go NPO. This was a lot of information. But know that we love you guys;go out and be your best self today. And, as always, happy nursing.
The desired outcome is we want these patients to have preserved functional ability. We want to protect the airway and prevent complications such as my student crisis or call an energy crisis on this slide. This slide is just giving you a little information about our cholinergic crisis versus myasthenic crisis. They look very similar, but they are different. The way we differentiate is we do something called a tensilon test. A tensilon test is when we give edrophonium. And if the symptoms improve temporarily the weakness, the muscle weakness, then the diagnosis for myasthenic is positive. If we give it and they get worse, if we give the edge of Folium and it gets worse than that means the patient does not have my stadia, they are in a cholinergic crisis. The antidote for the edrophonium is atropine. So just keep that in the back of your mind. Okay? So the subjective data, what are some things that the patient is going to present? How are they going to tell us, what are they seeing? How are they feeling? Well, this patient is going to have double vision. This patient is also going to complain of weakness or fatigue. This is going to be some dysphagia. So they're going to have some difficulty swallowing. So they're going to have some dysphasia, they're going to also have some difficulty breathing. They may have a cholinergic crisis. They are going to have some muscle cramps, nausea and a myasthenic crisis. They are going to have sudden severe weakness. Some objective data: they're going to have ptosis. And that is just droopy eyelids.
They are going to have some difficulty breathing, so their respirations are going to be up because the work of breathing is up. So they're going to have an increased respiratory rate. They're going to have an abnormal ABG. If you think about it, they're not able to get that full respiration. They're not able to expel all that air. So they're going to hold onto some of that CO2. The ABG is going to be a little off. They're going to have some diminished breath sounds or crackles. That'll be due to some atelectasis. Okay. If they are actually in a cholinergic crisis, there will be some vomiting and diarrhea. There's going to be bradycardia and hypotension. If they're in a myasthenic crisis, they're going to have increased heart rate. They're going to be tachycardic. Like I said, those respirations are going to be up and the BP is going to be up. The patient will have some hypoxia, low sats on the monitor. They're going to have some cyanosis, which is some bluing of the skin. They also will present with some bowel and bladder incontinence because those muscles are weak. They're not going to be able to control it.
The nursing interventions, what we want to do is we want to try to get this patient as close to their baseline before the symptoms of the myasthenia gravis has started to take effect. So in order to do that, we want to administer a cholinesterase inhibitor. Okay? The goal of this medication is to increase the net amount of acetylcholine activity at the nurse in absence. This is going to help improve conduction, and it's going to help the muscles have a little more strength. It's going to kind of combat some of that weakness. So that is a cholinesterase inhibitor. Okay. The next thing is we want to monitor respiratory status. So we want to monitor respiratory status. They are at high risk for respiratory distress due to muscle weakness and dysphagia. They can aspirate.
We are going to have a suction set up at bedside. Okay. We are going to make sure that these patients are prepared in the rooms in case of an emergency, because they are at a higher risk of aspiration and at a higher risk of respiratory distress. We're going to educate the patient on the signs and symptoms of cholinergic versus myasthenic crisis. Remember, we just went through those things and the cases can look very similar. Severe muscle weakness, respiratory depression, the most important thing is to protect the patient's airway. Intubation may be necessary.
They may require intubation. So we want to make sure that we're doing that. Okay. Here's the completed care plan. The path though, behind it on the key points is that this is a chronic progressive disorder. So progressive. It's going to continue to get worse, hopefully with the tensilon test, that we are going to be able to at least preserve some of that regular function. That's objective data that they are going to complain of. There's going to be sudden weakness. The weakness is going to be very sudden. They're going to have some dysphasia. They're going to have some difficulty swallowing. So you may hear some coughing when they take in liquids, dyspnea, some difficulty breathing because those muscles and the diaphragm that controls the lungs are going to be very weak. We're going to see on the monitor that they are going to have increased heart rate.
They're going to be tachycardic. The BP is going to be up there may also present with some droopy eyelids or ptosis, as well as some hypoxia. We're going to make sure we have suction at the bedside because this patient may go into V-fib and they may need some mechanical ventilation. I'm going to do a swallow evaluation because they are at high risk for aspiration due to their extreme muscle weakness. And we are going to evaluate this swallowing because they may need to go NPO. This was a lot of information. But know that we love you guys;go out and be your best self today. And, as always, happy nursing.
View the FULL Transcript
When you start a FREE trial you gain access to the full outline as well as:
- SIMCLEX (NCLEX Simulator)
- 6,500+ Practice NCLEX Questions
- 2,000+ HD Videos
- 300+ Nursing Cheatsheets
“Would suggest to all nursing students . . . Guaranteed to ease the stress!”
