Download Patient with Myasthenia Gravis

Running Head: Patient with Myasthenia Gravis
Patient with Myasthenia Gravis
Camille Cole
California State University, Stanislaus
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Running Head: Patient with Myasthenia Gravis
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Patient with Myasthenia Gravis
When Mr. Denver, a 58-year-old African American, was admitted to the hospital he
described having difficulty “getting enough air”, tires easily, reports food “getting stuck in his
throat”, and is having problems speaking clearly. He was diagnosed with myasthenia gravis
(MG) a few years ago which requires him to take pyridostigmine (Mestinon) and prednisone that
have given him a few symptoms. However, when he visited his daughter he felt severe weakness
in both his arms and had respiratory distress. Upon his physical examination they found jaw
muscle weakness, generalized weakness, shallow respirations, and was feeling tense and
anxious. Additional objective data showed his chest CT scan showed a large mediastinal mass,
possible thymoma as well as a pulmonary function test displaying decreased respiratory effort.
Myasthenia gravis is an autoimmune disease that affects the neuromuscular junction by
causing muscle weakness in certain skeletal muscles such as the ones moving the eyes,
swallowing, breathing, and speaking (Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2007).
In this disease antibody, nicotinicM, damages acetylcholine (ACh) receptors, thus making fewer
receptor sites available at the neuromuscular junction (Lewis et al, 2007). ACh is a
neurotransmitter that is responsible for peripheral and central nervous system functionalities
(Lehne, 2007). In the peripheral system this neurotransmitter is utilized for muscle activity as a
part of the autonomic system and for anti-excitatory purposes for the central nervous system
(Lehne, 2007). Without enough receptors this disallows Ach binding that is necessary for
muscle contraction resulting in muscle weakness. The muscles regarding the movements of
actions above can fluctuate with distinct symptoms. For example, the eyes can impair facial
expressions, it may be difficult to swallow or chew food, and speech may fade during
conversation (Lewis et al, 2007).
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In Mr. Tucker’s subjective data he stated he was experiencing various problems affecting
his ability to breath properly, eat, speak, and tires effortlessly. These are all signs of an
exacerbation, when someone who has myasthenia gravis, that is called myasthenia crisis.
Typical triggers of this exacerbation include infection, surgery, secondary illness, elevated
temperature, hypokalemia, inadequate drugs, drug overdose, and emotional stress (Lewis et al,
2007). The drugs that can alter the state of myasthenia gravis are aminoglycoside antibiotics,
procainamide, guanidine, beta-adrenergic blockers, phenytoin, psychotropics, and neuromuscular
blocking agents (Lewis et al, 2007). He has not had recent surgery and is not taking any of the
medications that aggravate MG. Mr. Tucker’s labs should be reviewed for signs of infection
(high white blood cell), electrolyte imbalance (potassium), and vital signs (rise in temperature).
His medication pyridostigmine (Mestinon) and prednisone may need adjustment if they are the
root of the cause of his therapy being inadequate or overstepping their therapeutic range into
overdose. The CT scan revealed a mediastinal mass, possible thymoma which MG patients can
acquire; a tumor located in the thymus, therefore, an indicator of a secondary illness, but needs to
be biopsied and confirmed by a pathologist for malignancy (Lewis et al, 2007). He expressed
that he was feeling tense and anxious after, a plausible cause of emotional stress, which should
prompt the nurse to perform a psychosocial assessment, identify stressors in life, and provide
support during the nurses’ evaluation. This may cause further damage to the patient’s condition
and should be controlled. Finally his pulmonary function test presented decreased respiratory
effort. Untreated this predicament can lead to respiratory insufficiency, aspiration, and
respiratory infection (Lewis et al, 2007).
The priority treatment in regards to his current predicament of myasthenic crisis is to
supply oxygen through either nasal cannula or venturi mask; depending on his arterial blood gas
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level, pulse oximetry, and respiration rate. After establishing a functioning airway for the patient
the nurse can apply the control measures of his exacerbation. Most patients needing treatment for
this autoimmune disease will be on a collaboration of drugs such as anticholinesterase,
immunosuppressant, and corticosteroids that alternate each day (Lewis et al, 2007). Mr. Tucker
is taking pyridostigmine, a reversible cholinesterase inhibitor, in order to hinder the breakdown
of ACh and lengthen its effects to promote muscular activity (Deglin & Vallerand, 2009).
Prednisone, a short-acting corticosteroid, is being utilized for suppression of Mr. Tucker’s
immune system’s response by which it attacks itself (Deglin & Vallerand, 2009). Even with
being on two of the three drug therapies he has gone into myasthenic crisis most likely from his
mediastinal mass and his medication should continue to be administered. The mediastinal mass,
if confirmed a thymoma, can be treated by undergoing a thymectomy; removing the thymus
gland to diminish its ability to produce ACh receptors autoantibodies (Lewis et al, 2007). By
removing the source of the problem it can alleviate all of the underlying imbalances between the
neurotransmitter and the receptors. Another possible treatment could be plasmapheresis, the
process of removing plasma that is thought to be contributing to the disease and replaced with
other fluids (Lewis et al, 2007). The blood that is drawn out of the patient is broken down into
WBCs, RBCs, plasma, and platelets so that the plasma can be retained, then the original blood
draw is inserted back into the patient with normal saline or lactated ringers supplementing for the
removed plasma (Lewis et al, 2007). If his labs come back indicating infection then it will need
to be further assessed of where the infection is originating from, be given potassium supplements
or potassium enriched foods for hypokalemia, and an antipyretic if he has an elevated
temperature greater than 104 degrees. Based on the expected outcomes of this disease process
the patient should also be encouraged to ingest a well balanced meal that requires less chewing,
Running Head: Patient with Myasthenia Gravis
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feed him if necessary, have small servings, obtain plenty of rest, advise a consult with speech
therapist if it is affected, or occupational therapist if it interferes with his activities of daily living
(ADLs) (Potter & Perry, 2009).
MG can change the lifestyle of a person in many ways. As a nurse tends to this patient
they need to be aware of possible nursing diagnoses in order to provide the ultimate care.
Ackley and Ladwig have classified these as proper nursing diagnoses: ineffective airway
clearance, interrupted family processes, fatigue, impaired physical mobility, imbalanced
nutrition, impaired swallowing, risk for caregiver role strain, risk for impaired religiosity, risk for
compromised resilience, and readiness for enhanced spiritual well-being. The ineffective airway
clearance, impaired physical mobility can be related to muscle weakness by not being able to
cough or swallow as well as the possibility to experience ptosis, diminishing eye movements, or
weaken gaze to result in disturbed sensory perception (Lewis et al, 2007). The muscle
weakening in the larynx, lips, mouth, pharynx, and jaw can then impair verbal communication.
Without the ability to use the organs needed for mastication and swallowing, the patient has an
imbalanced nutrition by not ingesting enough of what the body requires (Ackley & Ladwig,
2008). The muscle weakness can exhaust the body to aching where the patient can experience
fatigue and the disease itself can change his life so that is interrupts his family process of visiting
his daughter, putting a strain on his role as care giver for his debilitating illness, and
compromising his resiliency because he knows the severity of it, especially now after
experiencing this complication (Ackley & Ladwig, 2008). Depending on Mr. Tucker’s religious
beliefs it is a possibility that his beliefs are impaired due to the fact that he experienced
something that could have been detrimental to his life or he could be ready to embrace it in his
life for the exact same reason (Ackley & Ladwig, 2008).
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Now that Mr. Tucker is being cared for in the hospital setting for an exacerbation of his
disease he will undergo serious therapeutic treatments to return his bodies functionalities back to
normal. These procedures will need to be discussed with him so that he understands the
reasoning, the benefits, and the risks. He also needs to be educated on what to do in the future as
he lives on with myasthenia gravis so that he may be able to live as normal of life as he possibly
can.
Running Head: Patient with Myasthenia Gravis
References
Deglin, J. H. & Vallerand, A. H. (2007) Davis’s Drug Guide for Nurses. Philadelphia, PA: F. A
Davis Company. 11th ed.
Lewis, S. L., Heitkemper, M. M, Dirksen, S. R., O’Brien, P. G, & Bucher, L. (2007) Medical
Surgical Nursing: Assessment and Management of Clinical Problems. St. Louis, MO:
Mosby Elsevier. 7th ed.
Ackley, B. J & Laswig, G.B. (2008) Nursing Diagnosis Handbook: An Evidenced-Based Guide
to Planning Care. St. Louis, Mo: Mosby Elsevier. 9th ed.
Potter, P. A. & Perry, A. G. (2009) Fundamentals of Nursing. St. Louis, MO: Mosby Elsevier.
7th ed.
Lehne, R. A. (2007). Pharmacology for Nursing Care. St. Louis, MO: Saunders Elsevier. 7th ed.
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NCLEX NEURO QUIZ
1.
A patient found in a tonic-clonic seizure reports afterward that the seizure was preceded by
numbness and tingling of the arm. The nurse knows that this finding indicates a(n) _____ seizure.
a. absence
b. simple partial
c. complex partial
d. generalized myoclonic
2. When obtaining a health history and physical assessment for a patient with possible multiple
sclerosis (MS), the nurse should
a. confirm patient information with family members.
b. ask about a recent history of temperature spikes.
c. question the patient about any leg weakness or spasm.
d. determine whether hypersexuality has caused problems.
3. The nurse identifies the nursing diagnosis of impaired physical mobility related to bradykinesia for a
patient with Parkinson’s disease. To assist the patient to ambulate safely, the nurse should
a. allow the patient to ambulate only with assistance.
b. instruct the patient to rock from side to side to initiate leg movement.
c. have the patient take small steps in a straight line directly in front of the feet.
d. teach the patient to keep the feet in contact with the floor and slide them forward.
4.
A patient with myasthenia gravis (MG) is admitted to the hospital with severe weakness and
acute respiratory insufficiency. The health care provider performs a Tensilon test to distinguish between
myasthenic crisis and cholinergic crisis. During the test, it will be most important to monitor the
patient’s
a. pupillary size.
b. muscle strength.
c. respiratory function.
Running Head: Patient with Myasthenia Gravis
d. level of consciousness (LOC).
5. A patient with restless legs syndrome (RLS) tells the nurse, “My leg pain and twitching keep me
awake so much of the night, I am tired most of the day. Is there anything I can do?” Based on this
information, which nursing diagnosis is most appropriate?
a. Ineffective role performance related to fatigue
b. Chronic pain related to RLS
c. Anxiety related to lack of knowledge about RLS treatment
d. Sleep deprivation related to leg pain and involuntary movement
6. A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing
action will be included in the plan of care?
a. Observing for agitation and paranoia
b. Assisting the patient with active range of motion (ROM)
c. Using simple words and phrases to explain procedures
d. Administer muscle relaxants as needed for muscle spasms
7.
A hospitalized 24-year-old patient with a history of cluster headache awakens during the night
with a severe stabbing headache. Which action should the nurse take first?
a. Notify the patient’s health care provider immediately.
b. Start the ordered PRN oxygen at 9 L/min.
c. Give the ordered prn acetaminophen (Tylenol).
d. Put a moist hot pack on the patient’s neck.
MULTIPLE RESPONSE
8. When preparing to admit a patient who has been treated for status epilepticus in the emergency
department, which equipment should the nurse have available in the room? (Select all that apply.)
a. Suction tubing
b. Oxygen mask
c. Nasogastric tube
d. Siderail pads
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Running Head: Patient with Myasthenia Gravis
e. Tongue blade
f.
Oral airway
9.
A patient with Parkinson’s disease is admitted to the hospital for treatment of an acute
infection. Which nursing interventions will be included in the plan of care? (Select all that apply.)
a. Cut patient’s food into small pieces.
b. Provide high protein foods at each meal.
c. Observe for sudden exacerbation of symptoms.
d. Remind the patient to keep eyes ahead when ambulating.
e. Place an arm chair at the patient’s bedside.
f.
Use an elevated toilet seat.
10.
A 42-year-old patient who was adopted at birth is diagnosed with early Huntington’s disease
(HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide
information about the
a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms.
b. need to take prophylactic antibiotics to decrease the risk for pneumonia.
c. lifestyle changes, such as increased exercise, that delay disease progression.
d. availability of genetic testing to determine the HD risk for the patient’s children.
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