1. Nursing management of Myasthenia Gravis
Today’s topic is Nursing Management for clients with myasthenia gravis.

2. Pathophysiology – Myasthenia Gravis (MG)
A chronic progressive disorder of the peripheral nervous system affecting transmission of nerve impulses to voluntary muscles
Etiology: unknown
An autoimmune process triggers formation of autoantibodies that decrease number of acetylcholine receptors and widen gap between axon ending and muscle fiber in neuromuscular junction

3. Pathophysiology
Muscle contraction is hindered because IgG autoantibodies prevent acetylcholine from binding with receptors at neuromuscular junction
Onset is slow precipitated by emotional stress, hormonal disturbance (pregnancy, thyroid disturbance), infection/vaccination, trauma, surgery, temp extremes, excessive exercise

4. Etiology
Associated with continued production of autoantibodies by thymus gland in 75% of cases
family history of autoimmune disorders are implicated

5. Clinical Manifestations
Muscle weakness
Double vision (diplopia)
weak eyelids (unilateral ptosis)
Difficulty speaking or smiling
Difficulty chewing and swallowing

6. Specific clinical manifestations

7. Assessment of Labs/Diagnostics
Arterial Blood Gas & Pulmonary function tests
For respiratory compromise
Electromyography (EMG)
Decreased amplitude when motor neurons are stimulated
Confirming diagnosis
IV administration of edrophonium chloride (Tensilon)
Allows acetylcholine to bind with its receptors and temporarily improves symptoms
Weakness returns after effects of Tensilon are discontinued

8. Problems with MG Ineffective airway clearance
Impaired verbal communication
Activity intolerance

9. Interventions
Focuses on medication management with anticholinesterases
neostigmine (Prostigmin)
pyridostigmine (Mestinon)
Immunosuppressant
corticosteroids, azathioprine (Imuran), and cyclosporine (Neoral)
Anti-inflammatory medications
Thymectomy
Plasmapheresis
Removes IgG (antiacetylcholine) antibodies
Atropine sulfate for cholinergic crisis

10. Interventions
Maintain effective breathing pattern and airway clearance
Assess for respiratory distress
Monitor meals and teach client to bend head slightly forward while eating and drinking to improve swallowing
Teach client to avoid exposure to infections
Teach client to effectively coughing, use chest physiotherapy and incentive spirometry
Provide adequate nutrition
Schedule meds minutes before eating for peak muscle strength
Offer food frequently in small amounts that are easy to chew and swallow (soft or semisolid)
Promote improved physical mobility with referrals to physical therapy and/or occupational therapy
Provide eye care: instill artificial tears; use a patch over one eye for double vision; wear sunglasses to protect eyes from bright lights

11. Client education Take medication on time and keep prescriptions filled
Plan rest periods and conserve energy, plan major activities early in day, schedule activities during peak medication effect
Avoid extremes of hot and cold, exposure to infections, emotional stress and meds that may worsen or precipitate an exacerbation (alcohol, sedatives, and local anesthetics)
Recognize and report signs of crises
Use alternative methods of communication if needed

12. Evaluation: Desired Outcomes
Maintain Muscle function
Minimize side effects of medications
Minimize complications of MG (myasthenic or cholinergic crises)
Maintain quality of life

13. Comparison of myasthenia and cholinergic crises
Myasthenia Crisis
Cholinergic Crisis
Failure to take medication as prescribed or medication too low
Over dose of anticholinesterase medications resulting in increased Acetylcholine at the receptor sites

14. Evaluation Maintain optimal muscle function
Be free from side effects of medications
Client maintains patent airway and breathing without aspiration
Maintain activities of daily living with assistance
Demonstrates adequate coping skills for managing chronic and debilitating illness

15. References
Rangel-Castillo, L, Gopinath, S., & Robertson, C.S. (2009). Management of intracranial hypertension. Neurologic Clinics, 26(2),
Ignatavicius, D. D. & Workman, M. L. (2010). Medical-surgical nursing: patient-centered collaborative care (6th ed.). St. Louis, MO: Saunders Elsevier.
Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., & Bucher, L. (2014). Medical-surgical nursing: Assessment & management of client problems (9th ed.). St. Louis, MO: Mosby
Hogan, M., Dentlinger, N.C., & Ramdin, V. (2014). Medical- surgical: nursing pearson nursing reviews and rationales (3rd ed.). Boston, MA: Pearson.