Understanding Myasthenia Gravis (MG):
- Gain knowledge about the pathophysiology, etiology, and clinical manifestations of Myasthenia Gravis to provide effective and individualized care.
Assessment of MG Symptoms and Severity:
- Develop skills in assessing MG symptoms, including muscle weakness, fatigue, and respiratory compromise. Learn to differentiate between myasthenic and cholinergic crises and assess their severity.
Medication Management:
- Understand the pharmacological interventions commonly used in MG treatment, such as acetylcholinesterase inhibitors and immunosuppressive drugs. Learn to administer medications, monitor for side effects, and educate patients on proper drug management.
Implementing Strategies for Energy Conservation:
- Develop strategies to help patients conserve energy and manage fatigue. Provide guidance on planning activities, rest periods, and adapting the environment to accommodate their energy levels.
Emergency Preparedness and Crisis Management:
- Acquire skills in recognizing and managing myasthenic crises or cholinergic crises promptly. Understand the importance of respiratory support and emergency interventions, including the use of intravenous immunoglobulins (IVIG) or plasmapheresis.

Pathophysiology of Myasthenia Gravis (MG)

Autoimmune Dysfunction:
- Myasthenia Gravis is an autoimmune disorder characterized by the production of autoantibodies, mainly against acetylcholine receptors (AChR) at the neuromuscular junction.
Impaired Neuromuscular Transmission:
- The binding of autoantibodies to AChR leads to a reduction in the number of functional AChR, disrupting neuromuscular transmission. This results in decreased responsiveness of muscle fibers to acetylcholine, the neurotransmitter responsible for muscle contraction.
Muscle Weakness and Fatigue:
- The impaired neuromuscular transmission causes muscle weakness, especially during repetitive or sustained activities. As the disease progresses, fatigue becomes a prominent symptom due to the inability of muscles to maintain contraction.
Thymus Involvement:
- Many individuals with MG have abnormalities in the thymus, ranging from thymic hyperplasia to thymoma. The thymus plays a role in the development of autoantibodies, contributing to the autoimmune response.
Variable Symptom Severity:
- The severity of MG symptoms can vary widely among individuals. Factors such as stress, illness, or certain medications can exacerbate symptoms. The disease can affect various muscle groups, including those involved in facial expression, swallowing, and breathing.

Etiology of Myasthenia Gravis (MG)

Autoimmune Origin:
- Myasthenia Gravis is primarily an autoimmune disorder where the immune system mistakenly targets and attacks its own tissues. In MG, autoantibodies, particularly against acetylcholine receptors (AChR) at the neuromuscular junction, are produced.
Acetylcholine Receptor Antibodies:
- The most common etiological factor is the production of antibodies directed against the acetylcholine receptors on the surface of muscle cells. These antibodies interfere with the normal transmission of nerve impulses to muscles.
Thymus Abnormalities:
- Abnormalities in the thymus gland are often associated with MG. This can include thymic hyperplasia (enlargement) or the presence of a thymoma (tumor). The thymus is involved in the development of immune cells, and its dysfunction contributes to the autoimmune response.
Role of Complement System:
- The complement system, a part of the immune system, is activated in MG. Complement-mediated damage to the neuromuscular junction exacerbates the disruption of signal transmission between nerves and muscles.
Genetic Predisposition:
- While the exact genetic factors contributing to MG are not fully understood, there is evidence of a genetic predisposition. Certain genetic variations may increase susceptibility to the development of autoimmune diseases, including MG.

Desired Outcome for Myasthenia Gravis (MG) Nursing Care

Improved Muscle Strength:
- The primary goal is to achieve enhanced muscle strength, allowing the patient to perform daily activities with minimal fatigue. Improvement in muscle strength contributes to a better quality of life.
Symptom Management:
- Effectively managing and reducing the symptoms of MG, such as muscle weakness and fatigue, is crucial. The aim is to minimize the impact of the condition on the patient’s daily functioning.
Prevention of Myasthenic Crises:
- Prevention of myasthenic crises, which are severe episodes of muscle weakness that can compromise vital functions like breathing and swallowing, is a critical outcome. This involves close monitoring and prompt intervention to avoid crises.
Medication Adherence:
- Encouraging and ensuring medication adherence is vital for controlling MG symptoms. Achieving a stable medication regimen helps maintain neuromuscular function and prevent exacerbations.
Optimal Respiratory Function:
- Ensuring optimal respiratory function is essential, especially for patients with respiratory muscle involvement. The goal is to prevent respiratory complications, enhance lung capacity, and maintain adequate oxygenation.

Myasthenia Gravis (MG) Nursing Care Plan

Subjective Data:

Double vision
Weakness/fatigue
Dysphagia
Dyspnea

Cholinergic Crisis

Muscle cramps
Nausea

Myasthenic Crisis

Sudden, severe weakness

Objective Data:

Ptosis (drooping eyelid)
Tachypnea
Abnormal ABG
Diminished breath sounds or crackles due to atelectasis

Cholinergic Crisis

Vomiting, diarrhea
Bradycardia
Bronchial spasm
Hypotension

Myasthenic Crisis

Increased HR, RR, BP
Hypoxia and cyanosis
Bowel and Bladder incontinence

Nursing Assessment for Myasthenia Gravis (MG)

Clinical History:
- Obtain a detailed medical history, including the onset and progression of symptoms, previous diagnoses, and any known triggers or exacerbating factors.
Symptomatology Assessment:
- Evaluate the patient for common MG symptoms, such as muscle weakness, fatigue, diplopia (double vision), ptosis (drooping eyelids), difficulty in chewing and swallowing, and respiratory distress.
Muscle Strength and Function:
- Conduct a thorough examination of muscle strength and function, assessing different muscle groups. Use standardized scales like the Myasthenia Gravis Foundation of America (MGFA) classification for grading severity.
Respiratory Assessment:
- Assess respiratory function, especially focusing on signs of respiratory distress. Monitor respiratory rate, depth, and auscultate breath sounds for any abnormalities.
Neurological Examination:
- Perform a comprehensive neurological assessment, including cranial nerve examination, reflexes, sensation, and coordination. Note any abnormalities that may indicate neurological involvement.
Swallowing and Speech Assessment:
- Evaluate the patient’s ability to swallow and speak. Assess for dysphagia and any changes in speech patterns, as these can be affected in MG.
Activities of Daily Living (ADLs):
- Assess the impact of MG on the patient’s ability to perform daily activities, including self-care, mobility, and independence. Identify any limitations or challenges.
Medication History:
- Gather information about the patient’s current medications, including prescribed treatments for MG. Ensure awareness of medication adherence, possible side effects, and any adjustments made in the treatment plan.

Implementation for Myasthenia Gravis (MG)

Medication Administration:
- Administer prescribed medications, such as acetylcholinesterase inhibitors (e.g., pyridostigmine) and immunosuppressants (e.g., corticosteroids or other immunomodulating drugs), as per the physician’s orders. Ensure strict adherence to the medication schedule.
Respiratory Support:
- Monitor respiratory status closely, especially in patients with respiratory muscle weakness. Implement respiratory support measures as needed, such as assisted ventilation or mechanical ventilation in severe cases.
Energy Conservation Strategies:
- Collaborate with the patient to develop energy conservation strategies. Advise on pacing activities, scheduling rest periods, and prioritizing tasks to prevent excessive fatigue.
Mobility Assistance:
- Provide assistance with mobility and activities of daily living (ADLs) as needed. Implement measures to prevent falls and injuries, considering the impact of muscle weakness on the patient’s physical abilities.
Education and Emotional Support:
- Educate the patient and their family about MG, its management, and the importance of medication adherence. Offer emotional support and resources for coping with the psychological impact of chronic illness. Encourage communication with support groups or counseling services.

Nursing Interventions and Rationales

Administer cholinesterase inhibitors (Physostigmine) and ensure proper dosing/timing

The goal is to have a net increase of acetylcholine activity at the nerve synapses. This should help improve the conduction of impulses within the muscles.

Monitor respiratory status

Patients are at high risk for respiratory distress due to muscle weakness and dysphagia (aspiration)

Provide eye care

Ptosis and weakness of eye muscles can cause dryness and irritation of the eyes. Provide eye drops or an eye patch as appropriate.

Monitor feeding and ensure proper nutrition. Schedule meds 30-45 minutes before meals

Weakness and dysphagia make preparing and eating meals more and more difficult as the disease progresses. Scheduling meds 30-45 minutes before meals helps to minimize their symptoms as much as possible during mealtimes.

Maintain suction and emergency equipment.

Because of the risk of respiratory depression – this is especially important to have at the bedside when administering a Tensilon test because it can send the patient into V-Fib or cardiac arrest, or can make the cholinergic crisis worse, leading to respiratory distress or respiratory arrest. Ensure the suction regulator is functioning and the ambu bag is available.

Educate patient to identify and avoid triggers

This may include temperature extremes, stress, drugs, alcohol, infection, or caffeine. They should avoid any known triggers as much as possible.

Educate the patient on s/s of cholinergic and myasthenic crisis to report to the provider.

Both cases can cause severe muscle weakness and respiratory depression. Early intervention to protect the patient’s airway is imperative.

Cholinergic Crisis
- Withhold medication
- Administer antidote – anticholinergic medication
- Ventilatory support

A cholinergic crisis can be caused by taking too much medication or can occur after a dose adjustment.
Atropine may help but isn’t always enough – patients often need ventilatory support until the medication is out of their system.

Myasthenic Crisis
- Increase medication dose
- Ventilatory support

Myasthenic crisis is caused by having too little medication and is essentially an exacerbation of the disease.
Administer the missed dose or increase the dosage per provider orders. Patients often still require ventilatory support until the medication is at a therapeutic level again.

Evaluation for Myasthenia Gravis (MG)

Symptom Assessment:
- Regularly assess the patient for changes in MG symptoms, including muscle weakness, fatigue, and respiratory distress. Use standardized tools to quantify symptom severity and track trends over time.
Medication Efficacy:
- Evaluate the effectiveness of prescribed medications by monitoring the patient’s response. Assess if there are improvements in muscle strength, reduction in myasthenic crises, and any side effects associated with the medications.
Respiratory Function:
- Continuously monitor respiratory function, especially in patients with respiratory muscle involvement. Assess the need for respiratory support and evaluate the effectiveness of interventions, such as mechanical ventilation or other respiratory assistance.
Functional Status:
- Assess the patient’s overall functional status and ability to perform activities of daily living (ADLs). Evaluate any changes in mobility, independence, and the impact of MG on the patient’s quality of life.
Patient and Family Feedback:
- Seek feedback from the patient and their family regarding their experience with MG management. Evaluate their understanding of the condition, adherence to the treatment plan, and the effectiveness of the strategies implemented. Address any concerns or challenges they may be facing.

References

https://emedicine.medscape.com/article/1171206-overview

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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.