-
cause
- autoimmune
- thymus gland continues to produce antibodies
- thymus tumor 15%
-
area affected
- nueuromuscular transmission of impulses are affected for voluntary muscles of the body
- upper body
-
pathophysiology
- impairs transmission of impulses due to lack of acetycholine
- chronic
- progressive-slow
- NO ATROPHY OR LOSS OF SENSATION
- remissions and exacerbations
-
sxs
- profound muscle weakness produced by repeated movements and will disappear following rest
- sleepy/mask face
- diplopia and ptosis
- impaired speech and dysphagia-paralysis of pharyngeal muscles
- advanced-resp. distress to failure
- bladder/bowel incontinence
- INTELLECT OK
- CONSCIOUSNESS OK
- NO LOSS OF SENSATION OR MUSCLE ATROPHY
-
diagnose
- history
- rest improve?
- Tensilon Test
-
treatment
- Mestinon
- prostigmin
- steriods
- plasmapharesis
- eye care
- rest and reduce stress-nsg care around rest
- conserve energy
-
comlications
- resp failure
- aspiration
- drug crisis
- myasthenia crisis
-
Tensilion Test
- will strengthen muscles for a short time, 5-10 min if the pt has myasthenia gravis
- given in a 2mg dose then an 8mg dose b/c of s/e such as bradycardia and bronchospasms
- -have ER equipment ready
-
anticholinesterase drugs
- inhibit the destruction of acetylcholine
- improves nerve impulses
- Mestinon (pyridostigmine bromide)=antimyasthemics
- -least toxic, most commonly used
- -30-60 mg dose Q3-4 hrs initially, onset 30-35 min, duration 3-6 hrs
- -maintenace dose is 600 mg/day
- -s/e: GI-cramps, N/V, diarrhea, excess salivation, anorexia. Bradycardia, bronchospasms, hypotension, profuse sweating, seizures-most likely drug overdose
- adverse reaction-cholinergic crisis
- -teaching: drug therapy is lifelong-take med b/f doing activities, take 30 min b/f meals so they have the strength to eat, take w/ food or milk to dec. GI s/e, use lomotil for cramping, Atropine antidote for drug induced bradycardia,take as ordered-too early=overdose>>cholinergic crisis, too late=MG crisis
-
myasthenic crisis
- undermedication
- missed doses'infections
sxs- inc BP, P, R, sudden motor weakness-inability to swallow, speak, ptosis, diplopia, DANGER-resp. arrest, aspiration
tx-inc dose of Mestinon, resp. support-watch for aspiration
-
cholinergic crisis
- overmedication
- remissions
- after thymectomy
- sxs: severe muscle weakness, GI-cramps, diarrhea, bronchial spasms, increased secretions, dec P (brady), vertigo
- tx: temporary D/C meds, resp. support, Atropine to dec salivation
- DG:weakness w/i 1 hr after taking drugs: Mestinon if too much
Tensilon no longer used to diagnose crisis b/c of inc risk of resp arrest during a crisis. When used if myasthenia crisis you have improved strength after giving Tensilon, and in cholinergic crisis you have weakness w/i 1 hr after taking Tensilon.
-
immunosuppressive drugs
- suppress the immune response and dec amount of blocking antibodies
- 80-90% have remission when taking these
- ex:
- ACTH
- corticosteroids-Prednisone oral, Solu-Medrol IV
- -sx may worsen for 7-10 days after starting
- nonsteroidal-Imuran, Cytoxan
- -takes 4-8 months to see effects
- -causes fetal deformities
-
plasmapharesis
- plasma exchange, temporarily decreases the number of circulating antibodies
- -removes components causing the problem, replace with NS, LR, FFP, or albumin and re-infuse-similar to dialysis
- -3-4 times over 8=10 days, takes 2-3 hrs each time'-usually used for crisis and prior to and after thymectomy
-
thymectomy
- remove thymus gland located in the mediastinum
- biggest problem postop is pulmonary complications-PN, atelectasis
- because it produces antibodies
- may have tumor here causing the problem
- effects may take up to 3 yrs b/c T cells have a long life
these pts are ususally in the hospital b/c of resp tract infections or acute myasthenic crisis
-
nursing dx
ineffective breathing pattern
- cough and deep breathe while they can
- incentive spirometry to muscle are too weak to cough
- communication-let them know what's going on
-
HESI hint
with MG, be alert for changes in resp status, the mosst severe involvement may result in resp failure, bedrest often relieves sxs, bladder and resp infections are often a recurring problem-need for teaching, nursing focus should be pt and family education-meds being high priority
-
ineffective airway clearance
- cascade cough-deep breath followed by 3-4 coughs, sputummoves up with each cough
- suction at bedside
- incentive spirometry
- HOB elevated 3-45 degrees
- turn side to side q 2 hrs
- O2 may need to be humidified if dry
- check pressure areas
-
imbalanced nutrition LTBR R/T impaired swallowing
dietician can help
-
impaired swallowing r/t chewing problems
FOR MG, ALS, AND BG
- swallowing evaluation
- rest b/f meals-peak med action ex. Mestinon
- eat slow
- soft or semisolid food-giove what they can tolerate
- inc fiber and fluids for bowels
- assess for drooling
- end up with tube feeding
- -PEG for GB until improvement
- -PEG for MG as needed
- PEG for ALS as disease progresses
- -check for residual, distrended abd, raise HOB
-
activity intolerance r/t muscle weakness and fatigue
- medicate b/f
- space activities
- handicapped stricker
- have things close by, frequent rest periods
-
disturbed body image r/t inability to maintain ususal lifestyle and role responsibilites
- express feelings
- ask questions, provide reliable information and reinforce it
- prepare significant others for changes and supprt them
-
impaired physical mobility r/t muscle wasting and weakness
- assist pt while still moving
- cane, walker, tripod, utensils, lift chair, hospital bed
- support extremities if bedridden, turn q 2 hrs
- prevent bed sores and swelling-dependent extremities
- moon boots
- ROM at leadt BID-bathing is a good time
- prevent DVT-lovenox, compression devices, ambulation if they can
- pressure ulcers-pad boney prominenes, turn
- monitor labs-PRO, albumin
-
powerlessness r/t inability to control sx and unpredictable nature of condition
- allow time to talk
- -progression of disease
- -how to handle things
- explain all procedures
- give time to ask questions, prepare mentally for procedures
- let pt control what they can -positon, am care, TV, radio, cards
-
impaired verbal communication
- picture boards
- bells
- pad/pencil
- eye blinking
- keyboarding
- support lower jaw with hands when speaking-MG
-
fear r/t loss of control and paralysis
- allow to verbalize feelings
- same kind of things as in powerlessness
- guided imagery, book tapes, music tapes
- support groups
- teach family care if willing so they won't be fearful
- visitors
-
nsg dx
- high risk for ineffective mgmt of htherapeutic regimen r/t lack of knowledge of condition, treatments
- pain
- disturbed sensory perception
- -tape eyes closed at night, artificial tears, crutches-MG
- -double vision-tape one eye closed, alternate
- -eyeglasses can have crutches attached to lift lids
- -sunglasses
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