Nursing Care Plan for Myasthenia Gravis (MG)

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Pathophysiology

Chronic, progressive disorder characterized by decreased acetylcholine activity in the synapses. This is due to insufficient acetylcholine secretion and excessive secretion of cholinesterase, the enzyme that inactivates acetylcholine. This causes a decrease in effective transmission of nerve impulses in the muscles, causing weakness and fatigue, especially in respiratory muscles.

Etiology

MG is an autoimmune disorder which is often exacerbated by precipitating factors known as triggers. This includes stress, infection, hormone disturbances, trauma, and extreme temperatures.

Desired Outcome

Preserve functional ability, protect airway, and prevent complications such as myasthenic crisis or cholinergic crisis.

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 Interventions and Rationales

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

  2. 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.

  3. Monitor respiratory status

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

  5. Provide eye care

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

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

  8. 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 meal times.

  9. Maintain suction and emergency equipment.

  10. Because of 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 cholinergic crisis worse, leading to respiratory distress or respiratory arrest. Ensure suction regulator is functioning and ambu bag is available.

  11. Educate patient to identify and avoid triggers

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

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

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

  15. Cholinergic Crisis

    • Withhold medication
    • Administer antidote – anticholinergic medication
    • Ventilatory support
    • 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.

  16. 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.


References

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