Case Study 66 Myasthenia Gravis (also called MG) PDF

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Summary

Case Study 66 Myasthenia Gravis. A weakness and rapid fatigue of muscles under voluntary control.
The condition is caused by a breakdown in communication between nerves and muscles....

Description

Case Study 66 Myasthenia Gravis J.B. is a 58-year-old retired postal worker who has been on your floor for several days receiving plasma- pheresis every other day for myasthenia gravis (MG). About a year ago, J.B. started experiencing difficulty chewing and swallowing, diplopia, and slurring of speech, at which time he was placed on pyridostigmine (Mestinon). Before this admission he had been relatively stable. His medical history includes hypertension controlled with metoprolol (Lopressor) and glaucoma treated with timolol (ophthalmic preparation). Recently J.B. was diagnosed with a sinus infection and treated with ciprofloxacin (Cipro). On admission, J.B. was unable to bear any weight or take fluids through a straw. There have been periods of exacerbation and remission since admission. VITAL SIGNS

1.

Blood pressure

170/68 mm Hg

Heart rate

118 beats/min

Respiratory rate

32 breaths/min

Temperature

101.8 ⁰ F (38.8 C)

You note that the nursing assistive personnel (NAP) has just entered these vital signs into J.B.'s record. What is your immediate concern and why?

The respiratory rate is almost double of what it should be. 2.

What action do you need to take based on this concern?

Assessing O2 saturation and applying oxygen.

3.

What other assessment findings would support this complication being present?

Increased heart rate

4.

What medical treatment do you anticipate for J.B.?

Anticholinesterase such as pyridostigmine, corticosteroids like prednisone, immunosuppressive therapy such as azathioprine or cycloporine, plasmapheresis

5.

What is your nursing priority at this time?

Patient safety and respiratory status

6.

Based on this priority, what nursing interventions do you need to perform?

Due to the patient being in a myasthenic crisis he needs to receive edrophonium immediately, patient should be placed in. ICU for continuous monitoring of respiratory status, patient may need breathing assistance via ventilator, give patient fluids and nutritional support as needed.

7. Which actions do you need to implement to administer edrophonium (Tensilon) safely? Select all that apply. a.

Have intravenous (IV) atropine sulfate readily available.

b.

Monitor for changes in level of consciousness.

c.

Place J.B. on continuous cardiac monitoring.

d.

Initiate precautions to prevent excessive bleeding.

e.

Administer a prophylactic antiemetic before injection.

8.

What is the difference between a cholinergic crisis and myasthenic crisis?

Cholinergic crisis is too much medication and myasthenic crisis is to little medication. Myasthenic crisis is like fight or flight with increased HR, RR, BP, difficulty breathing and swallowing, absent cough reflex, anoxia, and cyanosis. Cholinergic crisis is like rest or digest with abdominal cramps, N/V/D, excessive pulmonary secretions.

9. J.B.'s wife asks you, “What may have caused my husband to get worse, and why does he keep having these episodes?” What explanation should you give her? Your husband’s medication was not enough for him causing him to be in a myasthenic crisis. With some time we will be able to figure out the correct dosage of medications that is best for your husband.

CASE STUDY PROGRESS J.B.'s condition improves after the administration of edrophonium (Tensilon). Two days later, after his condition has stabilized, you sit down to discuss discharge plans with J.B. and his wife.

10. J.B.'s wife tells you she does not have a lot of information about MG and she would like to know more about it. What should you tell her? MG is a chronic autoimmune disorder that produces antibodies that block, alter, or destroy receptors for acetylcholine at the neuromuscular junction which directly prevents muscle contraction. This disease has no cure, has episodes of remission and exacerbation but can be regulated with medication therapy.

11. They ask you to explain what to expect in terms of symptoms as his illness progresses. What should you tell them? He may experience symptoms like difficulty swallowing, slurred speech, voice impairment, sleepy mask-like facial expression with difficulty smiling. Sometimes within a year, patients experience generalized weakness in the trunk, arms, and legs.

12. J.B.'s wife asks, “How do they know that my husband has myasthenia gravis?” What should you tell her about how MG is diagnosed? Diagnostic tests such as EMG, nerve conduction tests for specific muscle fatigue by repetitive nerve stimulation, and may demonstrate decrements of the muscle action potential due to impaired nerve to muscle transmission. Thyroid function is also tested with assessment for thymoma by CT or MRI. Antinuclear antibody tests for presence of immune molecules or acetylcholine receptor antibodies. MG can also be diagnosed by giving edrophonium IV, if an improvement in muscular strength and reduction of ptosis is it considered a positive test and a

confirmed diagnosis.

13. J.B.'s wife asks why he receives plasmapheresis for the treatments of MG. Which of the following best describes the purpose of this procedure? a.

It replaces affected blood with unaffected blood.

b.

It decreases the production of antireceptor antibodies.

c.

It reduces inflammation by infusing immunoglobulins.

d.

It removes circulating abnormal antibodies from the blood.

14.

J.B. wants to know when he will be able to go home. How will you respond?

He may go home when he is no longer having symptoms of a crisis and his medications have been changed to be therapeutic for him.

15. J.B.'s wife asks you what information they will need before he goes home. Outline the points you need to teach J.B. and his wife. What cholinergic and myasthenic crisis is, what to expect and what to do. Medication management. Take medications at least an hour before eating so that muscle strength is available for eating. Have ambu bag and portable suction decide at home and patient/family knows how to use it and when to use it. Patient needs to wear a medical alert bracelet at all times. Avoid triggers such as stress, infection, vigorous physical activity, smoking, high temperatures, avoid drugs that may induce a crisis. Avoid contact with sick people especially those with colds or respiratory infections. Tell the dentist that patient has MG.

16. You teach J.B. and his wife that the most effective means of preventing myasthenic and cholinergic crises is by: a.

Doing all errands early in the day.

b.

Eating three large, well-balanced meals.

c.

Taking medications at the same time each day.

d.

Doing muscle-strengthening exercises twice a day.

17.

How will you know that your teaching has been effective?

J.B. and his wife are able to state the following: You will know that your teaching is effective when the patient and their family can repeat back all that you told them. They ask questions that signals to you that they understand what you have told them.

18.

What community resources might J.B. and his wife find helpful?

Support groups for both of them. J.B. to be in a group of patients with MG and his wife to be in a group of people whose significant others have MG. Social worker, dietitian, physical therapy, occupational therapy....