Myasthenia Gravis Nursing Care Plan

Myasthenia Gravis Nursing Care Plan

Myasthenia gravis is an autoimmune disorder. Autoimmune in short means that the body is attacking itself.  This disorder is characterized by fatigue and generalized weakness of any of the muscles that are under voluntary control. This disease attacks the peripheral nervous system (PNS), which is outside the brain and spinal cord. It can surface at any age, but is seen more in women over 40 and men over 60 years of age.

Myasthenia gravis causes a breakdown in normal transmission between nerves and muscles. While there is no cure for myasthenia gravis, there are treatments available to decrease the signs and symptoms.

Signs and symptoms:

Drooping eyes (ptosis), one or both

Double vision (diplopia)

Change in speaking

Difficulty with chewing or swallowing

Difficulty holding head up from causing weakness in neck

Nursing Diagnosis:

  1. Ineffective Breathing Pattern related to neuromuscular weakness of the respiratory muscles and throat.

 

Desired outcomes:

The patient will maintain an oxygen saturation of >92% and a respiratory rate of 12-20 with ADL’s.

InterventionsRationals
InterventionsRationals
Assess for signs of activity intolerance. Ask client to rate perceived exertion.Dyspnea on exertion, palpitations, headaches, or dizziness or patient states increased exertion level, are all signs of activity intolerance and decreased tissue oxygenation.
Monitor pulse oximetry and report O2 saturation <92%.O2 sat of <92% indicates the need to supplement oxygen.
Monitor the patients pulse oximetry every 4-6 hours. An O2 saturation of less than 92% may detect hypoxia and signals the need for supplemental oxygen.
Encourage deep breathing exercises and administer oxygen if indicatedIncreases oxygen delivery to the body.

 

 

 

  1. Risk for Aspiration related to difficulty swallowing

 

Desired outcomes:

Client is able to swallow independently without choking.  Able to maintain a patent airway.

InterventionsRationals
InterventionsRationals
Assess for signs of activity intolerance. Ask client to rate perceived exertion.Dyspnea on exertion, palpitations, headaches, or dizziness or patient states increased exertion level, are all signs of activity intolerance and decreased tissue oxygenation.
Monitor pulse oximetry and report O2 saturation <92%.O2 sat of <92% indicates the need to supplement oxygen.

 

 

  1. Self-Care Deficit related to muscle weakness, general fatigue.

Desired outcomes:

Patient is able to perform self-care activities independently and able to demonstrates ability to use adaptive devices for completion on ADL’s.

InterventionsRationals
InterventionsRationals
Observe the patient’s ability to perform activities of daily living. This will show performance challenges and the level which the patient needs assistance with completing ADL’s.
Allow enough time for task performance. DO not rush patient. Involve family and significant others in care activities. Observe activities to ensure patient can perform them safely without assistance.Allowing sufficient time preserves the patients energy and increases activity tolerance.

 

 

Other nursing diagnosis:

Impaired Physical Mobility related to weakness of voluntary muscles.

 

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Anna C. RN-BC, BSN, PHN, CMSRN Anna began writing extra materials to help her BSN and LVN students with their studies. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process. She is a clinical instructor for LVN and BSN students along with a critical care transport nurse.

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