Myasthenia Gravis

Myasthenia Gravis Nursing Diagnosis Interventions and Care Plans

Myasthenia Gravis NCLEX Review Care Plans

Nursing Study Guide on Myasthenia Gravis

Myasthenia Gravis is an autoimmune neuromuscular disorder characterized by muscle weakness and fatigue.

The weakness of skeletal muscles worsens upon exertion and improves after rest periods.

Myasthenia gravis results from failure or error in transmission of impulses between nerves and muscles.

Although it is a relatively rare condition, myasthenia gravis can affect people of all ages, and is most commonly seen in women younger than 40 years old and in men above 60 years old.

At present, there is still no cure for myasthenia gravis, but treatment aims in relieving signs and symptoms and improving the patient’s quality of life.

Signs and Symptoms of Myasthenia Gravis

As the weakness of the affected muscles improves with rest, muscle weakness can come and go, and is likely to progress over time along with other symptoms.

It usually worsens years after developing the disease. The degree of muscle weakness also varies. 

Majority of the cases involves complications of the eye as an initial symptom, while others develop neck and throat problems first.

  • Muscle weakness with activity- hallmark sign
  • Ocular myasthenia – weakness of the eye muscles
  • Ptosis -drooping of one or both eyelids
  • Diplopia – double vision
  • Speech impairment
  • Difficulty in chewing and swallowing
  • Change in facial expression
  • Limb and neck muscle weakness

Causes and Risk Factors of Myasthenia Gravis

Muscles and nerves communicate through neurotransmitters, which are chemicals released by the nerves and matches into the receptor sites found in the neuro-muscular junction.

When a continuous problem in this process of transmission occurs, myasthenia gravis can develop.

The immune system blocks the receptor sites for a neurotransmitter called acetylcholine by producing antibodies.

Less receptor sites cause insufficient acetylcholine secretion and fewer nerve signals result in muscle weakness.

These antibodies also block protein function and tyrosine kinase, a protein enzyme associated in the formation of neuro-muscular junction.

An abnormally large thymus gland and/or presence of thymomas (tumor in the thymus gland) also play a role in the development of myasthenia gravis by promoting the production of acetylcholine blockers.

There is also a type of myasthenia gravis that is antibody-negative, wherein the root cause is the antibodies by working against lipoprotein-related protein 4, and not by blocking the acetylcholine. 

Another type is a rare hereditary form called congenital myasthenic syndrome, which is present at birth.

Factors that may aggravate myasthenia gravis include:

  • Fatigue
  • Pre-existing illness
  • Stress
  • Certain medications such as beta blockers, quinidine gluconate, quinidine sulfate, quinine, phenytoin, certain anesthetics, and some antibiotics
  • Pregnancy- in rare cases, mothers with myasthenia gravis have children who are born with the same condition (known as neonatal myasthenia gravis or congenital myasthenic syndrome)
  • Menstrual period

Complications of Myasthenia Gravis

The complications of Myasthenia gravis can be treated while others can lead to critical conditions.

People with Myasthenia gravis may have the following complications:

  1. Myasthenic crisis. This is an acute exacerbation of the disease that occurs when muscle weakness progresses to the muscles that controls breathing. It is a life-threating condition that needs emergency treatment
  2. Thymus gland tumors. Most of these tumors are benign and not cancerous.
  3. Hypothyroidism (underactive thyroid) or Hyperthyroidism (overactive thyroid). Hypothyroidism causes cold intolerance, weight gain and others problems while it is the opposite for hyperthyroidism which causes heat intolerance and weight gain.
  4. Autoimmune conditions such as Rheumatoid arthritis or Lupus

Diagnosis of Myasthenia Gravis

  • Neurological examination
  • Edrophonium test – also known as Tensilon test; used to diagnose myasthenia gravis by injecting edrophonium chloride causing temporary improvement in the affected muscles.
  • Ice pack test
  • Blood analysis
  • Repetitive nerve stimulation
  • Single-fiber electromyography (EMG)
  • Imaging tests such as CT Scan or MRI
  • Pulmonary function tests

Treatment of Myasthenia Gravis

Treatment depends on age, severity and progression of the disease.

The following treatments may be used alone or in conjunction with other treatments:

1.      Medication Therapy

Cholinesterase inhibitors. These drugs aim to improve muscle strength and contractility by enhancing the communication between the nerves and muscles.

Corticosteroids. These drugs suppress the immune system by inhibiting production of antibodies. Corticosteroids such as prednisone should be used cautiously to prevent serious side effects.

Immunosuppressants. These drugs weaken the immune system which also increases the risk for infection.

2. Intravenous therapy

Plasmapheresis. This is a procedure that uses a filtration process to remove the antibodies. Repeated procedures may be necessary for this treatment since benefits usually lasts for only a few weeks. Associated risks include hypotension, bleeding, cardiac problems and allergic reaction.

Intravenous immunoglobulin (IVIg). This improves the immune system response by providing the body with normal antibodies.

Monoclonal antibody. This is an option for people unresponsive to other treatments.

3.      Surgery

In cases where a tumor in the thymus gland (thymoma) is present, surgical removal is necessary.

The procedure is called thymectomy, where in the doctor removes the thymus gland.

It can be done as an open surgery or using a minimally invasive approach such as Video-assisted thymectomy and Robot-assisted thymectomy.

These procedures have minimal blood loss and lower mortality rates.

Even in the absence of tumor, this procedure helps in the improvement of symptoms.

Nursing Care Plans for Myasthenia Gravis

Nursing Care Plan 1

Nursing Diagnosis: Ineffective Breathing Pattern related respiratory muscle weakness secondary to myasthenia gravis, as evidenced by shortness of breath, SpO2 level of 85%, and labored breathing

Desired Outcome: The patient will achieve effective breathing pattern as evidenced by respiratory rates between 12 to 20 breaths per minutes, oxygen saturation within the target range, and verbalize ease of breathing.

InterventionsRationales
Assess the patient’s vital signs and characteristics of respirations at least every 4 hours.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment.
Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.To increase the oxygen level and achieve and SpO2 value within the target range.
Administer the prescribed medications.Bronchodilators: To dilate or relax the muscles on the airways. Steroids: To reduce the inflammation in the lungs. Cholinesterase inhibitors – to improve muscle strength and contractility by enhancing the communication between the nerves and muscles.    
Elevate the head of the bed. Assist the patient to assume semi-Fowler’s position.Head elevation and semi-Fowler’s position help improve the expansion of the lungs, enabling the patient to breathe more effectively.
Prepare the patient for surgery if indicated.In cases where a tumor in the thymus gland (thymoma) is present, surgical removal is necessary. The procedure is called thymectomy, where in the doctor removes the thymus gland.

Nursing Care Plan 2

Impaired physical mobility related to weakness of voluntary muscles as evidenced generalized weakness, inability to do activities of daily living (ADLs) as normal, and verbalization of overwhelming tiredness

Desired Outcome: The patient will be able to perform activities of daily living within the limits of the disease.

InterventionsRationales
Assess the patient’s level of functional mobility and ability to perform ADLs.To assist in creating an accurate diagnosis and monitor effectiveness of treatment and therapy.
Assist the patient during exercises and when performing activities of daily living.To encourage the patient to perform muscle-strengthening exercises and promote dignity by allowing the patient to perform their ADLs while maintaining safety.
Ensure the safety of the environment. Check that the call bell is within reach, the bed rails are up when the patient is on the bed, the bed is in the lowest level, the room is well-lit, the floor is not slippery, and that important things like phone and eyeglasses are easy to reach.To maintain patient safety and reduce the risk of falls.      
Encourage the patient to perform range of motion (ROM) exercises in all extremities.To improve venous return, muscle strength, and stamina while preventing stiffness and contracture deformation.
Refer to the physiotherapy and occupational therapy team.To provide a specialized care for the patient to gain physical and mental support in performing ADLs and mobilizing.

Nursing Care Plan 3

Nursing Diagnosis: Fatigue related to muscle weakness secondary to myasthenia gravis as evidenced by generalized weakness, irritability, and verbalization of overwhelming tiredness

Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.

InterventionsRationales
Assess the patient’s degree of fatigability by asking to rate his/her fatigue level (mild, moderate, or severe). Explore activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.To create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance.
Encourage activity through self-care and exercise as tolerated Alternate periods of physical activity with rest and sleep.    Encourage enough rest and sleep and provide comfort measures.To help the patient balance his/her physical activity and rest periods.   To reserve energy levels and provide optimal comfort and relaxation.
Teach deep breathing exercises and relaxation techniques.   Provide adequate ventilation in the room.To allow the patient to relax while at rest. To allow enough oxygenation in the room.
Refer the patient to physiotherapy / occupational therapy team as required.To provide a more specialized care for the patient in terms of helping him/her build confidence in balancing daily physical activity and rest periods.

Other nursing diagnoses:

  • Risk for Aspiration
  • Activity Intolerance
  • Deficient Knowledge

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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