Myasthenia Gravis Nursing Care Plans Diagnosis and Interventions
Myasthenia Gravis NCLEX Review and Nursing Care Plans
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:
- Pre-existing illness
- 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:
- 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
- Thymus gland tumors. Most of these tumors are benign and not cancerous.
- 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 loss.
- 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.
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 Diagnosis for Myasthenia Gravis
Myasthenia Gravis Nursing Care Plan 1
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.
|Myasthenia Gravis Nursing Interventions||Rationales|
|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.|
Myasthenia Gravis 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.
|Myasthenia Gravis Nursing Interventions||Rationales|
|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.|
Myasthenia Gravis 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.
|Myasthenia Gravis Nursing Interventions||Rationales|
|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.|
Myasthenia Gravis Nursing Care Plan 4
Risk for Aspiration
Nursing Diagnosis: Risk for aspiration related to difficulty in swallowing secondary to myasthenia gravis
- The patient will be able to maintain a clear airway and avoid aspiration.
- The patient will be able to prevent developing aspiration pneumonia.
|Myasthenia Gravis Nursing Interventions||Rationale|
|Assess the patient’s level of consciousness and airway patency.||Decreased level of consciousness is the primary danger of aspiration. Keeping an open and clear air passage is important to maintain good respiration and reduce the possibility of aspiration.|
|Monitor the patient’s respiratory characteristics regularly. Assess for respiratory rate, breathing depth, and effort. Take note of any signs of aspiration, such as the difficulty of breathing, cyanosis, cough, wheezing breath sound, and fever.||Patients with myasthenia gravis have a higher risk of respiratory distress because of muscle weakness, which limits the patient’s ability to clear the airway. Any signs of aspiration should be determined immediately to avoid further aspiration and respiratory failure.|
|Auscultate breathing sounds to assess pulmonary status for clinical evidence of aspiration. Note for abnormal sounds like crackles and rhonchi. Chest x-ray is most of the time-ordered, Therefore keeping chest x-ray films is important for monitoring of aspiration and related complications.||the Aspiration of small matter that can happen when a patient eats, it may happen quickly with or without any respiratory distress. Pulmonary infiltration can be seen in chest x-ray and it indicates some amount of aspiration has already occurred.|
|Assess the patient’s swallowing ability by checking for the following: Coughing and gurgling sound while eating and drinking.|
-Gagging Wet and gurgly voice when eating and drinking
-Residual food stuck in the mouth after eating
-Backing up of food or fluid into the nares.
|Difficulty chewing and swallowing are common among patients with myasthenia gravis. Patients might choke easily with food, liquids, and saliva. In some cases, liquid comes out of the nose while drinking. Altered swallowing increases the danger of aspiration. Choking and coughing while eating indicates aspiration. Wet and hoarseness of voice are related to swallowing food or liquids that are stuck in the larynx or trachea after eating. These methods in screening for aspiration risk are vital for immediate response.|
|Check for the presence of nausea or vomiting. Encourage the patient to sit up when eating and drinking.||Nausea or vomiting while eating puts the patients at much risk for aspiration. In some cases, medications are prescribed to prevent aspiration due to the backing up of gastric contents. Keeping the patient in an upright position while eating and drinking will prevent food particles and liquid to be aspirated into the airway and lungs.|
|Assess for muscle status.||The first symptoms of myasthenia gravis involve face and throat muscles. It may affect breathing and speech. Swallowing is also difficult, muscles used for chewing might get tired in between meals. This may also change facial expression.|
|Monitor the patient’s ability in talking and swallowing. Advised the patient to take time in chewing foods and pause for a moment between bites.||This will help patients to cope with symptoms of myasthenia gravis. Food cut into smaller pieces and well-masticated food is easier to swallow and lesser risk for aspiration.|
|Provide liquids after the food is eaten.||Give liquids only after the patient finished his food. Ingesting both food and liquids together will just increase swallowing problems.|
|Administer medication as prescribed by the doctor.||Various treatments are already available to relieve symptoms of myasthenia gravis. Compliance with the treatment regimen is highly advisable to relieve symptoms and improve one’s condition. It is always recommended to follow Doctor’s prescribed medication.|
|For high-risk patients, keep a suction machine available. If aspiration does happen, suction immediately. Inform the physician immediately.||Immediate suctioning is needed if aspiration happens. Early intervention is vital to keep the airway clear.|
Myasthenia Gravis Nursing Care Plan 5
Nursing Diagnosis: Activity intolerance related to overwhelming tiredness secondary to secondary to myasthenia gravis, as evidenced by muscle weakness, physical exhaustion, fatigue, and shortness of breath when doing activities.
- The patient’s physical condition will improve.
- The patient will increase their ability to do activities of daily living, report a lesser occurrence of fatigue and shortness of breath upon activity.
- The patient improves muscle weakness and builds up muscle strength.
- The patient will verbalize a lessened occurrence of fatigue and shortness of breath upon activity.
|Myasthenia Gravis Nursing Interventions||Rationale|
|Evaluate the patient’s level of mobility and physical activity.||This baseline information is vital in preparing for a nursing care plan, and in setting up goals during and after the treatment.|
|Probe the patient’s insight into the causes of activity intolerance.||Several causative factors may contribute to the physical and psychological state of a patient. These factors can be temporary or permanent. Settling with these causative factors can serve as a guide for nurses during the execution of the nursing care plan.|
|Evaluate the patient’s baseline cardiac and pulmonary status before starting an activity. Check the blood pressure, heart rate, and orthostatic blood pressure||Heart rate should not increase greater than 20 to 30 beats per minute for normal adults. Older people are more prone to orthostatic drops in blood pressure with position change.|
|Continuous Monitoring of patient’s vital signs during, and after the physical activity. Take blood pressure, respiratory rate, and resting pulse. Monitor the rate, rhythm, and quality of the pulse.If the vital signs are normal, allow the patient to do the activity. After the activity, immediately check for the vital signs. Allow the patient to rest for at least 3 minutes and then recheck the vital signs.||Discontinue the activity if the patient experience any of the following: |
-Low pulse rate, systemic blood pressure, and respiratory rate
Reduce the time length and intensity of the activity if the following occur:
-Increase in respiratory rate after the activity.
-An increase in pulse rate takes longer to return to the normal rate.
|Monitor oxygen saturation and observe for oxygen desaturation during activity.||This is to identify if there’s an increase in the oxygen demand during the activity and if there’s a need for supplemental oxygen during physical activity.|
|Let the patient do the activity in a slower and longer time, with pauses or rest, and provide assistance if necessary.||This will help the patient to increase their tolerance for the activity.|
|Encourage patient’s activity progressively. |
-Increase the activity gradually, with an active range of motion exercises done in bed, next on a chair while sitting, and then increase to standing.
-Sitting for at least 30 minutes, three times daily.
-Walking inside the room for 1 to 2 minutes, three times daily. Walking through the house, then gradually shift to progressive walking outside the house.
-Deep breathing exercises three or more times daily.
|Step by step progression of the activity will lessen the risk of overexertion. Exercise will help in maintaining muscle strength, joint range of motion, and activity tolerance. Strength training is important to build the endurance of many ADLs.|
|Advised the patient to avoid doing nonessential activities.||Since the patient has limited activity tolerance, they need to prioritize important tasks first.|
|Give assistance with the activities in daily living, but avoid dependency.||Giving assistance with the patient’s ADLs will let them conserve energy. This will facilitate continuing tolerance and self-esteem.|
|Plan a consistent physical activity based on the patient’s energy level.||Encourage a sense of autonomy and give representational capacity.|
|Make a plan of activities within the times that the patient has more energy.||Planning for an activity will allow the patient’s high energy level to coincide. If the goal is below normal, they can negotiate.|
|Allow the patient to verbalize their feelings about limitations.||It is a coping mechanism that helps the patient to acknowledge that living with activity tolerance is challenging both physically and emotionally.|
Myasthenia Gravis Nursing Care Plan 6
Nursing Diagnosis: Deficient Knowledge related to unfamiliarity with the disease condition secondary to myasthenia gravis as evidenced by the incorrect carrying on with instructions and verbalization of faulty information.
- The patient will have a broader knowledge of the disease process, and also with the details about the treatment management and be aware of the possible complications as well.
- The patient can follow instructions correctly, especially with the precautions related to myasthenia gravis.
- The patient will satisfactorily perform essential procedures effectively and efficiently.
|Myasthenia Gravis Nursing Interventions||Rationale|
|Provide physical comfort for the patient.||According to Abraham Maslow’s theory of needs, physiological necessity must be dealt with first before the patient’s education. Providing physical comfort permits the patient to focus on what is being explained or exhibited.|
|Assess the patient’s current knowledge of the diagnosis, and also if there are any obstacles in learning. Note for any misbelief or inaccurate information related to the disease. Also, evaluate one’s capability to follow and execute actions concerning their disease condition.||Evaluating one’s current knowledge and perception of the disease is beneficial in making plans for individual care management. These baseline details are essential in providing health teaching. The assessment gives vital details in starting an educational session. Accurate knowledge corrects faulty ideas.|
|Provide a calm and conducive environment without any interruption. Establish rapport and ensure an atmosphere of respect, trust, and teamwork.||Allows the patient to focus more and concentrate completely. Providing education to patients, good working relationship is important, some of them have different values and beliefs that we need to work with to be corrected.|
|In making a teaching plan, include the patient at the beginning of objectives and goals.||This allows the patient to be aware of the things to be discussed and what to expect within the session. Goal setting allows them to be more focused and attentive when it comes to health teaching.|
|4. Identify the patient’s way of learning. Encourage them to ask a necessary question or if they have any clarification.||Evaluate the patient’s receptivity to new information by having a simple, but interactive discussion related to the disease process.|
|5. Make the conversation comfortable and learning-friendly.||Ensuring the patient a room for new learning opportunities is an advantage on their part and will make them grow.|
|Discuss the disease pathology or disease process, disease outcome, and future expectations among the patients.||This provides baseline information that will help the patient, especially in the decision-making. This will give transparency to the patient and the people treating them. Also, providing them resourceful materials about the treatment plan is helpful to refrain them from reading inaccurate data.|
|Assist the patient to combine health-related information into daily life.||This learning technique helps the patient to adjust in everyday life that will turn into the desired change in behavior.|
|Explain to the patient the importance of having lifestyle modification and quitting on risk behaviors.||Shifting from risky behavior to comfortable behavior can be challenging and complicated for some. A collaboration of emotional support, proper guidance, and empathy will improve the chances of attaining a total lifestyle change.|
|Highlight the significance of adhering to the standard management and continuous follow-up appointments.||Inconsistency and opposition to the treatment plans are some of the major reasons for the progression of a disease. Strict follow-up appointments and compliance with the treatment as well as in follow-up appointments are beneficial in the treatment and in preventing complications.|
|Include the family members in discussing any information about the disease as much as possible.||The involvement of the family members as a supportive measure with the treatment of the patient is helpful and motivating for them.|
|Apply teach-back technique to identify the patient’s understanding of what was taught. Use understandable words to explain difficult terminologies to the patient.||This evaluates the patient’s knowledge and what was learned with the discussion.|
|Know the patient’s understanding of commonly used medical terminology such as fatigue, aspiration, and others.||This is to guide the patient in reading and understanding some of the medical terminologies in printed materials like medicine labels, consents, consultation slips, and others.|
|Provide positive and constructive reinforcement of teaching||This helps the patient to feel good about their learning development and achieve self-confidence.|
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Gulanick, M., & Myers, J. L. (2022). 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
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