1. “Grave Muscle Weakness”
Myasthenia Gravis
“Grave Muscle Weakness”

2. dr yekefallah---phd of nursing
12/1/2018
dr yekefallah---phd of nursing

3. dr yekefallah---phd of nursing
12/1/2018
dr yekefallah---phd of nursing

4. dr yekefallah---phd of nursing
Myasthenia Gravis
Autoimmune disease affecting the neuromuscular junction
Not a brain disorder – brain functions normally
Characterized by fluctuating muscle weakness and fatigability
Disease may be generalized or ocular specific
12/1/2018
dr yekefallah---phd of nursing

5. dr yekefallah---phd of nursing
Pathophysiology
Antibodies attack Acetylcholine (ACH) receptors at the motor end plate
Decreased number of (ACH) receptor sites at neuromuscular junction
Prevents neurotransmitter (ACH) from attaching and stimulating muscle contraction
Resulting in loss of muscle strength
12/1/2018
dr yekefallah---phd of nursing

6. dr yekefallah---phd of nursing
12/1/2018
dr yekefallah---phd of nursing

7. dr yekefallah---phd of nursing
12/1/2018
dr yekefallah---phd of nursing

8. dr yekefallah---phd of nursing
Causes
No single cause has been identified
Abnormal thymus tissue found in most patients with MG
Thymic tumors found in 15% of patients
Virus infections have been found in some cases and are a suspected cause
12/1/2018
dr yekefallah---phd of nursing

9. dr yekefallah---phd of nursing
Incidence
Occurs in all races
MG affects 14 per 100,000 people in the United States
Can affect any age group
Women – peak incidence 20's to 30's
Men – peak incidence 50's to 60's
Three times more common in women than men
Juvenile onset or over the age of 70 onset is extremely rare
12/1/2018
dr yekefallah---phd of nursing

10. dr yekefallah---phd of nursing
Genetic Factors
Myasthenia Gravis is not a genetically inherited disease
Some families appear to carry a gene that increases the risk for developing the disease
No specific gene has been identified and there are no tests for genetic screening
12/1/2018
dr yekefallah---phd of nursing

11. dr yekefallah---phd of nursing
Diagnosis
Edrophonium test (Tensilon)
Blood analysis
Repetitive nerve stimulation
Single-fiber electromyography (EMG)
Imaging scans
12/1/2018
dr yekefallah---phd of nursing

12. dr yekefallah---phd of nursing
Tensilon Test
Injection may result in a sudden, although temporary, improvement in muscle strength — an indication of myasthenia gravis. Acts to block an enzyme that breaks down acetylcholine, the chemical that transmits signals from nerve endings to muscle receptor sites.
12/1/2018
dr yekefallah---phd of nursing

13. dr yekefallah---phd of nursing
Signs and Symptoms
Affects any of the muscles that you control voluntarily, certain muscle groups are more commonly affected than others
Eye, face, throat, neck, limb muscles
Difficulty speaking (dysarthria)
Difficulty swallowing (dysphagia),
Drooping eyelids (ptosis)
Double vision (diplopia)
Nasal-sounding speech and weak neck muscles that give the head a tendency to fall forward or backward. 
12/1/2018
dr yekefallah---phd of nursing

14. dr yekefallah---phd of nursing
Signs and Symptoms
Symptoms tend to progress over time, usually reaching their worst within a few years after the onset of the disease
Worsening muscle weakness with repeat activity
12/1/2018
dr yekefallah---phd of nursing

15. Exacerbation Trigger Factors
Infection
Stress
Fatigue
Cathartics (laxatives)
Heat (sauna, hot tubs, sunbathing)
12/1/2018
dr yekefallah---phd of nursing

16. dr yekefallah---phd of nursing
Diet/Nutrition
Eat small meals and snacks five to six times a day
Avoid using low fat or diet products when possible
Avoid eating lemons or tonic water
Eat warm rather than hot food
Runny or puree diet when swallowing is difficult
Alternate sips of liquid to avoid food from sticking
AVOID eating chewy or dry crumbly foods
12/1/2018
dr yekefallah---phd of nursing

17. Medications/Treatment
Immunosuppressive Therapy
Prednisone
Azathioprine
Acetylcholinesterase Inhibitors
First line of therapy
Neostigmine bromide (Pyridostigmine)
Edrophonium chloride (Tensilon)
12/1/2018
dr yekefallah---phd of nursing

18. Medications/Treatment
Plasmapheresis
Immunoglobulin Therapy
Thymectomy
12/1/2018
dr yekefallah---phd of nursing

19. Myasthenic Crisis VS. Cholinergic Crisis
Under medication
Increased HR/BP/RR
Bowel and bladder incontinence
Decreased urine output
Absent cough and swallow reflex
May need mechanical ventilation
Temporary improvement of symptoms with administration of Tensilon
Cholinergic Crisis
Overmedication
Decreased BP
Abd cramps
N/V, Diarrhea
Blurred vision
Pallor
Facial muscle twitching
Constriction of pupils
Tensilon has no effect
Symptoms improve with administration of anticholinergics (Atropine)
12/1/2018
dr yekefallah---phd of nursing

20. Nursing Interventions
12/1/2018
dr yekefallah---phd of nursing

21. Nursing Interventions
Maintain patent airway
Assess swallowing to prevent aspiration
Keep appropriate equipment available at the bedside: Oxygen, suction, Ambu bag, endotracheal intubation
Promote energy conservation measures
Consult Physical Therapy for medical equipment needs (i.e.walkers, wheelchairs)
12/1/2018
dr yekefallah---phd of nursing

22. Nursing Interventions
Consult OT for assistive devices to facilitate ADLs
Consult with speech and language therapist if weakening facial muscles impact communication
Monitor I/O, serum albumin levels, and daily weights
Know the signs and symptoms of both Myasthenic Crisis and Cholinergic Crisis
Administer Medications
Immunosuppressants: Prednisone, Imuran
Cholinesterase Inhibitors: Pyridostigmine
12/1/2018
dr yekefallah---phd of nursing

23. dr yekefallah---phd of nursing
Patient Teaching
12/1/2018
dr yekefallah---phd of nursing

24. dr yekefallah---phd of nursing
Patient Teaching
Teach patient/family disease process, complications, and treatments
Teach patient about their medications uses dosage etc
Teach medications to use with caution d/t muscle exacerbation
Beta blockers, calcium channel blockers, quinine, quinidine, procainamide, some antibiotics, neuromuscular blocking agents
Avoid certain medications
D-penicillinamine, A-interferon, botulinum toxin
12/1/2018
dr yekefallah---phd of nursing

25. dr yekefallah---phd of nursing
Patient Teaching
Teach s/sx of both Myasthenic Crisis and Cholinergic Crisis
Help patient plan daily activity to coincide with energy peaks
Stress need for rest periods
Explain that exacerbations, remissions, and daily fluctuations are common
Avoid strenuous exercise, stress, infection, exposure to hot or cold temperatures
Teach patient to wear medic-alert bracelet
Provide Info on Support groups
12/1/2018
dr yekefallah---phd of nursing

26. dr yekefallah---phd of nursing
Prognosis
Chronic disease with periods of exacerbation and sometimes remissions
Disease course is highly variable
Symptoms respond well to treatment and in most cases the patient can live a normal or nearly normal life
Ocular Myasthenia has the best prognosis
12/1/2018
dr yekefallah---phd of nursing

27. dr yekefallah---phd of nursing
12/1/2018
dr yekefallah---phd of nursing

28. dr yekefallah---phd of nursing
12/1/2018
dr yekefallah---phd of nursing