Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction. This condition is characterized by fluctuating weakness of skeletal muscle groups that worsens with use and improves with rest.
MG involves an autoimmune process in which antibodies attack the ACh receptors (AChR), resulting in fewer AChR at the neuromuscular junction. When this occurs, ACh molecules are not able to attach to these receptors and stimulate muscle contractions.
The classic sign of MG is fluctuating weakness of the skeletal muscles. This condition affects multiple muscle groups including muscles used to move the eyes and eyelids, and muscles for chewing, breathing, and speaking. Muscle weakness typically occurs with continued activity and becomes prominent by the end of the day.
The course of this condition is highly variable. Some patients become stabilized while others will have short-term remission between flare-ups and others develop severe symptoms. Various conditions can exacerbate MG including pregnancy, trauma, illness, stress, extreme temperature changes, and hypokalemia.
Diagnosis of MG may be based on the patient’s history and physical examination. However, diagnostic tests like electromyography (EMG) or a tensilon test may be performed to confirm the diagnosis.
Nursing Process
Since MG is a chronic and progressive medical condition, nurses support patients through ongoing assessments, treatment interventions, and providing accurate patient education about the disease, prognosis, treatments, and prevention of complications.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for myasthenia gravis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for myasthenia gravis.
Fatigue
Myasthenia gravis is associated with muscle weakness and rapid fatigue in voluntary muscle groups.
Nursing Diagnosis: Fatigue
Related to:
- Disease process
- Muscle weakness
As evidenced by:
- Decreased gait velocity
- Difficulty maintaining usual physical activity
- Difficulty maintaining usual routines
- Ptosis
- Diplopia
- Weak facial expressions
- Expresses tiredness
- Expresses weakness
- Inadequate role performance
- Lethargy
- Falls
Expected outcomes:
- The patient will demonstrate increased activity levels and participate in desired activities
- The patient will participate in supportive therapy to improve fatigue and muscle strength
Assessment:
1. Assess the patient’s severity and frequency of fatigue.
Assessing fatigue severity and frequency can help formulate the most appropriate treatment plan for the patient. Fatigue can lead to falls, injuries, and poor quality of life if not properly evaluated.
2. Assess the patient’s ability to perform ADLs.
This will help determine the degree of assistance that the patient will require in performing self-care and other activities of daily living.
3. Perform neurological evaluation.
The nurse should perform a neurological assessment to determine fatigue of the eyes, face, and reflexes.
Interventions:
1. Encourage the patient to perform activities as tolerated.
Allowing the patient to perform activities of daily living with adequate rest periods in between will promote a sense of control and independence.
2. Assist the patient in identifying MG triggers.
A patient can prevent an MG flare by understanding their triggers. Common triggers include illness/infections, inadequate sleep, some medications, extreme temperatures, menstruation, alcohol, and stress.
3. Refer the patient to appropriate therapies.
Physical therapy and occupational therapy can assist with motor strength exercises and recommend strategies and equipment to assist with ADLs.
4. Prepare for IVIG therapy.
Intravenous immunoglobulin (IVIG) is a transfused blood product that is believed to destroy damaged antibodies through healthy donor antibodies. A nurse can administer the transfusion in a medical office or the patient’s home. This treatment can be given for an MG crisis, to prevent an impending crisis, or as a treatment to stabilize the patient prior to surgery.
5. Prepare for surgery.
For some patients, the thymus gland itself or a tumor in the thymus gland (known as a thymoma) may contribute to MG. In an attempt to reduce symptoms, and in some cases cure patients, a thymectomy is performed.
Ineffective Airway Clearance
Myasthenia gravis is associated with muscle weakness usually affecting the muscles that control the eyes, throat, mouth, and limbs that worsen with activity. Weakness in the upper airway muscles can result in upper airway obstruction and respiratory failure.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Disease process
- Weak oropharyngeal muscle contractions
- Decreased ability to cough and swallow
As evidenced by:
- Absent or ineffective cough
- Adventitious breath sounds
- Altered respiratory rhythm
- Rapid, shallow breathing
- Cyanosis
- Difficulty verbalizing
- Nasal flaring
Expected outcomes:
- The patient will demonstrate effective coughing, clear breath sounds, and clear airways without respiratory distress symptoms
- The patient will verbalize one strategy to maintain airway strength and support
Assessment:
1. Assess respiratory rate, rhythm, and lung sounds.
Diminished lung sounds or the presence of adventitious lung sounds can indicate a blocked airway. Alterations in respiratory rate and rhythm are present when there is an attempt to compensate for ineffective airway clearance and breathing.
2. Evaluate and monitor ABG values.
Alterations in the patient’s ABG levels can indicate worsening respiratory failure. Do not rely on this information for treatment as abnormal values may not be obvious until respiratory failure is occurring.
3. Have the patient perform the single-breath test count.
This test has the patient inhale a maximal breath and then count out loud as long as they can before taking another breath. The ability to count to 50 indicates normal breathing. A count of less than 15 signals respiratory muscle weakness.
Interventions:
1. Monitor the patient’s ability to swallow or cough.
Since the primary symptom of MG is muscle weakness, it is important to monitor the patient’s ability to swallow or cough. This can help determine the progression of the disease and the need for additional interventions to protect the patient’s airway.
2. Suction secretions as needed.
Suctioning secretions help patients with MG who are unable to cough or swallow.
3. Elevate the head of the bed.
Elevating the head of the bed improves lung expansion and makes breathing easier.
4. Educate on myasthenia gravis crisis.
An MG crisis occurs when the respiratory muscles weaken and result in respiratory failure. This can be life-threatening and requires emergency assistance. Educate the client to seek assistance if they notice dyspnea, accessory muscle use, and a weak cough.
5. Refer for pulmonary function tests.
PFTs can assist in diagnosing MG as well as monitoring the progression of the disease. Not all patients will experience respiratory muscle involvement, but routine assessment can help prevent a crisis or other complications.
Risk for Aspiration
Dysphagia or swallowing difficulties are common in patients diagnosed with MG, making the risk for aspiration high. Silent aspiration can also occur in MG due to weak oropharyngeal muscle contractions, resulting in myasthenic crisis and aspiration pneumonia.
Nursing Diagnosis: Risk for Aspiration
Related to:
- Disease process
- Weak oropharyngeal muscle contractions
- Depressed gag reflex
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet and nursing interventions are directed at the prevention of symptoms.
Expected outcomes:
- The patient will maintain a patent airway and demonstrate clear breath sounds
- The patient will demonstrate strategies to safely swallow
Assessment:
1. Assess the patient’s ability to swallow and cough.
Assessing the patient’s swallow and gag reflexes is necessary to reduce the risk of aspiration and maintain clear airways.
2. Auscultate breath sounds.
Breath sounds assess the patient’s pulmonary status. Coarse crackles are often heard during auscultation with aspiration.
Interventions:
1. Assist the patient to a sitting position when eating and drinking.
Keeping the patient in an upright position while eating or drinking, and for 30 minutes following meals, can help prevent aspiration.
2. Consider the use of feeding tubes.
In severe cases of MG, a nasogastric feeding tube may be required for dysphagia until the client recovers from their MG flare.
3. Administer medications as indicated.
Medications like pyridostigmine are prescribed to help alleviate symptoms of MG.
4. Adjust the eating routine.
Educate the patient to eat when they have optimal muscle strength. Take time to chew, and focus on smaller meals. Choosing softer foods will require less chewing.
5. Consult with speech therapy.
A speech therapist can perform swallowing assessments and determine foods that are safe or unsafe to eat. They can also work with the client on strengthening their mouth and throat muscles.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Myasthenia Gravis Fact Sheet. NIH: National Institute of Neurological Disorders and Stroke. Reviewed: July 25, 2022. From: https://www.ninds.nih.gov/myasthenia-gravis-fact-sheet
- Myasthenia Gravis. Johns Hopkins Medicine. 2022. From: https://www.hopkinsmedicine.org/health/conditions-and-diseases/myasthenia-gravis
- Myasthenia gravis. Mayo Clinic. Reviewed: June 22, 2021. From: https://www.mayoclinic.org/diseases-conditions/myasthenia-gravis/symptoms-causes/syc-20352036
- Myasthenia Gravis. Medscape. Abbas A Jowkar, MBBS. Updated: March 7, 2022. From: https://emedicine.medscape.com/article/1171206-overview
- Myasthenic crisis. Neurohospitalist. Wendell LC, Levine JM. 2011 Jan;1(1):16-22. doi: 10.1177/1941875210382918. PMID: 23983833; PMCID: PMC3726100.
- Myasthenia gravis. NHS. Reviewed: January 17, 2020. From: https://www.nhs.uk/conditions/myasthenia-gravis/
- Nursing care of the patient with myasthenia gravis. Donohoe KM. Neurol Clin. 1994 May;12(2):369-85. PMID: 8041347.
