Pathophysiology of Myasthenia Gravis - Nursing Care Assessment Answer

Pathophysiology - Nursing Care Assignment

Assignment Task

1. Condition is myasthenia gravis and provide a brief overview of the underlying pathophysiology, including any risk factors and/or precipitating causes.
2. Identify the specific assessment data you would need to gather from a patient presenting with your chosen condition. Focus on history, physical examination and investigations. Briefly describe three (3) major problems or issues that may be seen in a patient with this condition based on your reading of current literature and derive nursing diagnoses.
3. Describe one (1) significant goal of nursing care for this patient related to each problem you have identified. That is, one goal or desired outcome for each problem. Use the clinical reasoning cycle as your guide. Briefly outline why this goal is important in addressing each problem.
4. Discuss the associated nursing care strategies necessary to meet each of these goals. Include a succinct summary of the rationale for the strategies. The discussion of nursing strategies and their rationale must be evidence-based and reflect current literature and/or national/international guidelines.

Overview and Pathophysiology of Myasthenia gravis (MG)

Myasthenia gravis (MG) is considered as a very common neuromuscular transmission disorder. The most causal cause behind this disorder is the acquired immunological abnormality. In the some of the cases it has also been reported that genetic abnormalities at the neuromuscular junction can also lead to this disorder (Anom Arie et al, 2013). The facts related to Myasthenia gravis are often under-diagnosed, and women are more tend to suffer from this disorder. This disease is now understood as an autoimmune disease and neuromuscular disorder, which results in weakness of the skeletal muscles. These muscles are very important for different movements in body. This disorder hampers the communication between the nerve cells and muscle cells (Hickey, 2013).

The main reason behind the occurrence of this disorder is due to autoimmune problems. Autoimmune disorders are caused, when the immune system mistakenly affect the healthy tissues (Jayam Trouth et al, 2012). In such situation that antibodies inside the body, which are proteins and normally attack foreign bodies, attacks the neurotransmitter substance acetylcholine (Ach) (Howard, 2016). This substance is very essential for communication between muscles and nerve cells. With every single impulse the amount of the released Ach from the presynaptic motor neuron is generally decreased (Farrugia, & Vincent, 2010). This happened due to the temporary reduction in the presynaptic ACh stores. This phenomenon is also called as the presynaptic rundown.

It is observed that in MG, there is a decrease in the number of AChRs, which are found at the muscle endplate, which also leads to flattening of the postsynaptic folds (Howard, 2016). Even if the normal amount of the ACh is released, it could only generate potential in few end plates and threshold value for potential generation could not be reached. Normally present phenomenon of presynaptic rundown and inefficient neuromuscular transmission results in the potential reduction in the amount of the muscle fibers, which are being activated by the nerve fiber impulses. This phenomenon explains the tiredness, less energy and fatigue in MG patients (Engel, 2012).

The indications are seen in the physical condition of the patient, when the number of Ach is decrease to approximately 30% from the normal level (Howard, 2016). It is also observed that smooth cardiac muscles have cholinergic receptors. These receptors have different antigenicity then skeletal muscles, thus they remain unaffected from the disease. It is observed that “decrease in the number of postsynaptic AChRs is believed to be due to an autoimmune process whereby anti-AChR antibodies are produced and block the target receptors, cause an increase the turnover of the receptors, and damage the postsynaptic membrane in a complement-mediated manner” (Anom Arie et al, 2013).

According to the clinical observations, immunogenic mechanisms play a very significant role in Pathophysiology of MG. This observations states that MG is caused due to presence of other autoimmune disorders such as, autoimmune thyroiditis, rheumatoid arthritis [RA]), and systemic lupus erythematosus [SLE] (Howard, 2016). Such disorders are also found in the patients suffering from Myasthenia gravis (MG). It is also noted that children born to myasthenic mothers can develop myasthenialike syndrome (Jayam Trouth et al, 2012). Such patient responds to various therapeutic treatments such as “immunomodulating therapies, including plasmapheresis, corticosteroids, intravenous immunoglobulin (IVIg), other immunosuppressants, and thymectomy” (Howard, 2016).

Assessment of Myasthenia gravis

Nursing care Goals

Proper Gas Exchange: The first nursing care goal includes assisting the patient in proper gas exchange. Due to the respiratory failure, patient may not be able to exchange gases normally. The impaired gas exchange occurs due to the muscle weakness and ineffective breathing pattern in patient suffering from MG. This also leads to the risk of aspiration, which is related to difficulty swallowing. The expected outcome for this nursing goal is no occurrence of aspiration. The nurses are responsible for providing quality care and thus this goal is very important to be achieved. This goal requires patient to maintain a respiratory rate of 12-20 with ADL’s and oxygen saturation of >92%(Fowler et al, 2013).

Self-Care Deficit: Self care deficit is associated with muscle weakness and general fatigue. This nursing goal is to encourage patients to perform their self-care activities and gain more independence. This is also important so that patient may demonstrate the ability to use the adaptive devices (Fowler et al, 2013). Due to the muscle weakness, patients are often unable to complete their self care tasks accurately, and thus depend on their family members or support team. This goal will help to gain the desired outcome of improving independence of patients. Due to muscle weakness, patient often suffer from impaired physical mobility. That can also be improved through this nursing goal.

Improve Imbalanced Nutrition: Providing balanced nutrition to body is important for better health and movement. The patient suffering from chronic illness of MG faces difficulty in chewing and swallowing food (Nutrition and myasthenia gravis (MG), 2010). Due to this, they could eat properly and often suffer from deficiency of nutrition. To maintain the normal functions of the body, it is important to intake balanced diet with adequate nutrients. The goal is to prevent problems like dysphagia, intubation, or muscle paralysis, which are related to the imbalance of nutrition according to the body requirements (Weeks, 2012).

Nursing Strategies or Care Plan

Ineffective breathing pattern or Impaired Gas Exchange:

The purpose of this strategy is to aid patient in maintaining the proper gas exchange. Interventions may include:

1. The patient must be provided with alternative communication options, if the patient is using ventilator. Ventilator may be required for the patient, who displays breathing difficulties.
2. Oxygen saturation must be regularly monitored, with oximetry and activity of the patient. It will help in understanding the condition of the patient regarding gas exchange. O2 saturation must be >92%, which indicate the need to supplement O2 (Gulanick & Myers, 2013).
3. Respiratory measures must be monitored regularly, in order to avoid any unsafe practice.
4. Professional collaboration of the nurses with physicians is important for anticholinergic medication.
5. Nurse should access the signs of any kind of activity intolerance in patient, and must also ask to rate the perceived exertion by the client. This is important because problems such as, Dyspnea on exertion, headache, palpitations, or dizziness increases the exertion level in patients (Gulanick & Myers, 2013). All these are the signs of decreased tissue oxygenation and activity intolerance.
6. Patient should be encouraged for performing breathing exercises and administer oxygen if required. Exercise helps in increasing the delivery of oxygen to the body.

Self-Care Deficit:

The purpose of this intervention is to understand the current capability of the client and encourage them to complete 25% of their tasks by themselves (Gulanick & Myers, 2013).

1. Self-care deficit is related to the weakness of the muscles and general fatigue. It is important that patients must be able to perform their self care independently. Thus, it requires to observe that activities of the patient (Weeks, 2012).
2. Monitoring the daily activities is important to analyze the self care capability, and what challenges do patient face in completing self-care needs.
3. Helping patient to develop self-care activity. It is important to assist them, so that they may understand the important of self-care and may develop hope and faith in treatment and self (Gulanick & Myers, 2013).
4. Allow patient to take break during different events, this will help them to regain energy and complete the task slowly. It will also prevent exhaustion.
5. Include family members and care givers, to assist the patient in self-care, if the patient is facing excessive muscle weakness.
6. Demonstrate some good techniques of saving energy. Due to muscle weakness patient often do not have enough energy to complete their daily tasks, thus they require saving energy (Gulanick & Myers, 2013).

Nutritional Balance: Nutritional imbalance in patients suffering from MG is very common, this is because patients face many challenges while eating, chewing and swallowing their food.

Purpose of this intervention is to save the patient from nutritional deficiency (Gulanick & Myers, 2013).

1. Nurse should provide the food to the patient, when they have optimal energy. This will help them to eat properly without getting tired.
2. Patients should be informed about eating slowly and must take breaks if necessary. Without taking breaks and fast eating, patient may loss their energy soon and may not be able to chew or swallow their food (Nutrition and myasthenia gravis (MG), 2010).
3. Identify the period of fatigue. If the fatigue is monitored in the later period of the day, then patient must have their meal early. This will help them to gain more nutrition, as due to fatigue patients are not able to eat properly (Gulanick & Myers, 2013).
4. Instead of 3 large meals, 5 to 6 small meals should be given. Large meals may take time to eat and patient may not be able to swallow food at once. Small meals will maintain the nutritional balance (Nutrition and myasthenia gravis (MG), 2010).
5. Measure the body weight of the patient after regular intervals. This will help to understand the change in health and efficiency of the treatment.