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Pathophysiology

A chronic, progressive disorder defined by lessened acetylcholine task in the synapses. This is as result of insufficient acetylcholine secretion and also excessive cheap of cholinesterase, the enzyme that inactivates acetylcholine. This causes a decrease in the effective transmission the nerve impulses in the muscles, leading to weakness and fatigue, specifically in respiratory muscles.

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Etiology

MG is an autoimmune disorder the is often exacerbated by precipitating factors known as triggers. This contains stress, infection, hormone disturbances, trauma, and extreme temperatures.

Desired Outcome

Preserve functional ability, safeguard the airway, and also prevent complications such as myasthenic dilemm or cholinergic crisis.

Myasthenia Gravis (MG) londonchinatown.org treatment Plan
Subjective Data:Double visionWeakness/fatigueDysphagiaDyspnea

Cholinergic Crisis 

Muscle crampsNausea

Myasthenic Crisis 

Sudden, severe weakness
Objective Data:Ptosis (drooping eyelid)TachypneaAbnormal ABGDiminished breath sounds or crackles because of atelectasis

Cholinergic Crisis

Vomiting, diarrheaBradycardiaBronchial spasmHypotension 

Myasthenic Crisis

Increased HR, RR, BPHypoxia and cyanosisBowel and Bladder incontinence

londonchinatown.org Interventions and Rationales

Administer cholinesterase inhibitors (Physostigmine) and also ensure ideal dosing/timing
The goal is to have actually a net boost of acetylcholine activity at the nerve synapses. This should aid improve the conduction that impulses in ~ the muscles.
Monitor respiratory tract status
Patients are at high threat for respiratory distress because of muscle weakness and also dysphagia (aspiration)
Provide eye care
Ptosis and weakness the eye muscles can reason dryness and irritation that the eyes. Provide eye autumn or one eye patch as appropriate.
Monitor feeding and ensure ideal nutrition. Schedule meds 30-45 minutes prior to meals
Weakness and also dysphagia do preparing and eating meals an ext and more difficult as the disease progresses. Scheduling meds 30-45 minutes prior to meals help to minimization their symptom as much as feasible during meal times.
Maintain suction and also emergency equipment.
because of the hazard of respiratory tract depression – this is specifically important to have at the bedside once administering a Tensilon test due to the fact that it have the right to send the patient into V-Fib or cardiac arrest, or have the right to make the cholinergic crisis worse, resulting in respiratory distress or respiratory arrest. Certain the suction regulator is functioning and also the ambu bag is available.
Educate patience to identify and also avoid triggers
This may encompass temperature extremes, stress, drugs, alcohol, infection, or caffeine. They need to avoid any known cause as lot as possible.
Educate the patient on s/s that cholinergic and myasthenic dilemm to report come the provider.
Both situations can reason severe muscle weakness and also respiratory depression. Early intervention to defend the patient’s airway is imperative.
Cholinergic CrisisWithhold medicationAdminister antidote – anticholinergic medicationVentilatory support
A cholinergic crisis can be caused by acquisition too much medication or can happen after a dose adjustment. Atropine may help, however isn’t always enough – patients often need ventilatory assistance until the medication is out of your system.
Myasthenic CrisisIncrease medicine doseVentilatory support
Myasthenic crisis is led to by having actually too little medication and is essentially an exacerbation of the disease. Provide the missed dose or boost the dosage every provider orders. Patients often still call for ventilatory assistance until the medication is in ~ a therapeutic level again.

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References

Transcript


This is the care setup for my myasthenia gravis. So the pathophysiology behind myasthenia gravis is a chronic steady disorder that is defined by decreased acetylcholine task in the synapses. This is because of insufficient acetylcholine indigenous an extreme secretion the acetylcholinesterase, which is the enzyme the inactivates acetylcholine. This causes a to decrease in effective transmission of the nerve impulses in the muscles. It causes weakness and fatigue, specifically in the respiratory tract muscles. So londonchinatown.org considerations, these space some points that we want to just be mindful of as soon as we space taking treatment of this patients. An initial thing we desire to do is to evaluate the airway. The airway is really important to have a master on. We desire to make sure that we have the right to differentiate in between a cholinergic crisis and a myasthenic crisis. And we would favor to take care of the aspiration risk because these patients are at risk for aspiration. 

The preferred outcome is we desire these patient to have preserved sensible ability. We desire to protect the airway and also prevent complications such together my student dilemm or speak to an energy crisis on this slide. This slide is just offering you a small information about our cholinergic crisis versus myasthenic crisis. Lock look an extremely similar, yet they space different. The means we identify is we carry out something referred to as a tensilon test. A tensilon check is when we give edrophonium. And if the symptoms improve temporarily the weakness, the muscle weakness, climate the diagnosis because that myasthenic is positive. If we offer it and they gain worse, if we give the leaf of Folium and it it s okay worse than that way the patient does not have my stadia, they are in a cholinergic crisis. The antidote for the edrophonium is atropine. So just keep the in the ago of your mind. Okay? so the spatu data, what space some things that the patient is going come present? how are lock going to tell us, what room they seeing? exactly how are lock feeling? Well, this patient is going come have double vision. This patient is likewise going come complain of weakness or fatigue. This is going to be part dysphagia. Therefore they’re walk to have some challenge swallowing. Therefore they’re walk to have actually some dysphasia, they’re walk to additionally have some difficulty breathing. Castle may have a cholinergic crisis. They space going to have some muscle cramps, nausea and a myasthenic crisis. They are going to have actually sudden serious weakness. Some objective data: they’re walking to have actually ptosis. And also that is simply droopy eyelids. 

They room going to have actually some difficulty breathing, so their respirations room going to it is in up due to the fact that the job-related of breath is up. Therefore they’re walk to have an enhanced respiratory rate. They’re walking to have actually an abnormal ABG. If girlfriend think about it, they’re not able to obtain that complete respiration. They’re not able come expel all the air. For this reason they’re walking to host onto few of that CO2. The ABG is walking to it is in a little off. They’re walking to have actually some diminished breath sound or crackles. That’ll be as result of some atelectasis. Okay. If they room actually in a cholinergic crisis, there will be some vomiting and also diarrhea. There’s walk to be bradycardia and also hypotension. If they’re in a myasthenic crisis, they’re going to have increased love rate. They’re walk to be tachycardic. Like I said, those respirations space going to it is in up and also the BP is walking to be up. The patience will have some hypoxia, low sats on the monitor. They’re walk to have actually some cyanosis, which is part bluing the the skin. They also will present with part bowel and also bladder incontinence since those muscles are weak. They’re not going to be able to control it. 

The londonchinatown.org interventions, what we want to execute is we want to shot to get this patient as close to their baseline prior to the symptom of the myasthenia gravis has started to take effect. Therefore in stimulate to execute that, we want to administer a cholinesterase inhibitor. Okay? The goal of this medication is to increase the net amount that acetylcholine activity at the nurse in absence. This is walk to aid improve conduction, and also it’s walk to aid the muscles have a little much more strength. It’s walking to type of combat some of that weakness. So that is a cholinesterase inhibitor. Okay. The following thing is we want to monitor respiratory tract status. For this reason we want to monitor respiratory status. They are at high threat for respiratory distress due to muscle weakness and dysphagia. They can aspirate. 

We space going to have actually a suction set up in ~ bedside. Okay. We space going to make sure that this patients are all set in the rooms in case of one emergency, since they are at a greater risk the aspiration and also at a greater risk of respiratory tract distress. We’re walking to educate the patience on the signs and also symptoms the cholinergic versus myasthenic crisis. Remember, we simply went with those things and also the instances can look really similar. Major muscle weakness, respiratory depression, the most essential thing is to protect the patient’s airway. Intubation might be necessary. 

They may require intubation. Therefore we desire to make sure that we’re act that. Okay. Here’s the completed treatment plan. The path though, behind it on the an essential points is that this is a chronic gradual disorder. So progressive. It’s walk to proceed to acquire worse, hopefully v the tensilon test, that we space going to be able to at the very least preserve few of that continual function. That’s objective data that they room going to complain of. There’s going to be sudden weakness. The weakness is going come be very sudden. They’re walk to have some dysphasia. They’re walking to have actually some an obstacle swallowing. For this reason you may hear part coughing as soon as they take in liquids, dyspnea, some difficulty breathing since those muscles and also the diaphragm the controls the lungs room going to be very weak. We’re going to see on the monitor that they space going to have increased heart rate. 

They’re walking to be tachycardic. The BP is walking to be up over there may also present v some droopy eyelids or ptosis, as well as some hypoxia. We’re going to make certain we have actually suction at the bedside since this patience may enter V-fib and also they may need some mechanical ventilation. I’m going to perform a sloop down evaluation because they room at high danger for aspiration due to their excessive muscle weakness. And also we are going to advice this swallowing because they may need to go NPO. This was a most information. But know that we love friend guys;go out and also be your best self today. And, together always, happy londonchinatown.org.