Myasthenia Gravis Nursing Care Plan & Management

EXPLANATION

✔Correct answer:

Contact the physician without delay. The symptoms described — elevated temperature, increased heart rate, heightened blood pressure, and incontinence — are concerning and may indicate a myasthenic crisis or a cholinergic crisis in a patient with myasthenia gravis. Both conditions are medical emergencies that require immediate intervention. A myasthenic crisis is characterized by severe muscle weakness that can affect breathing, while a cholinergic crisis results from an excess of acetylcholine due to overmedication with anticholinesterase drugs, leading to muscle overstimulation and similar symptoms. Prompt communication with the physician is crucial to determine the appropriate course of action and to initiate necessary treatments.

Myasthenia gravis involves an autoimmune attack on acetylcholine receptors at the neuromuscular junction, leading to muscle weakness. A myasthenic crisis can be triggered by factors such as infection, stress, or insufficient medication, leading to exacerbation of muscle weakness and potential respiratory failure. A cholinergic crisis, on the other hand, results from too much acetylcholine due to excessive anticholinesterase medication, causing muscle twitching, bradycardia, and other parasympathetic symptoms.

Think of the neuromuscular junction as a communication line. In a myasthenic crisis, the signal is too weak, leading to poor communication (muscle weakness). In a cholinergic crisis, there is too much noise on the line, causing confusion and overstimulation (muscle twitching and weakness).

Nurses should prioritize actions that ensure patient safety and prompt medical intervention.

• Contact the physician immediately to report the patient's symptoms and receive instructions on the next steps.
• Monitor the patient's respiratory status closely, as respiratory muscle weakness can lead to respiratory failure.
• Prepare for potential interventions such as the administration of anticholinergic drugs (e.g., atropine) if a cholinergic crisis is suspected, or respiratory support if a myasthenic crisis is diagnosed.
• Ensure the patient is in a safe environment and provide reassurance to reduce anxiety and stress.
• Document the patient's symptoms and vital signs thoroughly to provide accurate information to the healthcare team.

✘Incorrect answer options:

Provide an acetaminophen suppository to manage the fever. Managing the fever alone does not address the underlying critical condition. The patient's symptoms suggest a more serious issue that requires immediate medical assessment and intervention.

Postpone the patient's scheduled physical therapy session. While physical therapy may need to be postponed, this action does not address the immediate medical emergency. The priority is to ensure the patient's safety and seek urgent medical advice.

Plan to reassess the vital signs after one hour. Delaying action by waiting to reassess vital signs could result in worsening of the patient's condition. Immediate medical intervention is necessary to address the potential myasthenic or cholinergic crisis.

EXPLANATION

✔Correct answer:

The client's respiratory effectiveness and capability to swallow. Myasthenia gravis is a neuromuscular disorder that primarily affects voluntary muscles. It is characterized by muscle weakness and fatigue. The most critical and life-threatening complications associated with myasthenia gravis involve the respiratory muscles and the muscles involved in swallowing. Monitoring the client's respiratory effectiveness is crucial because respiratory failure can occur if the respiratory muscles become too weak to function properly. Similarly, monitoring the client's ability to swallow is essential to prevent aspiration, which can lead to pneumonia or airway obstruction.

In myasthenia gravis, antibodies attack acetylcholine receptors at the neuromuscular junction, impairing the transmission of signals from nerves to muscles. This results in muscle weakness and fatigue. The muscles involved in breathing and swallowing are especially at risk because their failure can lead to severe complications such as respiratory failure and aspiration pneumonia.

Imagine a delivery system where messages (signals) must reach various parts of a factory (muscles) to keep it running. If the delivery trucks (signals) can't reach the critical departments (respiratory and swallowing muscles) due to blocked roads (damaged receptors), the factory can experience a catastrophic shutdown (respiratory failure or aspiration).

Nurses should perform regular assessments of respiratory function and swallowing ability. These include monitoring vital signs, conducting respiratory assessments (such as measuring oxygen saturation and peak expiratory flow), and evaluating the client's ability to swallow safely.

• Perform frequent respiratory assessments, including measuring respiratory rate, depth, and effort, as well as oxygen saturation levels.
• Evaluate the client's ability to swallow by observing for coughing, choking, or drooling during eating or drinking.
• Be prepared to intervene with oxygen therapy, suctioning, or even mechanical ventilation if respiratory distress occurs.
• Ensure that the client is eating and drinking safely, possibly involving a speech therapist to assess and recommend appropriate dietary modifications or swallowing techniques.
• Educate the client and family about the signs of respiratory distress and the importance of immediate medical attention if these signs occur.

✘Incorrect answer options:

The client's capacity to chew and articulate words clearly. While difficulties with chewing and speaking are common in myasthenia gravis and important to monitor, they are not as immediately life-threatening as issues related to respiration and swallowing.

The client's ability to smile and close the eyelids fully. Facial muscle weakness, such as the inability to smile or fully close the eyelids, is a symptom of myasthenia gravis but is less critical compared to respiratory and swallowing issues. These symptoms do not pose an immediate risk to the client's life.

The client's level of anxiety concerning the diagnosis. While addressing the client's emotional response to the diagnosis is important for holistic care, it is not as critical as ensuring the client's respiratory effectiveness and swallowing capability, which are directly related to survival.

EXPLANATION

✔Correct answer:

Alzheimer's disease. Alzheimer's disease is a neurodegenerative disorder characterized by the progressive loss of cognitive function, memory impairment, and changes in behavior. It is primarily associated with the accumulation of amyloid plaques and neurofibrillary tangles in the brain. While the exact cause of Alzheimer's disease is not fully understood, it is not classified as an autoimmune disease. Autoimmune diseases are conditions where the immune system mistakenly attacks the body's own tissues.

In Alzheimer's disease, the main pathological features include the buildup of beta-amyloid plaques and tau tangles, leading to the degeneration and death of neurons. This process results in the loss of brain function over time. The immune system's role in Alzheimer's is more about inflammatory responses to these pathological changes rather than an autoimmune attack on specific body tissues.

Think of Alzheimer's disease like a house deteriorating over time due to internal structural issues (plaques and tangles) rather than being attacked by an external force (autoimmune attack).

Care for patients with Alzheimer's focuses on managing symptoms, providing support, and maintaining safety and quality of life.

• Provide cognitive stimulation activities to help maintain mental function.
• Ensure a safe environment to prevent falls and accidents due to confusion or memory loss.
• Support caregivers with education and resources for managing the disease's progression.
• Monitor and manage comorbid conditions that can exacerbate cognitive decline.

✘Incorrect answer options:

Graves disease. Graves disease is an autoimmune disorder where the immune system attacks the thyroid gland, causing it to produce excessive thyroid hormones (hyperthyroidism).

Insulin-dependent diabetes mellitus. Insulin-dependent diabetes mellitus (Type 1 diabetes) is an autoimmune disease in which the immune system attacks and destroys insulin-producing beta cells in the pancreas.

Myasthenia gravis. Myasthenia gravis is an autoimmune disease where antibodies attack acetylcholine receptors at the neuromuscular junction, leading to muscle weakness.

EXPLANATION

✔Correct answer:

Visual impairments, specifically double vision (diplopia). Myasthenia gravis is an autoimmune neuromuscular disorder characterized by weakness and rapid fatigue of voluntary muscles. The hallmark of myasthenia gravis is muscle weakness that worsens with activity and improves with rest. One of the earliest and most common symptoms is ocular involvement, which includes ptosis (drooping of one or both eyelids) and diplopia (double vision). These symptoms occur because the muscles that control eye and eyelid movement are often the first to be affected.

Myasthenia gravis occurs when the immune system produces antibodies that block or destroy many of the acetylcholine receptors at the neuromuscular junction, the site where nerve cells communicate with the muscles they control. With fewer acetylcholine receptors available, the muscles receive fewer signals from the nerve cells, leading to weakness and fatigue.

Think of the neuromuscular junction like a telephone line where messages (signals) need to be sent to activate muscles. In myasthenia gravis, it's as if the line is being blocked or interfered with, making it difficult for the message to get through, resulting in muscle weakness.

Nurses should focus on strategies to manage muscle weakness and prevent complications.

• Monitor the client's respiratory status, as respiratory muscles can also be affected.
• Administer medications as prescribed, such as anticholinesterase agents and immunosuppressants, to improve neuromuscular transmission and reduce the immune response.
• Educate the client on energy conservation techniques and the importance of frequent rest periods to manage fatigue.
• Assist with activities of daily living as needed, especially during periods of muscle weakness.
• Provide emotional support and resources for coping with a chronic condition.

✘Incorrect answer options:

Sudden, severe headache often described as “the worst headache” of the client’s life. This symptom is more indicative of a subarachnoid hemorrhage, a type of stroke caused by bleeding into the space surrounding the brain. It is not associated with myasthenia gravis.

Progressive paralysis that begins in the lower extremities and ascends. This describes Guillain-Barré syndrome, an autoimmune disorder in which the body's immune system attacks the peripheral nerves, leading to progressive weakness that typically starts in the legs and ascends to the upper body.

Stiffness in movement, characterized by cogwheel rigidity, and impaired coordination. These symptoms are characteristic of Parkinson’s disease, a neurodegenerative disorder that affects movement, leading to symptoms such as tremors, stiffness (rigidity), and impaired coordination.

EXPLANATION

✔Correct answer:

Acetylcholine.  Myasthenia gravis is an autoimmune disorder where antibodies attack and destroy acetylcholine receptors at the neuromuscular junction. Acetylcholine is a neurotransmitter that plays a critical role in transmitting nerve impulses to muscles. When acetylcholine binds to its receptors on muscle cells, it triggers muscle contraction. In myasthenia gravis, the reduction of acetylcholine receptors leads to impaired communication between nerves and muscles, resulting in muscle weakness and fatigue.

Acetylcholine is released from nerve endings and binds to receptors on the muscle cell membrane. This binding initiates a series of events that lead to muscle contraction. In myasthenia gravis, the immune system mistakenly targets and reduces the number of these receptors, diminishing the muscle's ability to contract in response to nerve impulses.

Think of acetylcholine as a key that fits into a lock (receptor) to open a door (muscle contraction). In myasthenia gravis, many of the locks are damaged or missing, so even though you have the key, you can't open as many doors, leading to muscle weakness.

Understanding the role of acetylcholine in myasthenia gravis is crucial for effective management. Treatments often aim to increase acetylcholine levels or improve its availability at the neuromuscular junction.

• Administer cholinesterase inhibitors like pyridostigmine (Mestinon) to prevent the breakdown of acetylcholine and enhance its effect on muscle contraction.
• Monitor and manage symptoms to prevent complications, such as respiratory failure due to weakened respiratory muscles.
• Educate the patient on the importance of medication adherence and the timing of doses to optimize muscle function.

✘Incorrect answer options:

Norepinephrine Norepinephrine is a neurotransmitter involved in the body's fight-or-flight response, regulating heart rate, blood pressure, and alertness. It is not primarily involved in muscle contraction at the neuromuscular junction.

Dopamine Dopamine is a neurotransmitter involved in regulating mood, motivation, and motor control. It plays a significant role in diseases like Parkinson's but is not directly involved in the neuromuscular transmission affected in myasthenia gravis.

GABA GABA (gamma-aminobutyric acid) is an inhibitory neurotransmitter in the central nervous system that reduces neuronal excitability. It does not play a role in the neuromuscular transmission disrupted in myasthenia gravis.

EXPLANATION

✔Correct answer:

Align her meal times with the peak action of her medication, Mestinon. Pyridostigmine (Mestinon) is a cholinesterase inhibitor used to treat myasthenia gravis by improving neuromuscular transmission and increasing muscle strength. By scheduling Selena's meals during the peak action of Mestinon, Nurse Ramirez can ensure that Selena has optimal muscle strength for swallowing, thus reducing the risk of aspiration.

Mestinon increases the availability of acetylcholine at the neuromuscular junction, enhancing muscle contraction. Since swallowing involves the coordinated action of multiple muscles, having maximal acetylcholine activity during meals helps maintain adequate muscle function, thereby preventing aspiration.

Imagine you have a flashlight (muscle strength) that runs on rechargeable batteries (acetylcholine). Mestinon acts like a battery charger. To ensure the flashlight shines its brightest when you need it (during meals), you charge it fully right before using it. This way, the flashlight has the most power (muscle strength) when you need it to see clearly (swallow safely).

To minimize aspiration risk, Nurse Ramirez should coordinate Selena's medication schedule with her meal times, ensuring she has maximum muscle strength when eating.

• Administer Mestinon 30-60 minutes before meals to maximize its effect during eating.
• Monitor Selena's swallowing ability and adjust meal times as necessary based on the medication's effectiveness.
• Educate Selena on the importance of taking her medication consistently and in relation to meal times.
• Encourage Selena to eat slowly and take small bites to further reduce aspiration risk.

✘Incorrect answer options:

Evaluate her breathing function before and after she eats. While monitoring breathing function is important for overall care, it does not directly address the immediate concern of optimizing swallowing function during meals to prevent aspiration.

Modify her diet from soft foods to exclusively clear liquids. Switching to a clear liquid diet may not provide adequate nutrition and does not necessarily prevent aspiration. Soft foods are often easier to swallow and can be more nutritious.

Ensure that an emergency tracheostomy kit is readily available in her room. Having an emergency tracheostomy kit is a precautionary measure for severe respiratory emergencies but does not directly prevent aspiration during meals. The focus should be on optimizing swallowing function.

EXPLANATION

✔Correct answer:

Prostigmine (neostigmine) Myasthenia gravis is an autoimmune disorder characterized by weakness and rapid fatigue of voluntary muscles. It is caused by a breakdown in the communication between nerves and muscles. The primary treatment goal is to improve neuromuscular transmission and increase muscle strength.

Neostigmine is a cholinesterase inhibitor that works by inhibiting the enzyme acetylcholinesterase, which breaks down acetylcholine in the synaptic cleft. By inhibiting this enzyme, neostigmine increases the amount of acetylcholine available to bind to receptors on the muscle endplate, thereby improving neuromuscular transmission and muscle contraction.

In myasthenia gravis, antibodies block, alter, or destroy the acetylcholine receptors at the neuromuscular junction, preventing muscle contraction. Cholinesterase inhibitors like neostigmine prevent the degradation of acetylcholine, enhancing communication between nerves and muscles, and thus improving muscle strength.

Imagine a key (acetylcholine) fitting into a lock (acetylcholine receptor) to open a door (muscle contraction). In myasthenia gravis, the lock is blocked by gum (antibodies). Neostigmine acts like an extra dose of lubricant that helps more keys stay around longer, making it more likely to open the lock despite the gum.

Nurses should monitor patients closely for signs of cholinergic crisis (overdose) or myasthenic crisis (underdose), as both conditions require prompt intervention.

• Administer neostigmine as prescribed and monitor for therapeutic effects, such as improved muscle strength and reduced fatigue.
• Educate the patient about the importance of taking medication on time to maintain steady drug levels and avoid exacerbation of symptoms.
• Watch for side effects, including bradycardia, increased salivation, muscle cramps, and gastrointestinal upset.
• Encourage the patient to rest between activities to manage fatigue effectively.
• Provide support for activities of daily living as needed, especially during periods of increased weakness.

✘Incorrect answer options:

Didronel (etidronate) Didronel is a bisphosphonate used to treat and prevent osteoporosis and Paget's disease of bone. It does not have any role in the treatment of myasthenia gravis, as it does not affect neuromuscular transmission or muscle strength.

Atropine (atropine sulfate) Atropine is an anticholinergic medication used to treat bradycardia (slow heart rate) and as a preoperative medication to reduce saliva production. It works by blocking the action of acetylcholine on muscarinic receptors, which is the opposite effect needed in myasthenia gravis treatment. Using atropine would actually worsen myasthenia gravis symptoms.

Tensilon (edrophonium) Tensilon is also a cholinesterase inhibitor like neostigmine, but it has a very short duration of action and is primarily used in the diagnosis of myasthenia gravis through the Tensilon test. While it is not typically used for long-term management, its function helps diagnose myasthenia gravis by temporarily improving muscle strength, confirming the diagnosis.

EXPLANATION

✔Correct answer:

The strength of the client's muscles. Edrophonium HCl (Tensilon) is a short-acting cholinesterase inhibitor used in the diagnosis of myasthenia gravis. This medication temporarily increases the level of acetylcholine at the neuromuscular junction by inhibiting the enzyme cholinesterase, which breaks down acetylcholine. By doing so, it enhances neuromuscular transmission and temporarily improves muscle strength in individuals with myasthenia gravis.

Myasthenia gravis is characterized by muscle weakness due to the immune system's attack on acetylcholine receptors at the neuromuscular junction. Edrophonium works by preventing the breakdown of acetylcholine, thus allowing more acetylcholine to be available to stimulate the remaining functional receptors. This leads to a temporary improvement in muscle strength, which helps confirm the diagnosis of myasthenia gravis if the test is positive.

Imagine a concert where the musicians (muscles) need sheet music (acetylcholine) to play their instruments. Normally, a clean-up crew (cholinesterase) removes the sheets too quickly, causing the musicians to struggle. Edrophonium acts like a temporary order to the clean-up crew to pause, allowing more sheet music to stay available. As a result, the musicians can play their instruments more effectively, improving the concert's quality (muscle strength).

During the Tensilon test, it is crucial for nurses to monitor the client for signs of increased muscle strength as well as any adverse reactions, such as bradycardia or bronchospasm, which require immediate intervention.

• Prepare emergency equipment and medications, including atropine, in case of a cholinergic crisis.
• Monitor the client’s vital signs before, during, and after the administration of Edrophonium.
• Observe and document any changes in muscle strength and any adverse reactions.
• Educate the client about the purpose of the test and what to expect during the procedure.

✘Incorrect answer options:

The symptoms of the condition. Edrophonium typically decreases the symptoms of myasthenia gravis temporarily by improving muscle strength, not increasing them. If symptoms worsen, it may indicate a cholinergic crisis rather than myasthenia gravis.

The client's blood pressure. Edrophonium primarily affects the neuromuscular junction and does not directly increase blood pressure. However, it can cause side effects like bradycardia, which may affect blood pressure indirectly.

The level of consciousness of the client. Edrophonium does not affect the level of consciousness. Its action is focused on the neuromuscular junction to improve muscle strength, not on the central nervous system.

EXPLANATION

✔Correct answer:

Inhibiting the activity of cholinesterase. Neostigmine (Prostigmin) is a cholinesterase inhibitor, meaning it works by inhibiting the enzyme cholinesterase. This enzyme is responsible for breaking down acetylcholine, a neurotransmitter that transmits signals from nerve cells to muscles. By inhibiting cholinesterase, Neostigmine increases the amount of acetylcholine available at neuromuscular junctions, thereby improving communication between nerves and muscles. This is particularly beneficial for patients with myasthenia gravis, a condition characterized by muscle weakness due to a decreased number of acetylcholine receptors.

In myasthenia gravis, the body's immune system attacks the acetylcholine receptors at the neuromuscular junction, reducing the muscle's ability to respond to nerve signals. Neostigmine prolongs the action of acetylcholine by preventing its breakdown, thus enhancing neuromuscular transmission and improving muscle strength.

 Think of acetylcholine as a messenger delivering instructions from the brain to muscles. Cholinesterase is like a messenger cleanup crew that removes these instructions. If the cleanup crew works too quickly, the messages don’t reach the muscles effectively. Neostigmine slows down the cleanup crew, ensuring the messages are delivered and acted upon.

Nurses administering Neostigmine must monitor for signs of both overdose (cholinergic crisis) and underdose (myasthenic crisis). Key assessments include muscle strength, respiratory function, and the presence of side effects such as increased salivation, sweating, and gastrointestinal upset.

• Ensure timely administration of the medication to maintain optimal acetylcholine levels.
• Educate the patient on recognizing signs of both cholinergic and myasthenic crises.
• Monitor respiratory function closely, as respiratory muscles can be significantly affected in myasthenia gravis.
• Provide regular follow-up and adjustment of dosage as needed based on the patient’s response and side effects.

✘Incorrect answer options:

Speeding up the transmission of signals along nerve pathways. Neostigmine does not directly speed up the transmission of nerve signals. Instead, it increases the availability of acetylcholine, enhancing the signal transmission at the neuromuscular junction specifically.

Activating the cerebral cortex. Neostigmine does not activate the cerebral cortex. Its action is peripheral, specifically at the neuromuscular junction, rather than central.

Substituting for neurotransmitters that are lacking. Neostigmine does not substitute for neurotransmitters. Instead, it increases the effectiveness of acetylcholine by preventing its breakdown, thereby making more acetylcholine available to stimulate muscle contraction.

EXPLANATION

✔Correct answer:

A reduced number of functional acetylcholine receptor sites. Myasthenia gravis is an autoimmune disease where the body's immune system produces antibodies that attack and destroy acetylcholine receptors at the neuromuscular junction. This reduction in the number of functional acetylcholine receptor sites leads to impaired communication between nerves and muscles, resulting in muscle weakness and fatigue.

Normally, acetylcholine is released from nerve endings and binds to acetylcholine receptors on muscle cells, triggering muscle contraction. In myasthenia gravis, the destruction of these receptors by antibodies decreases the muscle's ability to respond to nerve signals, leading to the characteristic muscle weakness seen in this condition.

Imagine trying to unlock a door with multiple keyholes (receptors). If many of the keyholes are damaged or blocked (destroyed receptors), even though you have the key (acetylcholine), you can't open the door (trigger muscle contraction) effectively, leading to difficulty in muscle movement.

Effective management of myasthenia gravis includes medications that increase acetylcholine levels or suppress the immune system, as well as supportive care to manage symptoms and prevent complications.

• Administer cholinesterase inhibitors (e.g., pyridostigmine) to enhance the action of acetylcholine at the neuromuscular junction.
• Monitor for signs of myasthenic or cholinergic crises and provide appropriate interventions.
• Educate the client about energy conservation techniques and the importance of medication adherence.
• Collaborate with other healthcare professionals, such as physical therapists, to optimize the client's functional abilities and quality of life.

✘Incorrect answer options:

A genetic error in the production of acetylcholine. Myasthenia gravis is not caused by a genetic error in acetylcholine production. It is an autoimmune disorder targeting the acetylcholine receptors.

A diminished quantity of the neurotransmitter acetylcholine. The amount of acetylcholine is not significantly reduced in myasthenia gravis. The problem lies in the reduced number of receptors that can bind acetylcholine, not in the quantity of the neurotransmitter itself.

An obstruction of the enzyme ACHE, resulting in end-plate deformities. The enzyme acetylcholinesterase (ACHE) breaks down acetylcholine. Inhibiting this enzyme is actually a treatment strategy for myasthenia gravis to increase acetylcholine availability. The disease does not involve obstruction of ACHE or result in end-plate deformities.

EXPLANATION

✔Correct answer:

Preserve the client's current level of muscle strength. During the diagnostic phase of myasthenia gravis, the primary nursing goal should be to preserve the client's current level of muscle strength. Myasthenia gravis is characterized by weakness and fatigue of voluntary muscles, and maintaining muscle strength is crucial for the patient's overall function and quality of life. By focusing on preserving muscle strength, Nurse Johnson can help prevent further decline in the patient's condition and prepare for appropriate treatment interventions.

Myasthenia gravis is an autoimmune disorder where antibodies attack acetylcholine receptors at the neuromuscular junction, impairing muscle contraction. This leads to fluctuating muscle weakness and fatigue, which can affect activities of daily living. Preserving muscle strength involves optimizing medication management, encouraging rest periods, and avoiding factors that exacerbate symptoms.

Imagine muscles are like batteries that need to be regularly recharged to maintain power. Preserving muscle strength is like ensuring these batteries are charged properly and not overused, preventing them from running out of power prematurely.

Nurses should implement strategies to help the client maintain their current muscle function and prevent deterioration.

• Administer prescribed medications, such as anticholinesterase agents, on schedule to improve neuromuscular transmission.
• Encourage the client to take frequent rest breaks to prevent muscle fatigue.
• Educate the client about avoiding factors that can exacerbate symptoms, such as stress, extreme temperatures, and infections.
• Monitor the client’s respiratory function, as respiratory muscles can be affected in myasthenia gravis.
• Collaborate with physical and occupational therapists to develop an exercise program that promotes muscle strength without causing fatigue.

✘Incorrect answer options:

Support the client in coping and adjusting psychologically to the diagnosis. While psychological support is important, it is not the primary focus during the diagnostic phase. The immediate priority is to preserve muscle strength to maintain the client’s physical function.

Formulate an educational plan tailored to the client's condition and needs. Education is crucial but secondary to preserving muscle strength during the initial phase of diagnosis. Once muscle strength is stabilized, education can be more effectively tailored to the client’s needs.

Prepare strategically for the potential onset of a myasthenic crisis. While preparing for a myasthenic crisis is important, it is more of a contingency plan. The primary goal during the diagnostic phase is to maintain the current level of muscle strength to prevent immediate deterioration.

EXPLANATION

✔Correct answer:

Intestinal obstruction. Pyridostigmine (Mestinon) is an anticholinesterase medication used to increase acetylcholine levels at the neuromuscular junction, thereby improving muscle strength in patients with myasthenia gravis. However, pyridostigmine enhances parasympathetic activity, which can increase gastrointestinal motility and secretions. This increased motility can exacerbate conditions such as intestinal obstruction, making it a contraindication for the use of this medication.

Anticholinesterase inhibitors like pyridostigmine work by inhibiting the enzyme acetylcholinesterase, which breaks down acetylcholine. Increased levels of acetylcholine enhance the transmission of signals at neuromuscular junctions, improving muscle strength. However, acetylcholine also acts on the muscarinic receptors in the gastrointestinal tract, increasing peristalsis and secretion. In a person with an intestinal obstruction, this effect could worsen the obstruction, potentially leading to serious complications like bowel perforation.

Imagine a blocked water pipe (intestinal obstruction). Pyridostigmine is like turning up the water pressure (increasing gastrointestinal motility) in an already blocked pipe, which can cause the pipe to burst (intestinal perforation).

Nurses should be aware of contraindications and assess the patient's medical history thoroughly before administering pyridostigmine.

• Review the patient's medical history for any indications of gastrointestinal issues, especially obstructions.
• Monitor the patient for symptoms of gastrointestinal distress, such as severe abdominal pain, vomiting, and lack of bowel movements.
• Educate the patient on the importance of reporting any new or worsening gastrointestinal symptoms immediately.
• Coordinate with the healthcare team to adjust the treatment plan if contraindications are present.

✘Incorrect answer options:

Blood dyscrasia. Blood dyscrasia, a condition affecting the blood, does not directly contraindicate the use of pyridostigmine. This medication does not have a significant impact on blood components or their function.

Spinal cord injury. While spinal cord injuries can lead to muscle weakness and other complications, they are not a contraindication for pyridostigmine. This medication specifically targets neuromuscular junctions to improve muscle strength and would not adversely affect a person with a spinal cord injury in the same way it would with an intestinal obstruction.

Ulcerative colitis. Although ulcerative colitis is a gastrointestinal condition, it primarily affects the colon and involves inflammation rather than obstruction. While increased gastrointestinal motility from pyridostigmine could theoretically exacerbate symptoms, it is not an absolute contraindication like an intestinal obstruction.

EXPLANATION

✔Correct answer:

Missing doses of prescribed medication. A myasthenic crisis is a severe exacerbation of myasthenia gravis characterized by extreme muscle weakness, which can lead to respiratory failure if not promptly treated. One of the most common precipitating factors for a myasthenic crisis is missing doses of prescribed medication, such as anticholinesterase agents (e.g., pyridostigmine). These medications are crucial for maintaining muscle strength by enhancing neuromuscular transmission. When doses are missed, the levels of acetylcholine in the neuromuscular junction drop, leading to severe muscle weakness and potentially a crisis.

Myasthenia gravis patients rely on regular administration of anticholinesterase medications to inhibit the breakdown of acetylcholine, which is necessary for muscle contraction. Missing doses disrupts this process, leading to decreased acetylcholine availability, impaired neuromuscular transmission, and consequently, severe muscle weakness.

Imagine a person with myasthenia gravis like a person who needs to charge their phone frequently to keep it running. Missing doses of medication is like forgetting to charge the phone, leading to a sudden shutdown when the battery (muscle strength) depletes.

Nurses should focus on ensuring medication adherence and educating patients on the importance of regular medication schedules.

• Assess the patient’s understanding of their medication regimen and emphasize the importance of not missing doses.
• Provide written instructions and reminders about medication schedules.
• Develop strategies with the patient to help them remember to take their medication, such as setting alarms or using pill organizers.
• Monitor the patient’s medication administration closely, especially during periods of adjustment to new dosages or medications.
• Educate the patient on recognizing early signs of a myasthenic crisis and when to seek medical help.

✘Incorrect answer options:

Consuming an excessive amount of medication. This would more likely lead to a cholinergic crisis rather than a myasthenic crisis. A cholinergic crisis occurs due to an excess of acetylcholine, often from overmedication, leading to symptoms like muscle twitching, increased salivation, and respiratory distress.

A rise in the consumption of fatty foods. Dietary changes, including an increase in fatty foods, are not typically associated with triggering a myasthenic crisis. Myasthenic crises are more directly related to medication management and physiological stressors.

Inadequate amounts of physical activity. While physical activity levels can impact overall muscle strength and fatigue in myasthenia gravis, insufficient physical activity alone is unlikely to directly precipitate a myasthenic crisis. The crisis is more closely linked to disruptions in medication adherence or increased physical or emotional stress.

EXPLANATION

✔Correct answer:

Monitor for signs of cholinergic crisis, such as muscle weakness and respiratory distress. Pyridostigmine bromide (Mestinon) is an anticholinesterase medication used to increase acetylcholine at the neuromuscular junction, improving muscle strength in individuals with myasthenia gravis. However, it’s crucial to monitor for signs of a cholinergic crisis, which occurs when there is too much acetylcholine, leading to muscle overstimulation. Symptoms of a cholinergic crisis include muscle weakness, respiratory distress, excessive salivation, and bradycardia. Detecting these signs early is critical because a cholinergic crisis can lead to severe respiratory compromise and requires immediate intervention.

Pyridostigmine inhibits acetylcholinesterase, the enzyme that breaks down acetylcholine. This action increases acetylcholine levels, improving neuromuscular transmission. However, too much acetylcholine can overstimulate the muscles, leading to symptoms of a cholinergic crisis.

Imagine a faucet that needs to release just the right amount of water (acetylcholine) to fill a cup (muscle function). Too little water leaves the cup empty (myasthenic crisis), while too much water overflows it (cholinergic crisis). Monitoring ensures the right balance is maintained.

Nurses should be vigilant in monitoring patients starting on pyridostigmine, especially during dosage adjustments, to prevent and promptly address a cholinergic crisis.

• Observe for symptoms of muscle weakness, respiratory distress, and other signs of cholinergic crisis.
• Have atropine (an anticholinergic drug) readily available to counteract the effects of a cholinergic crisis if it occurs.
• Educate the patient and family members about the signs of a cholinergic crisis and when to seek immediate medical help.
• Regularly assess the patient’s respiratory function, as respiratory muscles can be critically affected.
• Collaborate with the healthcare team to adjust medication dosages based on the patient’s response and side effects.

✘Incorrect answer options:

Ensure Taylor follows a high-protein diet to enhance medication absorption. While a balanced diet is important, dietary protein does not specifically enhance the absorption of pyridostigmine. Monitoring for a cholinergic crisis takes precedence.

Encourage Taylor to perform vigorous physical activities to improve muscle strength. Vigorous physical activity is not recommended during the initial adjustment period of pyridostigmine dosage. Overexertion can exacerbate muscle weakness in myasthenia gravis patients.

Schedule frequent ophthalmic exams to monitor changes in visual acuity. While monitoring for ocular symptoms like ptosis and diplopia is important in myasthenia gravis, it is not the top priority during the initial dosage adjustment of pyridostigmine. Ensuring the patient does not develop a cholinergic crisis is more critical.

EXPLANATION

✔Correct answer:

Adhering to a strict medication schedule to ensure stable therapeutic blood levels. Adhering to a strict medication schedule is crucial for individuals with myasthenia gravis to maintain stable therapeutic blood levels of their medications, such as cholinesterase inhibitors (e.g., pyridostigmine). These medications help improve neuromuscular transmission and muscle strength by increasing the availability of acetylcholine at the neuromuscular junction. Inconsistent medication administration can lead to fluctuations in blood levels, increasing the risk of both myasthenic crises (due to under-medication) and cholinergic crises (due to over-medication).

Myasthenia gravis causes muscle weakness due to the immune system attacking acetylcholine receptors, reducing the effectiveness of neuromuscular transmission. Medications like cholinesterase inhibitors work by preventing the breakdown of acetylcholine, thereby enhancing muscle contraction. Maintaining stable blood levels of these medications ensures continuous, optimal neuromuscular function, preventing severe exacerbations.

Think of medication adherence for myasthenia gravis like maintaining a consistent water supply to a garden. If you water the garden (take medication) regularly at the same times, the plants (muscles) stay healthy and strong. If you miss watering times (skip doses) or overwater (take extra doses), the plants either wilt (myasthenic crisis) or get waterlogged (cholinergic crisis), leading to poor garden health (muscle function).

Education on medication adherence is key for managing myasthenia gravis. This includes instructions on proper dosing times and understanding the signs of both myasthenic and cholinergic crises.

• Provide clear instructions on the timing and dosage of medications to avoid missed or extra doses.
• Teach the client to recognize early signs of a myasthenic crisis (e.g., increased muscle weakness) and a cholinergic crisis (e.g., excessive salivation, sweating, bradycardia).
• Encourage regular follow-up appointments to monitor medication efficacy and adjust dosages as needed.
• Advise the client to use alarms or reminders to help maintain a consistent medication schedule.

✘Incorrect answer options:

Completing household tasks early in the day when energy levels are higher. While managing energy levels is important for individuals with myasthenia gravis, it does not directly prevent myasthenic or cholinergic crises, which are more related to medication management.

Consuming large meals that are well-balanced. Eating well-balanced meals is important for overall health but does not specifically prevent myasthenic or cholinergic crises. In fact, large meals may be difficult to manage due to potential swallowing difficulties.

Engaging in muscle-strengthening exercises regularly. Regular exercise should be done cautiously and under medical supervision for individuals with myasthenia gravis. Overexertion can exacerbate symptoms, and while exercise is beneficial, it does not directly prevent myasthenic or cholinergic crises.

EXPLANATION

✔Correct answer:

Acetylcholine receptors. Myasthenia gravis (MG) is an autoimmune disorder characterized by weakness and rapid fatigue of the voluntary muscles. This condition occurs when the immune system produces antibodies that block or destroy many of the acetylcholine receptors at the neuromuscular junction, which is the site where nerve cells connect with the muscles they control. Acetylcholine (ACh) is a neurotransmitter that is released from motor neurons and binds to these receptors to stimulate muscle contraction. When these receptors are blocked or destroyed, the muscles cannot respond effectively to nerve impulses, leading to the symptoms of muscle weakness and fatigue seen in MG.

In a healthy neuromuscular junction, acetylcholine is released from the nerve ending and binds to acetylcholine receptors on the muscle cell membrane, initiating a series of events that result in muscle contraction. In myasthenia gravis, the antibodies that target acetylcholine receptors reduce the number of functional receptors available for acetylcholine binding. This impairs the muscle contraction process, causing the characteristic muscle weakness.

Think of acetylcholine receptors as keyholes and acetylcholine as the key that starts a car (muscle contraction). In myasthenia gravis, many of the keyholes (receptors) are blocked or damaged by glue (antibodies), preventing the key (acetylcholine) from turning and starting the car (initiating muscle contraction).

Nurses caring for patients with myasthenia gravis should focus on managing symptoms, preventing complications, and providing education.

• Administer medications such as anticholinesterase agents to improve neuromuscular transmission and corticosteroids to reduce antibody production.
• Monitor for signs of myasthenic crisis, which is a medical emergency characterized by severe muscle weakness affecting breathing.
• Encourage energy conservation techniques to manage fatigue, such as planning activities during peak energy times and taking frequent rest breaks.
• Educate patients about the importance of adhering to medication regimens and recognizing symptoms that require medical attention.
• Provide emotional support and resources for coping with the chronic nature of the disease.

✘Incorrect answer options:

Transient receptors Transient receptors are not involved in the pathology of myasthenia gravis. This term does not specifically relate to any known receptor type involved in neuromuscular transmission or autoimmune processes in MG.

Nicotinic receptors While acetylcholine receptors at the neuromuscular junction are indeed a type of nicotinic receptor, the more specific and relevant term in the context of myasthenia gravis is acetylcholine receptors. This specificity is important in understanding the exact pathophysiological mechanism of the disease.

Epinephrine receptors Epinephrine receptors, also known as adrenergic receptors, are involved in the body's response to stress and the regulation of heart rate and blood pressure. They are not related to the neuromuscular junction or the muscle weakness seen in myasthenia gravis.

EXPLANATION

✔Correct answer:

Reduce the creation of antibodies that mistakenly target and damage acetylcholine receptors. Myasthenia gravis (MG) is an autoimmune disorder where the body's immune system creates antibodies that attack acetylcholine receptors at the neuromuscular junction. These antibodies interfere with the communication between nerves and muscles, leading to muscle weakness and fatigue. Immunosuppressive therapy aims to reduce the production of these harmful antibodies, thereby improving muscle function and strength.

Normally, acetylcholine (ACh) is released from nerve endings and binds to receptors on muscle cells, triggering muscle contraction. In myasthenia gravis, antibodies block or destroy these receptors, reducing the muscles' ability to respond to nerve signals. Immunosuppressive drugs decrease the activity of the immune system, thereby reducing the production of these antibodies and preserving the acetylcholine receptors.

Think of the acetylcholine receptors as locks and acetylcholine as keys. In myasthenia gravis, the immune system produces glue that clogs the locks, preventing the keys from working. Immunosuppressive therapy acts like a solvent that prevents the production of the glue, keeping the locks clear and functional.

Nurses play a crucial role in managing patients on immunosuppressive therapy.

• Monitor the patient for signs of infection, as immunosuppressive therapy can make patients more susceptible to infections.
• Educate the patient about the importance of adhering to the medication regimen and attending regular follow-up appointments.
• Assess for side effects of immunosuppressive medications, which may include gastrointestinal disturbances, liver dysfunction, and bone marrow suppression.
• Encourage good hygiene practices and advise the patient to avoid exposure to infectious agents.
• Provide emotional support and resources for coping with the chronic nature of the disease and the therapy.

✘Incorrect answer options:

Enhance the production of acetylcholine at the site where nerves meet muscles. Immunosuppressive therapy does not directly increase the production of acetylcholine. Instead, it targets the immune system to reduce antibody production.

Prevent the degradation of acetylcholine where nerve signals are transmitted to muscles. Preventing the degradation of acetylcholine is the mechanism of action of cholinesterase inhibitors, such as neostigmine and pyridostigmine, not immunosuppressive therapy. These inhibitors increase acetylcholine availability at the neuromuscular junction but do not address the underlying autoimmune response.

Assist in eliminating antibodies that interfere with the transmission of neural signals. While this statement is partially correct, it does not fully capture the mechanism of immunosuppressive therapy. These therapies reduce the creation of antibodies rather than directly eliminating them. Treatments like plasmapheresis or intravenous immunoglobulin (IVIG) are more focused on removing circulating antibodies.

EXPLANATION

✔Correct answer:

A positive response to the edrophonium (Tensilon) test. Myasthenia gravis can be confirmed through a positive response to the edrophonium (Tensilon) test. Edrophonium chloride (Tensilon) is a short-acting acetylcholinesterase inhibitor that temporarily increases the levels of acetylcholine at the neuromuscular junction. In patients with myasthenia gravis, administration of edrophonium results in a rapid, but temporary, improvement in muscle strength, which is considered a positive test result. This improvement occurs because the increased acetylcholine compensates for the reduced number of acetylcholine receptors caused by the autoimmune attack in myasthenia gravis.

Myasthenia gravis is an autoimmune disorder where antibodies target and destroy acetylcholine receptors at the neuromuscular junction. Edrophonium works by inhibiting acetylcholinesterase, the enzyme responsible for breaking down acetylcholine. This leads to increased availability of acetylcholine, which briefly improves neuromuscular transmission and muscle strength in affected individuals.

Think of the neuromuscular junction as a toll booth where acetylcholine is the coin needed to pass through. In myasthenia gravis, the toll booth requires more coins (acetylcholine) due to fewer functional toll collectors (receptors). Edrophonium adds more coins temporarily, allowing smoother passage (muscle contraction).

Nurses should be prepared to monitor the patient during and after the Tensilon test and manage any potential adverse effects.

• Administer the edrophonium test under close medical supervision, typically in a hospital setting.
• Monitor the patient for immediate improvement in muscle strength, particularly in muscles that are easily observed, such as those controlling the eyes, facial expression, and limb strength.
• Be prepared to manage side effects such as bradycardia, bronchospasm, and increased salivation, with atropine (an anticholinergic drug) readily available to counteract these effects if necessary.
• Provide emotional support to the patient, explaining the test procedure and what they might experience during the test.

✘Incorrect answer options:

The presence of Brudzinski's sign. Brudzinski's sign is an indication of meningeal irritation and is commonly associated with meningitis. It is not related to the diagnosis of myasthenia gravis.

The detection of Kernig's sign. Kernig's sign is also a sign of meningeal irritation and is typically used in the diagnosis of meningitis, not myasthenia gravis.

A positive result on the sweat chloride test. The sweat chloride test is used to diagnose cystic fibrosis, a genetic disorder affecting the respiratory and digestive systems. It has no relevance to the diagnosis of myasthenia gravis.

EXPLANATION

✔Correct answer:

Both Pancuronium and Succinylcholine must be administered with careful monitoring. In clients with myasthenia gravis, the use of neuromuscular blocking agents (NMBAs) requires careful consideration and monitoring. Both Pancuronium and Succinylcholine can have exaggerated effects in patients with myasthenia gravis due to the altered neuromuscular transmission in these patients. The sensitivity to these agents is heightened, increasing the risk of prolonged neuromuscular blockade and subsequent respiratory complications.

Myasthenia gravis is characterized by a reduction in functional acetylcholine receptors at the neuromuscular junction. Neuromuscular blocking agents like Succinylcholine (a depolarizing NMBA) and Pancuronium (a non-depolarizing NMBA) interfere with neuromuscular transmission. Succinylcholine can cause sustained depolarization of the muscle membrane, while Pancuronium competes with acetylcholine for receptor sites, preventing muscle contraction. In myasthenia gravis patients, the response to these drugs is unpredictable and often exaggerated due to the compromised neuromuscular junction.

Imagine a damaged bridge (neuromuscular junction) that is already weak. Applying additional weight (neuromuscular blocking agents) must be done very cautiously, as the bridge is more likely to fail under stress compared to a normal, undamaged bridge.

When administering NMBAs to a client with myasthenia gravis, it is essential to monitor neuromuscular function closely and be prepared for potential complications.

• Use nerve stimulators to monitor the depth of neuromuscular blockade and adjust dosages accordingly.
• Have emergency resuscitation equipment, including ventilatory support, readily available.
• Collaborate with the anesthesiologist to ensure appropriate dosing and monitoring strategies.
• Educate the patient and family about the potential risks and the necessity of close monitoring during procedures involving NMBAs.

✘Incorrect answer options:

Avoid using Succinylcholine; however, Pancuronium may be administered in reduced doses. Both Succinylcholine and Pancuronium can have unpredictable and exaggerated effects in myasthenia gravis patients. It's not appropriate to assume that Pancuronium is safer without careful monitoring.

The client might exhibit decreased sensitivity to the effects of neuromuscular blocking agents. Patients with myasthenia gravis typically exhibit increased sensitivity, not decreased sensitivity, to neuromuscular blocking agents due to the reduced number of acetylcholine receptors.

Refrain from using Pancuronium; Succinylcholine, however, can be administered in lower doses. Succinylcholine can also cause significant complications in myasthenia gravis patients. Both agents should be used with caution and under careful monitoring, rather than preferring one over the other without due consideration.

EXPLANATION

✔Correct answer:

A quick, yet short-lived improvement in symptoms. The Tensilon test, also known as the edrophonium test, is used to diagnose myasthenia gravis. Edrophonium chloride (Tensilon) is a short-acting acetylcholinesterase inhibitor. When administered, it temporarily increases the levels of acetylcholine at the neuromuscular junction. In patients with myasthenia gravis, this leads to a rapid, albeit brief, improvement in muscle strength because it temporarily enhances neuromuscular transmission. The quick and short-lived improvement in symptoms following the injection of Tensilon is considered a positive indication for myasthenia gravis.

Myasthenia gravis is characterized by the production of antibodies that block or destroy acetylcholine receptors at the neuromuscular junction, impairing muscle contraction. Edrophonium works by inhibiting acetylcholinesterase, the enzyme responsible for breaking down acetylcholine. This inhibition increases the amount of acetylcholine available to bind to the remaining functional receptors, momentarily improving muscle strength.

Imagine a bridge where cars (acetylcholine) need to cross to reach the other side (muscles). In myasthenia gravis, many of the lanes (receptors) are blocked, causing traffic jams (muscle weakness). Tensilon temporarily opens more lanes, allowing more cars to pass through, which quickly but briefly alleviates the traffic jam.

Nurses should prepare the patient for the test and monitor them closely during and after the procedure.

• Explain the purpose and procedure of the Tensilon test to the patient, including what to expect in terms of symptom improvement and duration.
• Monitor the patient for immediate improvement in muscle strength, particularly in muscles that are easily observed, such as those controlling the eyelids, facial expression, and arm strength.
• Be prepared to manage potential side effects of edrophonium, such as bradycardia or other cholinergic symptoms, by having atropine (an anticholinergic drug) readily available.
• Provide emotional support and reassurance to the patient, addressing any concerns or anxiety about the test and its outcomes.

✘Incorrect answer options:

A long-lasting alleviation of symptoms. Edrophonium provides only a temporary improvement in symptoms due to its short duration of action. Long-lasting alleviation is not characteristic of the Tensilon test.

A temporary intensification of her current symptoms. An intensification of symptoms would suggest a negative response to the Tensilon test and might indicate a cholinergic crisis rather than myasthenia gravis.

An improvement in symptoms specifically related to eyelid drooping (ptosis). While improvement in ptosis can occur and is often observed, it is not specific enough on its own to confirm the diagnosis. The key feature of the test is the rapid and short-lived improvement in overall muscle strength.