Sarah S.

Taupan, RN, MN, DPA

INTRODUCTION
Myasthenia gravis (MG) is a complex, autoimmune disorder in which antibodies destroy neuromuscular connections. Causes problems with the nerves that communicate with muscles. Affects the voluntary muscles of the body, especially the eyes, mouth, throat, and limbs.

 Characterized by weakness and rapid fatigue

The cause of myasthenia gravis is a breakdown in the normal communication between nerves and muscles. No cure for myasthenia gravis, but treatment can help relieve s/s such as weakness of arm or leg muscles, double vision, drooping eyelids, and difficulties with speech, chewing, swallowing and breathing.
While myasthenia gravis can affect people of any age from neonatal to above 60 and more common in women younger than 40 and in men older than 60.

Chemicals messengers, called neurotransmitters, fit precisely into receptor sites on your muscle cells. In myasthenia gravis, certain receptor sites are blocked or destroyed, causing muscle weakness.

How antibodies against acetylcholine receptor block impulse conduction in synapse

CAUSES
Myasthenia gravis may be inherited as a rare, genetic disease, acquired by babies born to mothers with MG, or the disorder may develop spontaneously later in childhood.

Autoimmune disease
Excessive cholinesterase

Insufficient acetylcholine

Thymus gland, a part of your immune system located in the upper chest beneath the breastbone, may trigger or maintain the production of antibodies that result in the muscle weakness common in MG.

Face and throat muscles Speaking. - very soft or sound nasal

Swallowing-liquids may come out of the nose.

Chewing Facial expressions - "lost smile

Eye muscles 1st signs problems: Double vision ( diplopia ) Blurred vision and symptoms involve eye

Drooping of one or both eyelids (ptosis)

Arm and leg muscles Weakness in arms and legs - conjunction with muscle weakness in other parts of the body such as eyes, face or throat. The disorder usually affects arms more often than legs.

If it affects legs, may waddle when walking.

Normal dumbbell

Weakness dumbbell

Collaborative Management
1. Assess swallowing gag reflex before feeding 2. Administer medication 20-30 mins before meals 3. Administer medication at an exact time 4. Protect patient from falls 5. Implement aspiration precaution 6. Promote adequate ventilation

7. Start meal with cold beverage

8. Avoid infections, provide adequate rest

Factors worsening MG
Fatigue Illness

Stress
Extreme heat Medications such as beta blockers, calcium channel blockers, quinine and some antibiotics

COMPLICATIONS
1. Myasthenic crisis: A life-threatening condition =undermedication or delayed medication

=s/s : increase in BP & heart rate, cyanosis with severe respiratory distress, (-) for cough and gag reflex, restlessness, dysarthria and increased in secretions, diaphoresis and tearing

Mgt for Myasthenic Crisis 1. Increased the dose of cholinergics as long as the client respond positively to edrophonium
2. Tensilon test relieve symptoms 3. Mechanical ventilation

2. Cholinergic Crisis excessive medication

caused

by

= s/s : weakness with difficulty in swallowing, chewing, speaking, nausea and vomiting, diarrhea, abdominal cramps, increased salivation, secretions, sweating, lacrimation, fasciculations and blurring of visions

Mgt for Cholinergic Crisis 1. Discontinue all cholinergic drugs until cholinergic effects decreases 2. Ventilator support 3. Atropine

Other disorders

Underactive or overactive thyroid Lupus - painful or swollen joints, hair loss, extreme fatigue and a red rash on the face.

Rheumatoid arthritis - wrists and fingers, and can result in joint deformities
Thyroid Tumor

Diagnostic tests

Blood tests Genetic tests Electromyogram (EMG) CT SCAN Muscle biopsy Tensilon Test confirmatory test The client should informed about the test not be

Physical Assessment
Reflexes Muscle strength Muscle tone Senses of touch and sight Coordination Balance

CT Chest
Thymom a

Single-fiber EMG

TREATMENTS & DRUGS

Specific treatment to age, overall health, and medical history and extent of the condition

No cure for MG, but the symptoms can be controlled.

MG is a life-long medical condition and the key to medically managing MG is early detection. The goal of treatment is to prevent respiratory problems and provide adequate nutritional care to the patient since the swallowing and breathing muscles are affected by this condition.

Medications

Acetylcholinesterase/ Cholinesterase inhibitors. Enhance communication between nerves and muscles. These drugs don't cure, but improves muscle contraction and strength.

Prostigmin ( Neostigmine )
Mestinon ( Pyridostigmine )

Mytelase ( Ambenomium )

Nsg Mgt for Acetylcholinesterase

Monitor improvement of muscle strength and respiration

Observe for s/s of cholinergic crisis

Available antidote Atropine

Give the drugs before meals

Monitor for adverse effects : tearing, miosis, possible HPN, increased salivation, nausea, vomiting, abdominal cramps

Medications
Corticosteroids. These types of drugs inhibit the immune system, limiting antibody production. Prolonged use of corticosteroids, can lead to serious side effects, like bone thinning, weight gain, diabetes, increased risk of some infections, and increase and redistribution of body fat.

Immunosuppressants. To alter immune system, like azathioprine (Imuran), cyclosporine (Sandimmune, Neoral) or mycophenolate (CellCept).
Antacids

Therapy
Plasmapheresis. This procedure uses a filtering process similar to dialysis. Blood is routed through a machine that removes the antibodies that are blocking transmission of signals from nerve endings to muscles' receptor sites. However, the beneficial effects usually last only a few weeks.

Intravenous immune globulin. This therapy provides body with normal antibodies, which alters immune system response. It has a lower risk of side effects than do plasmapheresis and immunesuppressing therapy, but it can take a week or two to start working and the benefits usually last less than a month or two.

 Thymectomy Mechanical ventilation

Frequent monitoring
Drugs to be avoided :

Muscle relaxants
Bariturates Morphine sulfate Tranquilizers Neomycin

Myasthenia Gravis through yoga

Yoga Exercises
Help to stretch the body which increase the flexibility as well as strengthen the muscles of the body, which become weak due to MG. Improve blood circulation and remove carbondioxide from the body & provide oxygenated blood to every part of the body.

Pranayama yoga breathing

Helpful because the onset of MG often lead to mild depression but the practice of breathing exercises like, Nadi- Shodhan, Anulom-Vilom, Deep breathing and Mild Kapalbhati Helps to remove depression and relax the mind as well as the body. Meditation also brings more positive thinking.

Nutrition
Along with exercises & breathing practices eating habits should also be altered. Start meal with cold beverage Simple, nourishing, no stimulating foods, including plenty of fresh fruits & lightly cooked vegetable, particularly greens. Asparagus is considered excellent since it contains certain natural steroid-like nutritious elements, which help strengthen the weakened muscles caused by MG. . Food should have a blend of all necessary vitamins.

Survival Guide
Reschedule daily task Secure handicapped parking sticker

Frequent rest periods

Take medications on time

Patch each eye alternately

Initiate meal with cold liquids Avoid factors that can lead to respiratory infections : very hot or very cold weather, aerosol,alcohol, cigarette smoke

EXERCISE !!!!!!! 1. What complication that is caused by undermedication ? 2. In the presence of Cholinergic crisis what drug should be given ?

3. What are the early signs for MG?

MUCHAS GRACIAS !!!!