In this video, we’re walking through the nursing assessment and treatment for myasthenia gravis. We won’t stop there, we’re going to walk through the critical thinking behind it all, so you know why you are doing it.
Myasthenia Gravis Pathophysiology:
Myasthenia Gravis is a neurological condition that prevents muscles from contracting like they should.
Myasthenia Gravis Nursing Assessment:
- Safety concerns
- Vision
- Ability to swallow and their gag reflex
- Respiratory effort and monitor their respiratory muscles for involvement
Tensilon Test:
The medication Tensilon (or edorphonium) is an acetylcholinesterase inhibitor and it prevents the natural breakdown of acetylcholine. By preventing acetylcholine from being naturally broken down, it keeps more of it present at the neuromuscular junction and helps to flood the receptors and increase the chances of acetylcholine binding to any receptors that aren’t yet blocked by autoantibodies.
If there is improvement in muscle contraction and lack of weakness, then the test is positive for myasthenia gravis.
Myasthenic Crisis:
This is when the respiratory muscles are quickly weakening, or they are already weakened, which can lead to respiratory failure. If Tensilon is given and they temporarily become better, then they are in a myasthenic crisis.
Nursing Interventions for Myasthenia Gravis:
In the video, we’ll walk through the critical thinking for each of these and why you might do them. So you won’t need to memorize this list because you’ll actually understand the critical thinking behind each of these for your nursing exam.
- Have emergency equipment ready
- Assist with intubation as prescribed
- Elevate head of the bed
- Monitor meals
- Encourage small bites and larger meals earlier in the day
- Ensure they can ambulate safely
- Move personal belongings where they can see them
- Organize higher energy tasks in the morning
- Educate the patient on possible triggers
- Encourage rest
- Medication audit
- Give medications as prescribed
TIMESTAMPS:
Intro 0:00
Review 1:14
Nursing assessment 2:17
Treatment and nursing interventions 7:23
VIDEO TRANSCRIPT
In this video, we’re walking through the nursing assessment and treatment for myasthenia gravis.
Now, of course, we won’t stop there. We’re also going to walk through the critical thinking behind it all, so you’re not just memorizing these random nursing assessments and interventions you will be doing for your nursing school exam, but you actually will know how to critically think through it all and know why you are doing it.
Because let’s be real, when was the last time your nursing school exam tested you on memorization….
Yeah, never.
It just doesn’t work that way.
They are going to test you on how well you apply the information you’re learning and how well you critically think about. So I’m going to give you the critical thinking points you need to know, so you can learn how to critically think and ace your nursing school exam.
And of course, I have a free cheat sheet for you to help you learn things faster in nursing school. So be sure to stay until the end of the video and I’ll let you know where you can get that.
Now hit that subscribe button and click the notification bell and let’s dive in.
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Now, before we dive into the nursing assessment and treatment for myasthenia gravis, lets review the pathophysiology quick, so we have a solid foundation for our critical thinking. Like we’ve talked about in THIS video, when you think myasthenia gravis, the first thing that should come to mind is muscle weakness. Myasthenia gravis is a neurological condition that prevents muscles from contracting like they should. What’s happening here is that the patient’s immune system is attacking the connection between neurons and muscles. The neurons and the muscles can’t talk to each other, and the neurons can’t tell the muscles to contract. So when the immune system attacks like this, the muscles aren’t able to contract like they should.
Now that we have reviewed the pathophysiology and know that all the signs and symptoms of myasthenia gravis are going to be related to muscle weakness due to lack of muscle contraction. Let’s dive into what we will be assessing for as the nurse and the treatment for myasthenia gravis.
Of course, we won’t stop there though, no friend, we won’t just give you a list of nursing assessments and treatments. We will dive deeper and connect it all back to why we are doing those assessments and treatments. Connecting it all back to the pathophysiology of myasthenia gravis.
Remember, that the hallmark sign of this condition is that muscle weakness gets worse with activity but gets better with rest. That’s the key thing to know here! And all of the signs and symptoms are related to a lack of muscle contraction and muscle weakness, so keep that in mind as we go through our assessment.
So with this muscle weakness, one of the main things you want to assess for with your patient would be safety concerns. Assess their vision and if they are having strabismus with double vision.
Assess their ability to swallow and their gag reflex, which are needed to help them protect and maintain their airway. It is important to make sure the muscles they use to protect and maintain their airway are not affected, and if they are affected then the timing of meals is very important (like having them eat earlier on in the day before the muscles become tired).
You’ll also need to assess their respiratory effort and monitor their respiratory muscles for involvement. The respiratory muscles can become involved quickly as more acetylcholine is naturally broken down throughout the day. This leaves less and less of it to bind to any open nicotinic acetylcholine receptors, so the respiratory muscles can’t contract.
Remember back to the pathophysiology, the neurons and the muscles can’t talk to each other, and the neurons can’t tell the muscles to contract. So when the immune system attacks like this, the muscles aren’t able to contract like they should and get worse with activity, and better with rest. So our assessment is going to focus on muscle weakness and safety.
Another important factor to asses for is if the patient does in fact HAVE Myasthenia Gravis.
In order to assess this, a neurologist will do what’s call a tensilon test. The tensilon test can be given to help determine if the muscle weakness is caused by myasthenia gravis. The test is performed by giving the patient an injection of Tensilon.
The medication Tensilon (or edorphonium) is an acetylcholinesterase inhibitor and it prevents the natural breakdown of acetylcholine. By preventing acetylcholine from being naturally broken down, it keeps more of it present at the neuromuscular junction and helps to flood the receptors and increase the chances of acetylcholine binding to any receptors that aren’t yet blocked by autoantibodies.
If there is improvement in muscle contraction and lack of weakness, then the test is positive for myasthenia gravis. This test is usually used in combination with other hallmark signs and symptoms like ptosis (or dropped eyelids), lack of facial expression, and difficulty swallowing.
You also want to assess if the patient is in a myasthenic crisis. This means that the respiratory muscles are quickly weakening, or they are already weakened, which can lead to respiratory failure. This test is done by giving Tensilon as well. If you give them the tensilon and they temporarily become better, then they are in a myasthenic crisis and they will need more medication to help them improve.
If they become worse when you give them tensilon then they are in a cholinergic crisis. This means that the neuromuscular junction was already saturated with acetylcholine and now even more acetylcholine is present due to the tensilon. This is caused by the patient receiving too much of their treatment medications for myasthenia gravis.
If a patient is in a cholinergic crisis and is given tensilon, they can decline quickly, so it’s important to have emergency supplies very readily available before administering it. Atropine is the antidote to tensilon and will reverse it, so it should be administered if the patient is in a cholinergic crisis.
So those are the key nursing assessments you’ll need to do for a patient with myasthenia gravis. Again, relating it all back to the pathophysiology, and the why that we are doing these assessments.
The neurons and the muscles can’t talk to each other, and the neurons can’t tell the muscles to contract. So the muscles aren’t able to contract like they should and cause muscle weakness.
Now, lets talk about the nursing interventions and treatment that you might do for a patient with myasthenia gravis.
Don’t worry, we will again, walk through the critical thinking components for why we do each intervention. Let’s dive in.
Since their muscles aren’t contracting like they should, they may have muscle weakness, so they are at big risk for safety concerns with basic activities of daily living. The biggest component when taking care of patients with myasthenia gravis is SAFETY!
The biggest concern is the muscles of the respiratory system failing if they’re unable to contract. Make sure to have emergency equipment and suctioning equipment ready at the bedside at all times, and assist during intubation if necessary.
A key thing to remember is that weakness tends to worsen throughout the day as more acetylcholine is blocked and then naturally broken down over time. The muscles can’t contract without acetylcholine to tell them to. So since acetylcholine can’t bind to the receptors, there’s nothing there to tell the muscles to contract! Again, remember, that the hallmark sign of this condition is that muscle weakness gets worse with activity but gets better with rest. That’s the key thing to know here! And all of these interventions are related to a lack of muscle contraction and muscle weakness, so keep that in mind when you take your exam.
Simple tasks such as swallowing and eating food can become a challenge (especially as the meal progresses or the day goes on).
Keep the head of the bed elevated to help facilitate swallowing. And monitor their food consumption and encourage small bites, and larger meals early in day (when the muscles are most capable of contracting).
Assist them with tasks that might be difficult if they are having trouble seeing or experiencing double vision. And make sure they are safe when ambulating, and assist them when needed. You might also want to set up their personal belongings where they can see and reach them.
You will want to educate the patient on maximizing their energy when they have the most of it, like after times of rest, especially in the morning. Help them organize their most high energy demand activities in the morning, as well as eating bigger meals earlier in the day. This will allow their muscles to contract more during these times, since there’s more acetylcholine present to help stimulate those receptors.
Help your patient identify and minimize triggers that increase symptoms such as: illness, stress, hot temperatures, and hormonal changes (such as menstrual cycles). Minimizing these or preparing for them can help the patient manage their symptoms and know what to expect.
It’s also super important to encourage your patient to rest. With rest, muscle contractions can improve. Rest will allow more acetylcholine to build up at the neuromuscular junction and allow it to flood more of the receptors, helping the muscles to contract. Again, think back to that pathophysiology, the why behind our interventions.
The hallmark sign of this condition is that muscle weakness gets worse with activity but gets better with rest.
You may also need to work with the healthcare team to audit the patient’s medications, both prescribed and over the counter medications. There are many medications that interact with common meds prescribed for myasthenia gravis, and many medications may make their muscles weakness worse. So it’s important they talk with their doctor before they take any other medications.
The treatment is anticholinesterase medications, which blocks the breakdown of acetylcholine, making it more available at the neuromuscular junction site, therefore increasing muscle contraction.
With anticholinesterase you have to watch out for cholinergic crisis, which can happen when they receive too much of the medication. Signs of this would be bradycardia, pupil constriction, bronchoconstriction, respiratory failure, increase mucous production and saliva, GI upset, and incontinence. Atropine is the antidote to anticholinesterase medications, so that may be given if the patient becomes overmedicated.
Sometimes patients have relief from plasmapheresis, which removes the antibodies that are attacking the neuromuscular junction receptors, but this only works for a few months. They may also remove the thymus gland which may improve symptoms too but there is no true cure, just management of symptoms.
So those are the key nursing assessments you’ll need to do for a patient with myasthenia gravis.
Remember, that the hallmark sign of this condition is that muscle weakness gets worse with activity but gets better with rest.
The key thing to remember is that safety is your number one priority, and your first concern should be to make sure that their respiratory system isn’t compromised and that they are breathing well because of this muscle weakness that happens. And all of the nursing assessments and treatments are related to a lack of muscle contraction and muscle weakness, so keep that in mind when you take your exam.
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