Myasthenia Gravis Nursing Care

 

Nursing Diagnosis

Ineffective Breathing Pattern related to neuromuscular weakness of the respiratory muscles and throat.

Desired outcomes

The patient will maintain an oxygen saturation of >92% and a respiratory rate of 12-20 with ADL’s.

Nursing Interventions
  • Assess for signs of activity intolerance. Ask client to rate perceived exertion.
    • Rationale: Dyspnea on exertion, palpitations, headaches, or dizziness or patient states increased exertion level, are all signs of activity intolerance and decreased tissue oxygenation.
  • Monitor pulse oximetry and report O2 saturation <92%.
    • Rationale: O2 sat of <92% indicates the need to supplement oxygen.
  • Monitor the patients pulse oximetry every 4-6 hours.
    • Rationale: An O2 saturation of less than 92% may detect hypoxia and signals the need for supplemental oxygen.
  • Encourage deep breathing exercises and administer oxygen if indicated
    • Rationale: Increases oxygen delivery to the body.
Nursing Diagnosis

Risk for Aspiration related to difficulty swallowing

Desired outcomes

Client is able to swallow independently without choking.  Able to maintain a patent airway.

Nursing Interventions
  • Assess for signs of activity intolerance. Ask client to rate perceived exertion.
    • Rationale: Dyspnea on exertion, palpitations, headaches, or dizziness or patient states increased exertion level, are all signs of activity intolerance and decreased tissue oxygenation.
  • Monitor pulse oximetry and report O2 saturation <92%.
    • Rationale: O2 sat of <92% indicates the need to supplement oxygen.
Nursing Diagnosis

Self-Care Deficit related to muscle weakness, general fatigue.

Desired outcomes

Patient is able to perform self-care activities independently and able to demonstrates ability to use adaptive devices for completion on ADL’s.

Nursing Interventions
  • Observe the patient’s ability to perform activities of daily living.
    • Rationale: This will show performance challenges and the level which the patient needs assistance with completing ADL’s.
  • Allow enough time for task performance. DO not rush patient. Involve family and significant others in care activities. Observe activities to ensure patient can perform them safely without assistance.
    • Rationale: Allowing sufficient time preserves the patients energy and increases activity tolerance.
Nursing Diagnosis

Activity intolerance related to muscle weakness

Characterized by:

Subjective Data:

  • Patients say tired after doing the activity.
  • Patients report muscle weakness.

Objective Data:

  • Patient seems tired and listless.
  • Patient was not able to take action to meet their daily needs.
  • Increased pulse.
  • Increased blood pressure.
  • Breathing increases.
  • Decreased muscle strength.
Outcomes
  • Full muscle strength.
  • Atrophy does not occur.
  • Good muscle tone.
  • Patients can perform the activity gradually.
  • Muscle weakness does not occur.
Nursing Interventions
  • Assess the strength of muscles, ptosis, diplopia, eye movement, ability to chew, swallow, cough reflex, talk.
    • Rationale:  The rate of muscle weakness may be different in other parts of the body.
  • Assess muscle strength before and after drug administration.
    • Rationale: Knowing the effects of drug administration.
  • Perform scheduled breaks, keep quiet surroundings.
    • Rationale: Period after the break, increased muscle strength.
  • Encourage participation in treatment.
    • Rationale: Train activity gradually.
Nursing Diagnosis

Impaired verbal communication related to muscle weakness.

Characterized by:

Subjective Data:

  • Patients say difficulty speaking

Data Objective :

  • Patients appear to difficulties in verbal expression.
  • Changes in behavior are not willing to communicate.
  • The use of sign language / body.
Outcomes

Patients expressing themselves verbally or non-verbally.

Nursing Interventions
  • Assess the patient’s ability to speak with the examination of cranial nerves V, VII, IX, X, XII.
    • Rationale: knowing the patient’s ability to speak.
  • Ask a closed question, yes or no or body movements.
    • Rationale: Facilitate patient easily answered.
  • Talk with slow motion.
    • Rationale: Can see the speaker’s lip movements.
  • Use images, paper or other means.
    • Rationale: Using media allows patients to express desire.
  • Inform staff or family, about the limitations of the patient in communication.
    • Rationale: Communication patterns that one would add to the frustration of patients.
Other Nursing Care Plans
  • A Client with Myasthenia Gravis