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