Nur 212 Myasthenia Gravis

Front 1

MYASTHENIA GRAVIS
(PATHOPHYSIOLOGY)

Back 1

MG is thought to be an autoimmune disease that has an unpredictable course that has periods of exacerbation and remission.
-Chronic nueromuscular disorder
-The pt's blood cells and thymus gland produce antibodies that are directed at the acetycholine receptor sites, and block or destroy the transmission of impulses across the neomuscular juntion.
-Few receptors ae available for stimulation leading to muscle weakness that escalates with continuous activity.

Front 2

MYASHTENIA GRAVIS
(INCIDENCES)
-WHO DOES IT AFFECT?
-DOES IT AFFECT ONE GENDER MORE THAN THE OTHER?
-WHAT AGE RANGE IS AFFECTED FOR MEN/WOMEN?

Back 2

-MG affects both men and women
-Yes, it affects women 3xs more than men
-MG targets women aged 20 to 40 years and men aged 60 to 70 years.

Front 3

MYASTHENIA GRAVIS
(MANIFESTATIONS)
-WHERE DO THE SYMPTOMS INITIATE?
A)WHAT ARE THESE SYMPTOM?

Back 3

Symptoms initiate in the ocular (eyes)
A) Ocular symptoms include; diplopia (double vision) and ptosis (drooping of the upper eyelid)

Front 4

MYASTHENIA GRAVIS
(MANIFESTATIONS)
-AFTER THE INITIAL SYMPTOMS WHAT AREA IS AFFECTED NEXT?
A) WHAT ARE SOME OF THE SYMPTOMS IN THIS AREA?

Back 4

After the initial ocular symptoms of (diplopia/ptosis) the patient experiences facial symptoms
A) Symptoms include
1. weakness of facial muscles
2. weakness of the throat
3. Dysarthria (difficulty speaking)
4. Dysphagia (difficulty swallowing)

Front 5

MYASTHENIA GRAVIS
(MANIFESTATIONS)
-WHAT IS A PT. WITH SYMPTOMS OF DYSPHAGIA AT RISK FOR?

Back 5

A pt. with dysphagia is at risk for aspiration (breathing in of foreign objects; eg. food into the airway)

Front 6

MYASTHENIA GRAVIS
(MANIFESTATIONS)
-MUSCULOSKELETAL

Back 6

-Fatigue & weakness (more so later in the day than in the morning).
-Fine motor movements are difficult
-Decreased functioning of hands, arms, legs and neck muscles

Front 7

MYASTHENIA GRAVIS
(MANIFESTATIONS)
-RESPIRATORY

Back 7

-Weakening of the intercostal muscles
-Decrease in diaphragm movement
-Dyspnea
-Poor gas exchange

Front 8

MYASTHENIA GRAVIS
(MANIFESTATIONS)
-What can result if a patient has weakening of the intercostal muscles and decreased diaphragm movement

Back 8

-This can result in a decreae in vital capacity (maximum amt of air a person can expel from the lungs after a maximum of inspiration) leading to respiratory failure.

Front 9

MYASTHENIA GRAVIS
(MANIFESTATION)
-NUTRITIONAL

Back 9

Due to weakness the patient can have difficulty chewing and swallowing (dysphagia)

Front 10

MYASTHENIA GRAVIS
-What are some risks for a patient presenting symptoms of dysphagia and difficulty chewing?

Back 10

This patient is at risk for;
1. aspiration
2. choking
3. malnutrition
4. weight loss

Front 11

MYASTHENIA GRAVIS
(MEDS)
-WHEN SHOULD MEDS BE GIVEN (in relation to meals)?

Back 11

Patient"s with MG should be given meds 30 minutes prior to meals and they should be extended release form.

Front 12

MYASTHENIA GRAVIS
(DIAGNOSTIC TEST)
-WHAT IS THE TENSILON TEST
A)HOW IS IT PERFORMED
B) HOW ARE THE RESULTS READ AND DOCUMENTED AS

Back 12

-The Tensilon test, test if the patient is (+/-) for Myasthenia Gravis
A) The pt. is given Tensilon (edrophonium chloride) starting with 2mg. if the pt's symptoms are releived in 30secs, then the pt. has MG
-or- If there are no changes in symptoms with the first dose, the dose is increased to 8mg, wait another 30 secs..if symptoms are resolved the patient is (+) for MG.
-If the patient has been given the drug (2mg. f/up with 8mg) and there's no change the pt. does not have MG.
B) If the symptoms are resolved it's documented as "The patient had a (+) Tension Test"

Front 13

MYASTHENIA GRAVIS
(TENSILON TEST)
-If a patient has a (+) Tensilon test meaning they have Myasthenia Gravis, after they are given Tensilon does it cure the patient's symptoms? resolved.

Back 13

-When the patient is give Tensilon their symptoms are only resolved for approx 5mins.

Front 14

MYASTHENIA GRAVIS
(DIAGNOSTIC TEST)
-WHAT ARE THE DIFFERENT TEST FOR MYASTHENIA GRAVIS

Back 14

1. Tensilon Test
2. Antiacetylcholine receptor antibody serum levels
3.Repetitive stiumlation of motor nerves
4. CT Scan of Chest
5. EMG

Front 15

MYASTHENIA GRAVIS
(DIAGNOSTIC TEST)
-WHAT DOES EACH DIAGNOSTIC TEST, TEST FOR AND OR HOW IS IT ADMINISTERED?
1.Tensilon Test
2.Antiacetylcholine receptor antibody serum levels
3. REPETITIVE STIMULATION OF MOTOR NERVES
4. CT SCAN OF CHEST
5. EMG

Back 15

1. Tensilon Test administers IV Tensilon for resolution of systems that would confirm MG
2. Anti-ACh receptor antibody serum levels testdetects antibodies in the serum
3. Repetative nerve stimulation would show a decrease in successive action potential
4. CT Scan of the chest is to check for enlargement of the thymus gland (hyperplasia)
5. EMG: Single-fiber electromyography; mild currents are given that stimulates the muscle.

Front 16

MYASTHENIA GRAVIS
(MEDICATIONS)
-ANTICHOLINESTERASE AGENTS
A)NAME THEM AND IT'S SIDE EFFECTS

Back 16

1.Mestinon (pyridostigmine bromide)
2. Prostigmin (neostigmine bromide)
-Side Effects: abdominal pain, nausea, diarrhea, increased oropharyngeal secretions

Front 17

MYSASTHENIA GRAVIS
(TEACHINGS/MEDICATION)
A) WHAT ARE SOME THINGS TO TEACH THE PATIENT ABOUT;
1) ANTICHOLINESTERASE AGENTS
2) CYTOTOXIC MEDS
3) OTHER MEDS
B) WHAT SHOULD PATIENTS BE AWARE OF?

Back 17

Anticholinesterase agents:
1. Meds should be on time! in order to stable muscle strength.
2. Pt. should take meds 1/2 before meals.
3. If they have severe nausea they can take their medicine with milk to decrease S/E
Cytotoxic meds;
1.Can take up to 1yr to work

B)Patient's should be aware of what exacerbates their condition; ie. dentist (Novican), antiseizure and beta blockers, increased temp, stress, exercise

Front 18

MYASTHENIA GRAVIS
(OTHER MEDICATIONS/TEACHINGS)
*Risks & Benefits of all other medications must be weighed by MD, pharmacist & patient.
Many exacerbate myasthenic symptoms

Back 18

*fyi*

Front 19

MYASHTENIA GRAVIS
(PLASMAPHERESIS)
-WHAT IS IT?
-WHAT IS THE GOAL?

Back 19

-Plasmapheresis is exchange of plasma
-The goal is removal and reduction of antiacetylcholine receptor antibodies

Front 20

MYASTHENIA GRAVIS
(PLASMAPHERESIS)
1. WHAT DOES IT REMOVE AND SEPARATE?
2. WHAT IS IT REPLACED WITH
3. WHAT IS REINFUSED?
4. HOW LONG DOES IT TAKE TO REINFUSE
5. WHAT INSERTION SITES ARE NEEDED
6. WHAT NEEDS TO BE MONITORED DURING/AFTER THE PROCEDURE?

Back 20

1. Plasmapheresis is the removal and seperation of plasma and cellular components
2. It's replaced with colloids or donor plasma
3. Cells & plasma is reinfused
4. Reinfusion takes approx. 2 to 5hrs.
5. Need an arterial & venous insertion site
6. Nurse should monitor CBC, Platelet, & clotting studies

Front 21

MYASTHENIA GRAVIS
(PLASMAPHERESIS)
1. CAN THE PATIENT BE GIVEN THEIR MATAINENCE MEDICATION BEFORE/DURING THE PROCEDURE?
2. HOW AFFECTIVE IS PLASMAPHERESIS?

Back 21

1. No. All meds should be held until after the procedure.
2. Improvement is seen in 75% of patients.

Front 22

MYASTHENIA GRAVIS
(PLASMAPHERESIS)
1. WHAT ALTERNATIVE PROCDURE CAN BE GIVEN INSTEAD OF PLASMAPHERESIS?

Back 22

1. Instead of plasmaphereisis they can use Immuno globulin.

Front 23

MYASTHENIA GRAVIS
(SURGERY)
1. WHAT TYPES OF SURGERY ARE DONE?

Back 23

1. Thymectomy Surgery;
a) Transcervical
b) Transternal approach

Front 24

MYASTHENIA GRAVIS
(PATHOPHYSIOLOGY)
1. WHERE IS ANTIBODY PRODUCTION BELIEVED BE LOCATED?

Back 24

1. The thymus gland is believed to be the site of antibody production.

Front 25

MYASTHENIA GRAVIS
(PATHOPHYSIOLOGY)
1. WHAT DO 80% OF PEOPLE WITH MG HAVE?

Back 25

1. 80% of patients with myasthenia gravis have either thymic hyperplasia or a thymic tumor.

Front 26

MYASTHENIA GRAVIS
(CLINICAL MANIFESTATIONS)
1. DOES (MG) HAVE ANY EFFECT ON OF SENSATION OR COORDINATION?

Back 26

1. No. Myasthenia Gravis is purely a motor disorder and has no effect on sensation or coordination.

Front 27

MYASTHENIA GRAVIS
(MEDICATIONS)
1. WHAT IS A SIDE EFFECT OF TENSILON (edroponium)
2. WHAT IS THE ANTIDOTE FOR TENSILON IF THE PATIENT EXPERIENCE ADVERSE SIDE EFFECTS?

Back 27

1. Side effect of Tensilon (edroponium) is bradycardia, sweating, and cramping.
2. The antidote for Tensilon is Atropine and should be available during administration of the Tensilon Test

Front 28

MYASTHENIA GRAVIS
(MEDICAL MANAGMENT)
1. WHAT ARE SOME THERAPEUTIC MODALITIES FOR MG?

Back 28

1. Anticholinesterase medications, immunosuppressive therapy, plasmapheresis and thymectomy.

Front 29

MYASTHENIA GRAVIS
*Management of MG is directed at improving functions and reducing and removing circulating antibodies. B&S

Back 29

*fyi*

Front 30

MYASTHENIA GRAVIS
1. WHAT IS AN EXAMPLE OF A FIRST LINE ANTICHOLINESTERASE MED?
2. HOW DOES IT WORK TO PROVIDE SYMPTOM RELIEF FOR THE PATIENT?

Back 30

1. Mestinon (pyridostigmine bromide) is a first line therapy.
2. It works by inhibiting the breakdown of acetylcholine and increasing the relative concentraion of available acetylcholine at the neromuscular juction.

Front 31

MYASTHENIA GRAVIS
(MEDICATION/ANTICHOLINESTERASE AGENTS)
1. WHY WOULD MESTINON(pyidostigmine bromide) be prefered over other anticholinesterase agents?
2. IF PYRIDOSTIGIMINE BROMIDE DOES NOT IMPROVES MUSCLE STRENGTH WHAT AGENT IS USED NEXT?

Back 31

1. Mestinon (pyridostigmine bromide) has fewer side effects than other anticholinesterase medications.
2. Immunosuppresive thereapy is used if pyridostigmine bromide does not improve muscle strength.
a) starting with corticosteroids, then cytoxics if steroids don't work.

Front 32

MYASTHENIA GRAVIS
(IMMUNOSUPPRESIVE THERAPY)
1. WHAT IS THE GOAL OF THIS TYPE OF TREATMENT

Back 32

1. The goal of immunosuppresive therapy is to reduce production of the antibody.
*An initial does of prednisone is given daily; as symptoms improve the medication is tapered and a maintenance does may be given indefinitely. As the corticosteroid dosage is gradually increased the anticholinesterase dosage is lowered.B&S

Front 33

MYASTHENIA GRAVIS
(MEDICATION)
1. WHAT DOES CYTOTOXIC MEDICATIONS DO TO HELP PT SYMPTOMS OF MG?

Back 33

1. Cytotoxic agents are used to inhibit T-lymphocytes and reduces the aceytlcholine receptor antibody levels.

Front 34

MYASTHENIA GRAVIS
(MEDCIATION)
1. HOW LONG DOES IT TAKE FOR THERAPEUTIC EFFECTS OF CYTOTOXIC AGENTS TO BE SEEN?

Back 34

1. It can take 12months (B&S "3 to 12months) before therapeutic effects are seen.

Front 35

MYASTHENIA GRAVIS
(MEDICATIONS)
1. WHAT ARE SOME CLASSIFICATIONS/DRUGS THAT CAN EXACERBATE (MG)?
2. WHAT MEDS SHOULD PATIENTS ABSOLUTELY AVOID?

Back 35

1. Physician, and patient should weigh the risk and benefits before any new meds are prescribed including antibiotics, cardiovascular meds, antiseizure and psychotropic medications, morphine, quinine, beta-blockers, and nonprecription meds.
2. Patient's should AVOID Novocain(procaine) and should advise their dentist of their illness.

Front 36

MYASTHENIA GRAVIS
(PLASMAPHERESIS)
1. WHY IS THIS TECHNIQUE USED?
A) WILL THIS TREATMENT CURE THE SYMPTOMS?

Back 36

1. Plasmapheresis is used to treat exacerbations
2. No, it only temporarily reduces the level of circulating antibodies.
a) improvement only last for a few weeks after treatment is complete.

Front 37

MYASTHENIA GRAVIS
(SURGICAL MANAGEMENT)
1. WHAT OTHER INTERVENTIONS CAN BE DONE IF THERE'S NOT AN IMMEDIATE IMPROVEMENT OF SYMPTOMS AFTER SURGERY

Back 37

1. If the patient doesn't exhibit immediate response it's common to have plasmapheresis to rid of some of the circulating T-cells. By riding the antibodies help to expedite the recovery.

Front 38

MYASTHENIA GRAVIS
(SURGICAL MANAGMENT)
1. HOW LONG AFTER SURGERY COULD IT TAKE BEFORE THE PATIENT SHOW'S IMPROVEMENT?
A)WHY DOES IT TAKE THIS LONG?

Back 38

1. It can take up to 3 years after the thymus gland is removed for the patient to benefit from the procedure
A) R/T the long life of circulating T-cells.

Front 39

MYASTHENIA GRAVIS
(SURGICAL MANAGEMENT)
1. WHICH TYPE OF THYMECTOMY DO SURGEONS PREFER AND WHY?
2.WHAT IS VERY IMPORTANT TO MONITOR AFTER A THYMECTOMY?

Back 39

1. Surgeons prefer transsternal approach because the entire gland must be removed for optimal clinial outcomes.
2. It's very important to monitor the patients respiratory
a) very dramatic surgery
b) Pt. can have a lot of respiratory implications and end up with a treach or chest tube.

Front 40

MYASTHENIA GRAVIS
(PREOPERATIVELY)?????????

Back 40

1. The patient is tapered from steroid therapy
2. Mestinon (pyridostigmine bromide)

Front 41

MYASTHENIA GRAVIS
(POSTOPERATIVELY)
1. Pulmonary hygiene
2. Chest tube (transternal)
3. Pain control (huge with transternal surgery, not as much with transcervical).
***PRIORTIY IS TO MONITOR THE PT.'S AIRWAY REGARDLESS OF WHICH SURGERY-RESPIRATORY IS THE MAIN ISSUE*****

Back 41

*fyi*

Front 42

MYASTHENIA CRISIS
1. WHAT IS IT?
2. WHAT IS THE PATIENT AT RISK FOR DURING THIS CRISIS?
3. IS THIS AN EMERGENCY? WHERE IS THE PATIENT MONITORED?
2. WHAT S&S WOULD THE PATIENT DISPLAY?

Back 42

1. Sudden acute exacerbation of motor weakness.
2.The patient is at risk for respiratory failure and aspiration.
3.Yes, this is an emergency and the patient is monitored in the ICU
4. S&S;
a)SOB
b)^HR
c) Restless
d) dysarthria (impaired speech)
e) dysphagia (difficulty swallowing)
f) ptosis, diplopia
g) acute respiratory distress
1. causing major anxiety

Front 43

MYASTHENIA GRAVIS
(MG CRISIS)
A. WHAT CAN THE PT BE TAUGHT ABOUT WHAT CAN CAUSE A CRISIS
2. WHAT SHOULD THE PT. BE TOLD TO WEAR?

Back 43

1. If the pt. forgot their meds
2. undermedicated
3. pregnancy
4. heat
5. ^ temp (body & environment)
6. infection
7. stress
8. OTC
9. fatigue

B) Pt. should wear a Medic-Alert bracelet

Front 44

MYASTHENIA GRAVIS
(MG CRISIS)
1. WHAT IS THE PRIMARY CAUSE OF MG CRISIS AND RESPIRATORY FAILURE?

Back 44

1. The most common factor of myasthenia crisis is respiratory infection. as well as surgery, pregnancy, meds, mediction change (usually underdose).

Front 45

MYASTHENIA GRAVIS
(CHOLINERGIC CRISIS)
1. WHAT ARE SYMPTOMS OF THIS TYPE OF CRISIS?

Back 45

1. GI symptoms
2. Severe muscle weakness
3. Vertigo
4. Respiratory distress

Front 46

MYASTHENIA CRISIS
(CRISIS-CHOLINERGIC & MG CRISIS)
*Difficul to distinguish which crisis the patient is in,both present symptoms of severe muscle weakeness and respiratory distress and both intubation and ventilation is possible.

Back 46

*fyi*

Front 47

MYASTHENIA GRAVIS
(CHOLINERGIC CRISIS)
1. WHAT USUALLY CAUSES CHOLINERGIC CRISIS ?
A) WHAT IS THE ANTIDOTE

Back 47

1. Per lecture overdose is usually the cause of cholinergic crisis, but per B&S overmedication with cholinesterase inhibitors are rare.
A) Atropine sulfate should be on hand to treat bradycrdia or respiratory distress.

Front 48

MYASTHENIA GRAVIS
(MG CRISIS & CHOLINERGIC CRISIS)
1. WHAT IS THE TREATMENT OF ALL CRISIS?

Back 48

1.Stop all medications
2. Monitor in ICU
3. Have atropine sulfate on hand for bradycardia
4.IVIG or plasmaphoresis

Front 49

MYASTHENIA GRAVIS
(CRISIS-MG CRISIS)~Vs~CHOLINERGIC CRISIS
-IT CAN BE HARD TO TELL WHICH CRISIS A PATIENT IS IN, BUT WHAT ARE TWO SYMPTOMS THAT ARE DISTINCT IN EACH CRISIS, WHAT SYMPTOMS ARE SEEN IN BOTH?

Back 49

1. Respiratory distress and sever muscle weakness are seen in both crisis.
2. MG crisis the patient usually has an increased HR, whereas Cholinergic crisis the patient has bradycardia.

Front 50

MYASTHENIA GRAVIS
(CRISIS)
1. WHEN A PATIENT IS IN A CRISIS WHEN CAN THEIR MEDICATION START?

Back 50

1.Anticholinesterase inhibitors are stopped during a crisis and gradually restarted after the patient's symptoms improve along with plasmapheresis or IVIG.

Front 51

MYASTHENIA GRAVIS
(NURSING MANAGMENT)
*Teaching focused on patient and family since pt's are mostly seen as an outpatient (med. mngmnt, prevention of complications, stratergies for ocular manifestation, energy conservation).B&S

Back 51

*fyi*

Front 52

MYASTHENIA GRAVIS
(NURSING MANAGMENT)
1. WHEN SHOULD THE PATIENT BE TAUGHT REGARDING MEALTIMES
2 WHAT POSITION SHOULD THE PATIENT BE IN DURING MEALS?

Back 52

1. Pt. should be taught that the mealtimes should coincide with the peak effects of anticholineterase medication.
2. Rest before meals to reduce muscle fatigue.
3. Take medicine 30mins before meals.
4. Sit upright with neck slightly flexed to facilitate swallowing and eat soft foods if swallowing is difficult.

Front 53

MYASTHENIA GRAVIS
(NURSING INTERVENTIONS)
1. WHAT MEDS SHOULD BE AVOIDED IF THE PATIENT IS IN CRISIS?
A) WHY?

Back 53

1. Tranquilizers and sedatives because they aggravate hypoxia and hypercapnia and can cause respirtory and cardiac depression

Front 54

MYASTHENIA GRAVIS
(NURSING INTERVENTION)
1. WHEN IS THE BEST TIME TO PERFORM POSTURAL DRAINAGE
A) WHY?

Back 54

1. Postural drainage should be performed 30 min after a meal
a) The pt. has more energy to withstand the procedure

Front 55

MYASTHENIA GRAVIS
(ANTICHOLINESTERASE AGENTS)
1. WHAT IS IT'S ACTION?
2. MEDICATIONS?

Back 55

1. Anticholinestrase medications increases the levels of acetycholine at the myonerual junctions.
2.Meds; Prostigmin (neostigmine); Mestinon (pyridostigmine); Tensilon (endrophonium)

Front 56

MYASTHENIA GRAVIS
(ANTICHOLINESTERASE AGENTS)
1. SIDE EFFECTS
2. WHEN'S SHOULD THE MEDICINE BE ADMINSTERED?
3. WHAT'S THE ANTIDOTE?

Back 56

1.Side effects: sweating, salivation, nausea, diarrhea, abdominal cramping, bradycardia, hypotension
2. Anticholinesterase should be administered 30 mins before meals and with milk if the pt. has severe nausea to reduce GI upset
3. The antidote for anticholinestrase agents is atropine sulfate.

Front 57

MYASTHENIA GRAVIS
(MEDICATIONS)
1. WHAT IS ATROPINE USED FOR?
2. WHAT'S IT'S ACTION

Back 57

1. Atropine is an antidote for adverse reactions to anticholinestrase agents.
2. It's action as an antidote for anticholinestrase agents are it;
-reduces secretions
-relief of GI spasms (cramping)
-treats bradycardia (by blocking the vagus nerve of the parasympathetic system)
-reduces sweating (at the parasympathetic nervous system it inhibits salivary, sweat and mucus glands)

Front 58

MYASTHENIA GRAVIS
(SURGERY)
-TRANSCERVICAL
1. WHERE IS THE SURGICAL INCISION?

Back 58

1. There's a small incision in the neck.

Front 59

MYASTHENIA GRAVIS
(SURGERY)
-TRANSTERNAL
1. WHERE IS THE INCISION?
2. IS THIS SURGERY MORE/LESS INVASIVE THAN TRANSCERVICAL? WHICH IS SURGERY IS MORE COMMON?

Back 59

1. The surgical approach is through the breast bone
2. More invasive and more common than the transcervical approach.