Myasthenia

Gravis
Group 4
Antonio, Astrid Luyo, Wiengher
Aspiras, Kristen Sagun, David
Cancino, Charmaine
Federes, Reinalyn
Galang, Kate
Silva, Lyka
Vallejo, Therese
Ventura, Bianca
INTRODUCTION
Myasthenia gravis (MG) is a chronic autoimmune disorder in which antibodies destroy the communication between nerves and muscle, resulting

in weakness of the skeletal muscles. Myasthenia gravis affects the voluntary muscles of the body, especially those that control the eyes, mouth,

throat and limbs

Myasthenia gravis is a rare long-term condition that causes muscle weakness.

It most commonly affects the muscles that control the eyes and eyelids, facial expressions, chewing, swallowing and speaking. But it can affect

most parts of the body.

It can affect people of any age, typically starting in women under 40 and men over 60.

People with MG lose the ability to control muscles voluntarily. They experience muscle weakness and fatigue of various severity. They may not

be able to move muscles in the eyes, face, neck and limbs. MG is a lifelong neuromuscular disease. There isn’t a cure, but treatments can help

and some patients may achieve remission.MG mostly affects women aged 20 to 40 and men aged 50 to 80. About one in 10 cases of MG occur in

teenagers (juvenile MG). The illness can affect people of all ages but is rare in children.

Autoimmune MG is the most common form of this neuromuscular disease. Autoimmune MG may be:
The intensity of muscle weakness often changes from day to day. Most people feel strongest at the start of the day and

weakest at the end of the day.

Symptoms of MG include

Double vision

Drooping eyelids (ptosis)

Difficulty speaking, chewing or swallowing.

Difficulty moving their neck up or holding up their head.

Limb weakness

Trouble walking
Objectives
Objectives:

Upon fulfillment of this case presentation, the student nurse should be able to:

1. Identify the risk factor/s contributing to the instance of the disease.

2. Formulate significant nursing diagnosis with the related nursing care.
3. Identify the different medications administered for this disease as well as the drug
indication, contraindications, side effects and specific nursing responsibilities.
4. To provide health teaching to the patient and family management of the disease,
medications and complications.
5. To identify the modern technologies to treat the disease for overcoming the problem
and educate them about Myasthenia Gravis.
Physical
Assessment
 SKIN

AREA/FEATURE TECHNIQU KEY ANALYSIS AND

SKILLS
TO ASSESS E FINDINGS INTERPRETATION
Color Inspection Inspect variations in skin color
under natural sunlight to ensure
accuracy findings.

Lesions Inspection Note for color, size, and

anatomic location and
distribution.
Palpation
Palpate lesions with finger pads
for mobility and contour (flat,
raised, or depressed) and
consistency (soft or durable)

Moisture Inspection Note amount and distribution

and
Palpation

Temperature Palpation Palpate with dorsum of hand

noting for uniformity of warmth.
 SKIN
AREA/FEATURE TO TECHNIQUE SKILLS KEY ANALYSIS AND
ASSESS FINDINGS INTERPRETATION

Texture (quality, Palpation Palpate with finger pads in different areas

thickness, suppleness)

Mobility and turgor Palpation Assess mobility and turgor to measure Skin does not snap back when pinched. Due to fluid retention
(elasticity) elasticity of skin to determine the degree of
hydration.

Palpate dependent areas like the sacrum,

feet, and ankles for mobility by applying
pressure with thumb for 5 seconds. Rate
the degree of edema (accumulation of fluid
in intercellular spaces) by assessing depth
of indention.
Edema may be described on a scale as
follows:
1. 0 = no pitting
2. 1+ = trace/mild (2mm)
pitting
3. 2+ = moderate (4mm)
pitting
4. 3+ = deep/severe (6mm)
5. 4+ = very deep/severe
(greater than 8mm)
Pinch a fold of skin on the sternal area
using forefinger and note for the spread
with which it returns to place (turgor).
 HAIR
AREA/FEATURE TO TECHNIQUE SKILLS
KEY ANALYSIS AND
ASSESS
FINDINGS INTERPRETATION
Color and
Inspect Assess for color and
Distribution
distribution of scalp
hair, eyebrows,
eyelashes, and body
surface.

Palpation Assess for the skin’s Hair is

Texture and oiliness
texture and oiliness straight, shiny
with the use of palm. and resilient.

Inspection Free from any

infestation Assess for any
infestation.
presence of infestation
by examining the hair
and scalp.
 SCALP
AREA/FEATURE TO TECHNIQUE SKILLS
KEY FINDINGS ANALYSIS AND
ASSESS
INTERPRETATION

Scaliness and scars Inspection Part the hair The scalp is shiny and Normal
repeatedly all over the smooth without
scalp and inspect for lesions, lumps, or
scaliness and scars. masses.

Tenderness, lesions, Palpation Place finger pads on Absence of redness or Normal

lumps, masses the scalp at the front scaliness.
and palpate down the
midline and each side
for tenderness,
lesions, lumps, or
masses.
 NAILS
AREA/FEATURE TO TECHNIQUE SKILLS
KEY FINDINGS ANALYSIS AND
ASSESS
INTERPRETATION

Inspect for color and Due to decreased

Color, shape, and Inspection Nailbeds are slightly
shape cardiac output.
texture pink and round.
Palpate nail bed for Normal
Palpation firmness and texture Nailbeds are firm.

Capillary refill Palpation Press two or more The nails do not Due to decreased
nails between thumb return to their normal blood flow.
and index finger and color after 1.5
note the degree of seconds.
blanching and return
to normal color.

Lesions Inspection Inspect the tissue Tissue surrounding Normal

surrounding nails for the nail is intact.
lesions.
 SKULL
AREA/FEATURE TO TECHNIQUE SKILLS
KEY FINDINGS ANALYSIS AND
ASSESS
INTERPRETATION

Shape and symmetry Inspection Inspect skull for

shape, symmetry,
size in proportion to
body and position.

Contour, Masses, Palpation Palpate with

Depressions and fingerpads beginning
Tenderness in frontal area and
continuing over
parietal, temporal,
and occipital areas
for contour, masses,
depressions, and
tenderness.
 FACE
AREA/FEATURE TECHNIQUE SKILLS
KEY FINDINGS ANALYSIS AND
TO ASSESS
INTERPRETATIO
N

Face is Due to muscle

Facial features Inspection Inspect facial features weakness
asymmetrical
for expression, shape,
and symmetry of
eyebrows, placement
of nose, eyes, and
ears.

Edema and Inspection Inspect for any

masses presence of edema
and masses
 EYES
AREA/FEATURE TO TECHNIQUE SKILLS
KEY FINDINGS ANALYSIS AND
ASSESS
INTERPRETATION

Blurred visions Due to trouble focusing and

Visual Acuity Inspection Test visual acuity.
drooling of eyelid
1. Position Snellen chart 20 ft. in front of client.
2. Remove corrective lenses, if appropriate.
3. Instruct client to cover one eye and read lines starting
with top of chart from left to right.
4. Note the line where client reads more than half of the
letters.
5. Record results as a fraction sc (without correction), 20/
distance number, and the number of the letters missed.
6. Repeat same steps for the other eye.
If appropriate, repeat steps with patient wearing the corrective
device.

Double vision Due to weakness of the eye

Inspection Test eye for extraocular muscle movements:
muscles leads to
1. Place the client in sitting position. misalignment of the eyes
2. Instruct the client to hold head still.
3. Ask the client to follow an object with eyes.
Move objects with 6 fields of gaze.
 EYES
AREA/FEATURE TO TECHNIQUE SKILLS
KEY FINDINGS ANALYSIS AND
ASSESS
INTERPRETATION

***The 6 Fields of Gaze

Appearance of Due to damage of
nystagmus
1. Conjugate left lateral gaze oculomotor nerve
2. Left down and lateral gaze
3. Right down and lateral gaze
4. Conjugate right lateral gaze
5. Right up and lateral gaze
6. Left up and lateral
7. Observe for parallel eye movement.
8. Pause during upward and lateral gaze field to detect in
voluntary rhythmic oscillation of eyes.
9. Note position of upper eyelid in relation to the iris and
eyelid bag as the client’s eye move from up and down.
Move object forward to about 5 inches in front of the client’s nose
at the midline and observe for convergence, and record result.

Observe upper eyelid. Droopy eyelid Due to breakdown in the

External anatomical Inspection
normal communication
structures between nerves and muscles.

Check eyes and eyelids for inflammation, crusting, edema or

masses. Due to orbicularis muscle
Dry eyes weakness that resulting to
Inspect lacrimal glands and sacs for swelling. reduced blinking
 EYES
AREA/FEATURE TO TECHNIQUE SKILLS
KEY FINDINGS ANALYSIS AND
ASSESS
INTERPRETATION

Check for blocking of nasolacrimal duct by pressing against inner

Palpation Lacrimal gland is not
orbital rim of lacrimal sac.
palpable.
Inspect duct by palpating on the lacrimal sac and observing for
regurgitation of fluid.

Slow eyed Due to weak muscle of the eye

Inspection Inspect bulbar and palpebral conjuctiva and sclera.
movement
a. Instruct client to look upward while depressing lower lid
with thumb.
b. Inspect for color, redness, swelling, exudates, or foreign
bodies.
c. Inspect cornea, lenses, pupil, iris, and anterior chamber:
1. Stand in front of the client.
2. Shine penlight directly on cornea.
3. Move light laterally and view cornea from that
angle; note color, discharge, and lesions.
4. Look at pupil and note size and shape.
5. Shine penlight directly on pupils to assess lens
and color.
6. Look at iris for size, and ability of pupils to
react to light.
Shine a light obliquely through anterior chamber from lateral side
toward nasal side.
 EYES

AREA/FEATURE TO TECHNIQUE SKILLS

KEY FINDINGS ANALYSIS AND
ASSESS
INTERPRETATION

Inspection Test for papillary response to light and reaction to accommodation

in dimly lit room.
1. Instruct client to look straight ahead.
2. Bring penlight from side of the client’s face to directly in
front of the pupil.
3. Note quickness or response to light.
4. Shine light into same eye observing for response or pupil
for equality of size and repeat steps to the other eye.
5. Instruct client to gaze at your finger held 4-6 inches from
her nose then to glance at a distant object while you note
papillary reflex.
6. Move finger toward the bridge of client’s nose noting
response of both pupil.
Record results PERRLA (pupils equal, round, reactive to light
accommodation).
 EARS

AREA/FEATURE TO TECHNIQUE SKILLS

KEY FINDINGS ANALYSIS AND
ASSESS
INTERPRETATION

External ear Inspection Examine external ear, called the auricle or pinna for placement,
symmetry, color, discharge and swelling.

Palpate the auricle between the thumb and index finger noting lesions or
Palpation
tenderness by moving auricle up and down, same with the mastoid tip.
Press inward on tragus noting any tenderness.

Auditory acuity Inspection The Whispered Voice Test

1. Instruct the client to occlude one ear with finger and repeat the
words when heard.
2. Stand 1-2 feet away from the client, out of view to avoid client
from lip reading, and softly whisper numbers on side of the ears.
Increase voice volume until client identifies uttered number.
3. Repeat procedure on other ear.
4. Record results.
 NOSE AND SINUSES
AREA/FEATURE TO TECHNIQUE SKILLS KEY ANALYSIS AND
ASSESS FINDINGS INTERPRETATION

Nose Inspection Inspect the nose for symmetry,
deformity, flaring, or inflammation
and discharge from the nares.
Test patency of each nostril:
a. Instruct client to close the
mouth and apply pressure
on one naris and breathe
b. Repeat test on opposite
nares.
Located symmetrically, midline of the face, and is without Normal
swelling, bleeding, lesions, or masses.
Nasal flaring
Due to muscle weakness
that affects the primary
inspiratory muscle that
leads to blunted ventilatory
responses

Nasal cavities Inspection Inspect the nasal cavity with a Mucosa is pink or dull without swelling or polyps. Normal
penlight: Septum is midline and intact.
a. Tilt client’s head in an A small amount of clear watery discharge is observed.
extended position.
b. Place non dominant hand
on client’s head using your
thumb, and lift the tip of
the nose.
c. With the lit penlight, asses
each nostril; and note for
color of anterior nares,
nasal septum for deviation,
perforation, or bleeding,
and inspect for swelling
and discharge.

Nasal sinuses Palpation Apply gentle upward pressure on None-tender air-filled cavities. Normal
frontal and maxillary areas
avoiding pressure on the eyes.
Percuss area and note the sound. Resonant sound upon percussion.
 MOUTH
AREA/ TECHNIQUE SKILLS KEY ANALYSIS AND
FEATURE TO FINDINGS INTERPRETATION
ASSESS

Breath Inspection Stand 12-18 inches in front of client and smell the
breath.

Lips Observe lips for color, moisture, swelling, lesions

a. Instruct client to open mouth and use tongue
depressor to retract buccal mucosa and note
color, hydration, inflammation, or lesions.
b. Invert lower lip with thumbs on inner oral
mucosa and muscle tone. Repeat procedure
with thumb and index finger for upper lip.

Gums Inspection Inspect gums for gingivitis and note color, edema,
retraction, bleeding and lesions.

Palpation Palpate gums with tongue blade for texture

 MOUTH

AREA/ TECHNIQU SKILLS KEY ANALYSIS AND

FEATURE TO E FINDINGS INTERPRETATION
ASSESS

Teeth Inspection Ask client to clench teeth to assess position and

alignment with the use of a tongue depressor,
expose molars and note for tartar, cavities,
extraction and color.

Tongue Inspection Instruct client to protrude tongue: Bulbar tongue is present Due to muscle weakness
1. Inspect dorsum of tongue and note for
color, hydration, texture, symmetry.
2. With penlight, inspect sides and ventral
surface and note for size, texture, nodules,
or ulcerations.
3. Still with penlight, inspect floor of mouth,
salivary glands, and duct openings.
Grasp tongue with a gauze and gently pull it to
Palpation one side and palpate full length of tongue.
 MOUTH

AREA/ TECHNIQU SKILLS KEY ANALYSIS AND

FEATURE TO E FINDINGS INTERPRETATION
ASSESS

Palate Inspection Inspect the soft and hard palate with a penlight:
a. Instruct client to extend head backward and
hold mouth open.
Inspect the hard palate (roof of mouth) and soft palate
for color, shape, lesions.

Pharynx Inspection Inspect pharynx using tongue depressor and penlight: Diminished gag reflex due to neuromuscular
a. Explain procedure to client. disorder
b. Instruct client to tilt head back and open mouth.
c. With non-dominant hand, place tongue
depressor on middle third of tongue. With the
dominant hand, shine light into back of throat.
d. Instruct client to say “ah” and note position,
size, appearance of tonsils and uvula.
Inform client of eliciting gag reflex by touching the
posterior 1/3 of tongue with tongue blade if palate and
uvula fail to rise symmetrically with phonation.
 NECK

AREA/FEATURE TO KEY ANALYSIS AND

TECHNIQUE SKILLS
ASSESS FINDINGS INTERPRETATION

Symmetry and Inspection Instruct client to: Muscles are symmetrical

Musculature a. Flex chin to chest and to teach side and shoulder to test with head in central
anterior sternocleidomastiod muscle. position.
Hyperextend the neck backward to test posterior trapezia.

Lymph nodes Palpation Palpate lymph nodes and instruct client to relax and flex neck lymph nodes are observed. Due to the disease
slightly forward. progression that will
1. Stand in front of seated client. increase the amounts of
2. Methodically palpate both sides of face and neck lymphocytes that leads to
simultaneously with gentle pressure, move pads and tip of swelling
middle three fingers in small circular motion. Follow a
systematic sequence in palpating the lymph nodes.
Note size, shape, mobility, consistency and tenderness.

Trachea Inspection Note for position. Midline position above the Normal
suprasternal notch.

Palpation Place thumbs and index finger on sides of trachea and apply gentle
pressure and palpate.
 NECK
AREA/FEATURE TO KEY ANALYSIS AND
TECHNIQUE SKILLS
ASSESS FINDINGS INTERPRETATION

Thyroid Palpation With client seated, assessment may be done with posterior and anterior Thyroid is smooth, soft, Normal
approach: non-tender and not
enlarged.
A. POSTERIOR APPROACH
1. Stand behind client and place thumbs on nape of neck and
bring fingers interiorly around neck with their tips resting
over tracheal rings.
2. Ask client to tilt chin forward to relax neck muscles and
swallow.
3. Palpate the isthmus rise under fingers and feel each lateral
lobe before and while client swallow.
4. Ask client to flex forward and to left, and displace thyroid
cartilage to right with tips of left fingers. Note any bulging of
gland.
5. Press fingers of left hand against left side of thyroid cartilage
to stabilize it while palpating with the fingers of right hand
while client swallows.
6. Note consistency, nodularity, or tenderness as gland moves
upward.
7. Repeat steps to opposite side.
B. ANTERIOR APPROACH
1. Stand in front of the client.
2. Instruct client to tilt chin forward and place right thumb on
thyroid cartilage and displace cartilage to the right.
3. Grasp elevated displaced right lobe with thumb and fingers
of left hand and palpate for consistency, nodularity or
tenderness as client swallows.
4. Repeat steps to opposite side.

Auscultation If gland appears enlarged, place the bell of the stethoscope over gland
and listen for vascular sounds such as soft, rushing sound, or bruit.
 THORAX and LUNGS
AREA/FEATURE TO TECHNIQUE SKILLS KEY ANALYSIS AND
ASSESS FINDINGS INTERPRETATION

Shape, symmetry, and Inspection Place client in sitting position with arms folded across chest, back Respiratory rate is 23bpm Due to muscle weakness
diameter exposed. that affects the gas exhange
1. Assess shape and symmetry by taking note of the rate and
rhythm of respirations, movement of chest wall with deep
inspiration and full expiration.
Estimate anteroposterior diameter in proportion to lateral diameter.

Lesions Palpation 1. Palpate for lesions or areas of pain. Thumb is not separated Due to shortness of breath
2. Palpate thoracic expansion at 10th rib by placing thumb close during thoracic expansion.
to client’s spine and spread hands over thorax. Note
divergence of thumbs; feel for range and symmetry of Posterior thorax is free
movement during deep inhalation and full exhalation. from tenderness, lesions
3. Place ulnar aspect of open hand at right apex of lung and place and pulsations.
hand at each posterior thorax location. Then instruct client to Normal
say “99” and palpate for tactile fremitus (vibrations caused by
vibrations). Note areas of increased and decreased fremitus.
Move hands from side to side, from light to left with client
repeating the words with the same intensity every time hands are
placed on the back.

Due to weakness of
Increased Fremitus on both primary inspiratory muscle,
sides of thorax. fluid may overload that
causes lung consolidation
 THORAX and LUNGS

AREA/FEATURE TO TECHNIQUE SKILLS KEY ANALYSIS AND

ASSESS FINDINGS INTERPRETATION

Sound Percussion 1. Start at lung apices by moving hands from side to side across Dullness sound is heard. Due to accumulation of
the top of each shoulder. Note sound produced from each fluid in the air sac causing
percussion strike and compare with contralateral sound. pulmonary edema
Continue downward and post lateral every other intercostals
space. Note intensity, pitch, duration, and quality of percussion.

Breath sounds Auscultation 1. Place diaphragm of stethoscope on right lung apex. Instruct Fine crackles are heard Due to fluid overload that
client to inhale and exhale deeply and slowly when leads to accumulation of
stethoscope is felt on the back. Repeat on left lung apex. fluid in the smaller airways
2. More downward every other intercostals spaces and auscultate,
placing stethoscope in the same position on both sides.
3. Auscultate lateral aspect by placing stethoscope directly below
right axillae instructing client to breath only through the
mouth and to inhale and exhale deeply and slowly. Proceed
downward on every other intercostals space on the same side.
Repeat last step on the left side.

AREA/FEATURE TO
ASSESS
Symmetry, rhythm and Inspection
slope
Tenderness, pulsation, Palpation
masses and crepitance
Respiratory excursion
Tactile Fremitus
ANTERIOR THORAX
TECHNIQUE SKILLS KEY ANALYSIS AND
FINDINGS INTERPRETATION
Place client in sitting position or supine position. Inspect client’s Increased respiratory rate. Due to muscle weakness,
chest for: consolidation might
1. Symmetry and depth of movement. accumulate on the air sac
Slope of ribs and musculoskeletal deformities. that leads to the decreased
gas exchange
1. Place fingerpads on right apex above the clavicle. Proceed Thumb is not separated Due to shortness of breath
downward to each rib and intercostals space and note for during thoracic expansion.
tenderness, pulsation, masses and crepitance. Repeat on left
side.
2. Assess respiratory excursion by placing thumbs along each
costal margin with hands on lateral rib cage. Instruct client to
inhale deeply; note for divergence of thumbs on expansion; Posterior thorax is free Normal
feel range and symmetry of respiratory movement. from tenderness, lesions
Palpate for tactile fremitus. Gently displace female breasts as and pulsations.
necessary.
Increased tactile fremitus Due to pulmonary edema
 ANTERIOR THORAX
AREA/FEATURE TO TECHNIQUE SKILLS KEY ANALYSIS AND
ASSESS FINDINGS INTERPRETATION

Symmetry and sound Percussion Percuss anterior surface by: Dullness sound over lung Due to fluid buildup in the
1. Percuss 2-3 strikes along right lung apex and repeat on tissue is heard. lungs
left lung apex. Proceed downward, percussing in every
ICS going from right to left in same positions on both
sides.

Assess each thorax area:

2. Resonant lung filled.
3. Cardiac dullness: 3rd-5th ICS left of sternum.
4. Liver dullness: place finger parallel to upper border of
expected liver dullness in right midclavicular line;
percuss downward.
5. Gastric air bubble: repeat procedure done on liver
dullness on the left side.
Anterior sounds:
Auscultate anterior surface by instructing client to breathe through Adventitious sound is Due to fluid build up in the
the mouth and compares symmetrical areas of lungs from above heard lungs that causes unusual
downward: airflow through the lungs.
Auscultation 6. Listen to breath sounds and note intensity and identify
variations from normal.
7. Identify any added sounds by location on chest wall and
time in the respiratory cycle.
If breath sounds are diminished, ask client to breath hard and fast
with mouth open.
 CARDIOVASCULAR

AREA/ TECHNIQUE SKILLS KEY ANALYSIS AND

FEATURE TO FINDINGS INTERPRETATION
ASSESS

Arterial Pulses Palpation 1.Compress the radial artery with your index finger and middle 105 bpm Due to increase muscle
finger. contraction of the heart

Heart Inspection Precordial Movement 3 heart sound is heard Due to regurgitation of

1. Position the patient supine with the head slightly elevated the blood the
2. Always examine from the patient’s right side. ventricle is forced
3. Palpate for point of maximal impulse. (normally located at 4th to dilate beyond
or fifth ics, lmcl) its normal range
4. Listen with diaphragm at the right 2nd ICS
5. Listen 2nd ICS near sternum.
Palpation 6. 3rd, 4th, 5th ICS near sternum
7. Listen for apex

Auscultation

Tissue perfusion
Palpation Perform the Allen Test to determine patency of radial and ulnar Palms slowly turned pink. Due to decreased blood
arteries. Instruct client to rest hands on lap. flow.
1. Compress both the radial and ulnar arteries.
2. Firmly compress arteries and instruct client to open
hand.
3. Note color of palms.
4. Release one artery and note the color of palm.
5. Repeat steps on other artery on the same hand.
 ABDOMEN
AREA/FEATURE TO ASSESS TECHNIQUE SKILLS KEY FINDINGS ANALYSIS AND
INTERPRETATION

Generalized appearance of Inspection Placing client in supine position

abdomen with knees flexed over a pillow,
hands at side or over the chest,
undrape patient from xiphoid
process to symphysis pubis to
expose abdomen.
1. Inspect abdomen
from rib margin to
pubic bone and note
for contour and
symmetry.
2. Inspect umbilicus for
contour, location,
signs of inflammation
or hernia.
3. Observe for smooth,
even respiratory
movements.
4. Observe for surface
motions (visible
peristalsis)
 ABDOMEN
AREA/FEATURE TO ASSESS TECHNIQUE SKILLS KEY FINDINGS ANALYSIS AND
INTERPRETATION

Bowel sounds Auscultation Auscultate the bowel sounds on

the abdominal quadrants using
the diaphragm of the
stethoscope.
1. Begin by placing the
diaphragm on the
RLQ. Listen for a full
minute to the
frequency and
character of bowel
movements.
2. Repeat same step
proceeding in
sequence to RUQ,
LUQ, and LLQ.
3. Listen at least for 5
minutes before
concluding the
absence of bowel
sounds.
 ABDOMEN

AREA/FEATURE TO ASSESS TECHNIQUE SKILLS KEY FINDINGS ANALYSIS AND

INTERPRETATION

Abdominal quadrants Percussion Begin percussion in RLQ, move

upward to RUQ, cross over to
LUQ, and down to LLQ. Note
when tympani change to
dullness.
 NEUROLOGIC SYSTEM
ASSESSMENT OF COMMON DEEP TENDON REFLEX
ANALYSIS AND INTERPRETATION
TYPE ASSESSMENT KEY
FINDINGS

Biceps 1. Flex client’s arm between 45-degree Arms and elbows can be flexed slowly. Due to weakness of brachium.
angle and 90 degrees.
2. Place thumb firmly on biceps tendon just
above the crease of antecubital fossa.
3. Tap thumb with reflex hammer.

Triceps 1. Flex client’s arm at 45 degrees and 90- Slow extension of elbow is observed. As a result of the loss of strength and muscle
degree angle. mass.
2. Tap triceps tendon just above the elbow.

Brachioradialis 1. Flex client’s arm at 45-degree angle and Slow flexion of forearm Due to loss of strength of
place on lap with the arm semi pronated. forearm muscle
2. Tap brachioradialis tendon on thumb side
of the wrist.

Due to loss of strength and mass in leg

Patellar 1. Ask the client to sit in a chair or on edge Slow extension of leg below the knee.
muscles
of bed with legs hanging freely or in
supine position with knee flexed.
2. Tap patellar tendon just below the patella.
 NEUROLOGIC SYSTEM
ASSESSMENT OF COMMON DEEP TENDON REFLEX

ANALYSIS AND INTERPRETATION

TYPE ASSESSMENT KEY
FINDINGS

Achilles 1. Ask client to sit with feet dangling and Pain in the ankles are present Due to weakness of distal limb
partially dorsiflexed or in a supine such as muscle aches and muscles.
position with legs flexed at knee and cramps.
thigh externally rotated.
2. Tap the Achilles tendon just above the
heel.

Plantar (Babinski) 1. Position client’s ankle firmly against the Slow bending of the toes downward. Due to loss of strength and
bed. mass in distal phalanges.
2. Slowly stroke client’s sole with the
handle of the reflex hammer.
Diagnostic Tests
and Laboratory
Findings
 Diagnostic Tests and Laboratory
Findings

Electromyography (EMG)
EMG is a form of electrodiagnostic testing that is used to
study nerve and muscle function. It measures the electrical
activity within muscle fibers in response to nerve
stimulation when the muscle are at rest and when they are
being used. The resulting record is called an
electromyogram. Electromyography is the most frequently
used when people have symptoms of weakness, and
examination shows impaired muscle strength.
 Diagnostic Tests and Laboratory
Findings

SCANS (CT and MRI)

Many people with MG have problems with the thymus
gland, a small organ in your upper chest. Your provider
may order a CT scan (computed tomography) or an MRI
(magnetic resonance imaging) to see if you have an
enlarged thymus or a thymus tumor, which can be a sign of
MG.
 Diagnostic Tests and Laboratory
Findings

Edrophonium (Tensilon) Test

A Tensilon test is a diagnostic test used to evaluate
myasthenia gravis, which is a neuromuscular condition
characterized by muscle weakness. The test involves an
injection of Tensilon (edrophonium), after which ptosis and
muscle strength is evaluated to determine whether the
weakness is caused by myasthenia gravis or not.
 Diagnostic Tests and Laboratory
Findings

Blood test: Acetylcholine Receptor (AChR)

antibody test
An acetylcholine receptor (AChR)
antibody test is used to help diagnose myasthenia
gravis (MG) and to distinguish it from other
conditions that may cause similar symptoms, such
as chronic muscle fatigue and weakness.
Anatomy and
Physiology
The neuromuscular junction is, hence the name, where the neuron and the muscle fiber meet
together and where the neurotransmitter acetylcholine is going to be released. Within that
neuromuscular junction there are other important structures that play a role. There are Nicotinic
Acetylcholine receptors and Muscle-Specific Kinase. Its role is for helping maintain and build
within this neuromuscular junction. At the neuromuscular junction, axons of the motor nerves are
situated across a synapse from the post synaptic membrane on the muscle cell. The axons release a
neurotransmitter from the presynaptic membrane and this neurotransmitter at these junctions is
called acetylcholine. Basically, the neuron which is made up of cholinergic fibers is going to
receive an impulse. Cholinergic fibers release acetylcholine, so whenever it receives an impulse it’s
going to release acetylcholine.

Acetylcholine, a neurotransmitter, travels across the synapse and attaches itself to receptors on the
post synaptic membrane. The acetylcholine stimulates the receptors and this leads to muscle
contraction. In order for the motor nerves to communicate with the muscle cells, they need to
release acetylcholine and this needs to bind to the post synaptic membrane as was mentioned. It
will go down and bind with those Nicotinic Acetylcholine Receptors. When that happens, muscle
contraction will occur.
The immune system functions as the body’s defense mechanism against invasion and allows a
rapid response to foreign substances in a specific manner. The immune system is composed of an
integrated collection of various cell types, each with a designated function in defending against
infection and invasion by other organisms.
The function of the immune system is to remove foreign antigens such as viruses and bacteria to
maintain homeostasis.
The thymus is located in the upper anterior (front) part of the chest directly behind the sternum
and between the lungs. The pinkish-gray organ has two thymic lobes. It plays a very important
role in the immune system’s health. It is the creator of T lymphocytes (also known as T cells), and
those cells fight viruses and bacteria. The thymus reaches its maximum height (about 1 ounce)
during puberty. In children, the thymus gland tends to be larger than an adult because by puberty
the thymus gland has already produced the lifelong supply of T cells that the body needs, but as
the person ages eventually to older ages, the thymus gland will then turn into fatty tissue and it is
now small.
The musculoskeletal system, involving the muscles and bones, particularly includes the cartilage,
ligaments, tendons, and connective tissues. The skeleton provides a framework for the muscles and other
soft tissues. The system support the body’s weight, maintains posture, and helps with movement. As
mentioned before, once the muscles contract, then the muscles pull on the bone, causing movement.

The steps of skeletal-muscle contraction from the start is, when an action potential travels along a motor
neuron toward a skeletal muscle. Their point of connection is called neuromuscular junction which was
discussed previously. After that, at the neuromuscular junction, acetylcholine vesicles are released, and so
acetylcholine binds to its receptor on the sarcolemma causing sodium influx into the muscle fiber,
generating an action potential within the muscle fiber. Next, the action potential travels through the T-
tubules, allowing calcium channels to open and release calcium into the cytoplasm. Calcium ions activate
the actin-myosin binding sites and cross-bridges for between the actin and the myosin heads. After that,
ATP is hydrolyzed to provide energy for flexing the myosin heads. Flexion brings the actin filaments
closer to the middle of the sarcomere. The overall length of the sarcomere is shorter. Lastly, in order for
relaxation to occur, ATP must be used to pump calcium back into the sarcoplasmic reticulum. Once the
tension is released and relaxation occurs, the muscles will go back to a resting position. The cycle of
skeletal-muscle contraction will then repeat.
Pathophysiology
Drug Study
NAME CLASSIFICATION INDICATIONS ACTION CONTRAINDICATION SIDE ADVERS NURSING
EFFECTS EFEFECTS RESPONSIBILITIES

Brand name; Acetylcholinesterase administered increases extracellular Hypersensitivity to drug our •stomach •extreme •Give orally with food or
Mestinon Inhibitor intravenously, it is acetylcholine levels in to bromides mechanical •pain muscle milk to minimize side
indicated for the the neuromuscular obstrution of the GI tract •nausea weakness, effects oral not
Generic name; reversal or junction by impairing know alcohol intolerance •vomiting •loss of interchangeable with IV
pyridostigmine antagonism of the its breakdown by with syrups precautions •diarrhea movement in (parenteral is 30 times
neuromuscular acetylcholinesterase. includres asthma ulcer •muscle any part of your more potent) do not
blocking effects of disease cardiovascular cramps body, crush.
inj solution nondepolarizing disease, epilepy •twitching •weak or
5mg/mL muscle relaxants hyperthyordism. •sweating shallow
tablet, controlled increased breathing, • Assess pluse,
release •salivation • slurred respiratory rate, and Bp
180mg •cough with speech, prior to administration
tablet mucus •vision
60mg •rash and problems, and
syrup blurred worsening or no • Keep fluid intake up,
60mg/5mL vision improvement in take with food or milk
(240mL) your symptoms
of myasthenia • Take as directed do not
gravis skip or double up does
take med. at prescribed
time to avoid adverse
effects carry
identification with
disease and medication
regimen.

• Monitor pulse
respiratory rate, and Bp
evaluate for desired
outcome ( improved
chewing, swallowing
and extremity strength)
NAME CLASSIFICATION INDICATIONS ACTION CONTRAINDICATION SIDE ADVERS EFEFECTS NURSING
EFFECTS RESPONSIBILITIES

Brand name; Antineoplastics, Treatment of Is a folic acid Pregnancy, lactation, • Reddening • Ulceleration of the • Monitor for bone
Trexall Antimetabolite, gestational antagoinst that alcholism, chronic liver of skin mounth and GI marrow depression
DMARDs, choriocarcinoma, inhibits DNA disease, • Execess disturbances (e.g • Assess for bleeding
Generic name; Immunomodulators chorioadenoma, synthesis. It Immune deficiencues blood, uric acid in stomatitis diarhoea). ( gums,bruising,urine
methotrexate destruens Irreversibly dyscrasias, hypersensitivity the blood bone marrow depression, etc)
hytidiform. binds to to methotrexate. • Gum hepatotaxicity, renal • Monitor I&O ,appetite,
Tablets; 25, 5, dihydrofolale disease failure, skin reaction, nutritional intake
7.5, 10, 15 mg Symptomatic reductose (gingivitys) alopecia, ocular • Monitor IV site
Powder for control of severe, inhibits the • Nousea of irritation, arachnoiditis in carefully & maintain
injection 20mg recalcitrant formation of vomiting intrathecal use, patency
1mg per vial disabling psoriasis. reduced folates • Diarrhea megaloblastis aneamia, • Advice patients to use
Injection 25 and • Loss of asteoporosis precipitation sunscreen; severe
mg/mL thymildylate appetite of diabetes, arthralgias, sunbern can occur even
sythetase, • Sore throat necrosis, of soft tissue with low weekly doses
resulting in • chills, fever and bone, anaphylaxis • Leocoverin must be
inhibition of impaired fertility. admenistered exaclty on
purine and • Pontentially fatal time
thymidylic acid pulmonary reactions (e.g • Avoid vitamins
synthesis. interstitial lung disease); containing folic acid to
neurotoxicity avoid the methabolic
( luekoencephalopathy, block couses by
paresis, demyelination ) methotrexate
with intrathecal use; • Discontinue Bactrim
foetal deaths. prophylaxis during high-
dose methotrexate
 NAME OF CLASSIFICATION INDICATION ACTION CONTRAINDICATTION SIDE EFFECTS ADVERSE NURSING
DRUGS EFFECTS RESPONSIBILITY

Generic Corticosteroids Indicated on severe Decreases the Contraindicated in patients - Nausea - Hiccups - Determine if the
Name: inflammation, inflammation, hypersensitive to drug or its -Puffiness of patient is sensitive to
prednisone immunosuppression, mainly by components; in those with - Vomiting the face other corticosteroids
endocrine disorders. stabilizing systemic fungal infections, - Growth of - Monitor patient’s BP,
Brand leukocyte cerebral malaria or active - Heartburn facial hair sleep patterns and
Name: Rayos Treatment of metastatic lysosomal ocular herpes simplex and in - Thinning and potassium levels
castration- resistant membranes, those receiving - Increased easy bruising - Weigh the patient
Dosage: prostate cancer, allergic supresses immunosuppressive doses appetite skin daily, report sudden
Oral solution: reactions, dermatologic immune together with live virus - Impaired weight gain prescriber
5mg/5ml disease and response, vaccine. - Weight gain wound healing -Monitor patient for
gastrointestinal diseases stimulates bone - anaphylaxis hypothalamic pituitary
Tablets: 1 mg, marrow and - Headache (severe adrenal axis
2.5 mg, 5 mg, influences allergic supersession and
10 mg, 20 protein, fat, and - Loss of reactions) cushingoid effects.
mg, 50 mg. carbohydrate potassium - Vision - Always adjust to
metabolism. changes lowest effective dose
Tablets - Muscle - congestive - Reduce dosage
(delayed weakness heart failure gradually and reinstitute
release): 1 and heart corticosteroid if needed.
mg, 2 mg, 5 - Restlessness attack - Monitor patients for
mg. and problem - Fainting signs and symptoms of
sleeping - Pulmonary infection.
edema - Instruct the patient to
- Thinning skin - Low blood take drug with food or
pressure milk and to swallow
- acne - convulsions delayed release tablets
whole
- Warn the patients on
long term therapy about
cushingoid effects
(moon face, buffalo
hump)
 NAME OF CLASSIFICATION INDICATION ACTION CONTRAINDICATION SIDE EFFECTS ADVERSE NURSING
DRUGS EFFECTS RESPONSIBILITY
Generic Chemical class: Purine To prevent kidney May prevent ACE inhibitors and drugs CNS: SKIN: Advise patient to take
Name: analogue rejection after proliferation and that affect bone Fever Acute febrile oral drug with food
azathioprine Therapeutic class: transplantation differentiation of marrow and cell malaise neutrophilic or meals to minimize GI
Antimetabolite, activated B and T development in bone GI: Abdominal dermatosis upset.
pain, (Sweet’s
Brand Name: immunosuppressant cells by interfering marrow, such as co- diarrhea, Syndrome),
Imuran Pregnancy category: D with purine (protein) trimoxazole: hepatotoxicity alopecia, Before I.V. use, add 20
and (elevated liver cancer, rash ml sterile water for
Dosage: nucleic acid (DNA nondepolarizing function test RESP: injection to
Tablet, IV and RNA) synthesis. neuromuscular blockers: results), nausea, Reversible azathioprine vial and
pancreatitis, interstitial swirl until clear solution
infusion Possibly decreased or forms. Resulting drug
Initial: 3 to 5 reversed action of steatorrhea, pneumonitis
vomiting Other: concentration is 100 mg
mg/kg neuromuscular blocker and can be diluted
daily P.O. or MS: Arthralgia, Infection,
myalgia lymphomas further as prescribed.
I.V. as a single and other
dose on neoplasms, Calculate
Maintenance: negative infusion rate based on
1 to 3 mg/kg nitrogen final volume to be
daily P.O. balance infused. Then give over
30 to 60 minutes
Adults. Initial: or as prescribed (5
1 mg/kg (50 to minutes to 8 hours).
100 mg) Obtain results of
daily as a baseline laboratory
single dose or tests,
twice daily for including WBC, RBC,
6 to and platelet counts.
8 wk.
 NAME OF CLASSIFICATION INDICATION ACTION CONTRAINDICATION SIDE EFFECTS ADVERSE NURSING
DRUGS EFFECTS RESPONSIBILITY
Generic Chemical class: Purine To prevent kidney May prevent ACE inhibitors and drugs CNS: SKIN:
Name: analogue rejection after proliferation and that affect bone Fever Acute febrile Expect to monitor
azathioprine Therapeutic class: transplantation differentiation of marrow and cell malaise neutrophilic results once a week
Antimetabolite, activated B and T development in bone GI: Abdominal dermatosis during first month of
pain, (Sweet’s therapy, twice a
Brand Name: immunosuppressant cells by interfering marrow, such as co- diarrhea, Syndrome), month during second
Imuran Pregnancy category: D with purine (protein) trimoxazole: hepatotoxicity alopecia, and third months,
and (elevated liver cancer, rash and once a month or
Dosage: nucleic acid (DNA nondepolarizing function test RESP: more thereafter.
Tablet, IV and RNA) synthesis. neuromuscular blockers: results), nausea, Reversible
infusion Possibly decreased or pancreatitis, interstitial Hematologic reactions
Initial: 3 to 5 reversed action of steatorrhea, pneumonitis typically are dose-
mg/kg neuromuscular blocker vomiting Other: related and may occur
daily P.O. or MS: Arthralgia, Infection, late in therapy,
myalgia lymphomas especially in patients
I.V. as a single and other with transplant
dose on neoplasms, rejection.
Maintenance: negative
1 to 3 mg/kg nitrogen
daily P.O. balance
Adults. Initial:
1 mg/kg (50 to
100 mg)
daily as a
single dose or
twice daily for
6 to
8 wk.
Medical and
Surgical
Management
 Minimally Invasive Thymectomy
Thymectomy has traditionally been performed as an open procedure in
which the central breast bone, or sternum is cut, and the chest opened
(sternotomy). A sternotomy is major surgery, requiring three to five days
in the hospital, and up to six weeks to recover.

Bilateral VATS Thymectomy

The procedure may also be performed minimally invasively through the side of the chest, via video-assisted
thoracoscopy (VATS). The surgeon creates two or three small (3/4-inch) incisions. Small surgical instruments and a
camera for viewing the procedure are inserted through the incisions. Surgery takes place entirely inside the closed
chest. Benefits include reduced recovery time and less postoperative pain than the open approach. This is the most
cosmetically appealing of thymectomy procedures due to the location and the small size of the incision.
Robotic Thymectomy
In a robotic thymectomy the surgeon makes three tiny incisions 鈥 each about a half-
inch long 鈥 on one side of the chest. The same tiny camera and surgical instruments
used in a minimally invasive thymectomy are inserted through the incisions. But then
the arms of the daVinci robot are attached to those instruments. The surgeon sits at a
console, controlling the robotic arms, which separates the thymus gland from its
surrounding tissue and bone and removes it through one of the incisions.
Nursing Care
Plan
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective breathing pattern After 8 hours of nursing Independent: To create baseline data for After 8 hours of nursing
Madalasakong nahihirapan related to respiratory muscle intervention the patient will patient and to monitor intervention the patient was
huminga.” as verbalized by weakness secondary to be able to maintain Assess patient’s vital sign. effectiveness of medical able to maintain respiratory
the patient myasthenia gravis respiratory rates within ask the patient and treatment rates within normal limits and
normal limits and patient will characteristics of respiration patient will verbalize ease of
verbalize ease of breathing at least every 2 hours breathing
Objective: Head elevation and semi
Elevate the head of the bed. fowlers position help
✓ SOB assist the patient in semi improve the expansion of the
✓ Labored breathing fowlers position lungs, enabling the patient to
✓ Tachypnea breath effectively
✓ Presence of fine
crackles upon
auscultation Dependent: To dilate and relax muscle on
✓ RR of 23bpm Administer bronchodilator as the airways
prescribed
To reduced lung
Administer steroids if inflammation in the lungs
prescribed
To improve muscle strength
and contractility by
Administer cholinesterase enhancing the
inhibitors as prescribed communication between the
nerve and the muscles

To increase oxygen level and

achieve O2 sat within normal
Administer supplemental range
oxygen as prescribes.
 Assessment
Subjective data:
“Palagi na lang akong
napapagod, konting galaw
lang nanghihina na ako,” as
verbalized by the patient.
Objective data:
· Progressive fatigability
with repetitive or
prolonged muscle use
· Muscle weakness
· Impaired coordination
· Decreased muscle
strength/control
Nursing Diagnosis Planning Interventions
Impaired physical After 2 hours of nursing INDEPENDENT
mobility related to intervention, the patient · Assess client’s developmental
neuromuscular will be able to level, motor skills, ease and
impairment as demonstrate techniques capability of movement, posture,
evidenced by or behaviors that enable and gait.
progressive fatigability resumption of activities. · Assess nutritional status and
with repetitive or client’s report of energy level.
prolonged muscle use,
muscle weakness,
impaired coordination, · Encourage adequate intake of
and decreased muscle fluids and nutritious intake of
strength/control foods for adequate energy
resources and metabolic
requirement.
· Assist the patient during exercises
and when performing activities of
daily living.
· Identify energy-conserving
techniques for ADLs.
· Schedule activities with adequate
rest periods during the day.
· Evaluate the need for assistive
devices if necessary.
· Provide a safe environment for the
patient by elevating the side rails
and lowering the bed level; the
room should be well-lit, the floor
should not be slippery, and the call
bell, as well as the patient's
important belongings, should be
easily accessible.
Rationale Evaluation/Expected
Outcome
After 2 hours of nursing
·To determine presence of intervention, the patient
characteristic of client’s unique was able to demonstrate
impairment and to guide choice of techniques or behaviors
interventions. that enable resumption
·To determine if the client's nutrition of activities.
is enough or inadequate, as this
influences their energy level.
·To promote client’s well-being and
maximizes energy production.
· To encourage the patient to
perform muscle-strengthening
exercises and promote dignity by
allowing the patient to perform
their ADLs while maintaining
safety.
· To limit fatigue and maximize
participation
· To reduce fatigue. Rest periods are
essential to conserve energy.
· To enhance activity, lessen the
danger of falls, and promote
independence.
· To promote a safe, secure
environment and may reduce risk
for falls
 Assessment
Subjective data:
“Palagi na lang akong
napapagod, konting galaw lang
nanghihina na ako,” as
verbalized by the patient.
Objective data:
· Progressive fatigability
with repetitive or
prolonged muscle use
· Muscle weakness
· Impaired coordination
· Decreased muscle
strength/control
Nursing Diagnosis Planning Interventions Rationale Evaluation/Expecte
Outcome
Impaired physical After 2 hours of nursing After 2 hours of nursin
mobility related to intervention, the patient intervention, the patien
neuromuscular will be able to DEPENDENT · To provide a specialized care for the was able to demonstrat
impairment as evidenced demonstrate techniques · Collaborate with occupational or patient to gain physical and mental techniques or behavior
by progressive or behaviors that enable physical therapists. support in performing ADLs and that enable resumption
fatigability with resumption of activities. mobilizing. activities.
repetitive or prolonged
muscle use, muscle
weakness, impaired
coordination, and
decreased muscle
strength/control
CUES DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Imbalanced Nutrition: SHORT-TERM GOAL: Collaborate with the To provide more and Client has
" Nahihirapan Less than body dietician to adequate nutrition show a progressive
Akong lumunok, Requirements related Client will gain 2 determine the for the client. weight gain during
hindi ako to to difficulty pounds per week. numbers of calories hospitalization.
nakakakain ng swallowing. requires.
maayos” as LONG-TERM GOAL: Client is able to
verbalized by the pt. Weight client daily. Weight loss and gain verbalize
Client will exhibit no is important the importance of
OBJECTIVE: signs or symptoms of assessment info. adequate
malnutrition by time of nutrition and
• Loss of weight discharge from Large amounts of fluid intake
• Weakness treatment. Ensure that the client food may be
• Poor skin turgor receives small, objectionable, or
frequent feedings, even intolerable to
including a bedtime the client.
snack, rather than
three larger meals.

Stay with client

during meals.
To assist the client
as needed and to
offer support.
determine client’s
like and dislike Client is more likely
to eat the food
he/she particularly
enjoys.

Explain the Client may have

importance of inadequate
adequate nutrition knowledge regarding
and fluid intake. the contribution of
good nutrition.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective data: Fatigue related to muscle After 3 hours of proper INDEPENDENT: After 3 hours of proper
“Sobra na sobrang pagod weakness secondary to nursing intervention, the nursing intervention, the
ako palagi, kahit konting myasthenia gravis as patient will be able to Explore the patient’s activities of daily To create a baseline data of patient was able to
activity lang ang ginagawa evidenced by irritability, demonstrate active living and assess the patient’s degree the activity levels and have demonstrate active
ko.” as verbalized by the and verbalization of participation in necessary of fatigability by asking them to rate knowledge on the degree of participation in necessary
patient. overwhelming tiredness. and desired activities, and his/her fatigue level (mild, moderate, fatigability of the patient. and desired activities, and
also show an increase in or severe). also has shown an increase
activity levels. To create a baseline data on in activity levels.
Objective data: Ask the patient about his/her the patient’s feelings,
perceived and actual limitations to worries, and thoughts about
- Change in facial physical activity, and as well as what his/her fatigue and to create
expression form of exercise he/she did before, or an open comfortable
- Droopy eyelids what he/she wants to try or do. environment, as well as to
(ptosis) figure out planning of
activities.

To have the patient still be

Encourage activity through self-care able to do activities of daily
and exercise as tolerated. living, and maintain
independence, and also
exercise without them
getting close to being
fatigued.

To help the patient balance

Alternate periods of physical activity his/her physical activity and
with rest and sleep. rest periods without the
chance of them getting
fatigued.

To reserve energy levels and

Encourage enough rest and sleep and to provide optimal comfort,
provide comfort measures. peace, unwinding, and
relaxation.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective data: Fatigue related to muscle After 3 hours of proper After 3 hours of proper
“Sobra na sobrang pagod weakness secondary to nursing intervention, the nursing intervention, the
ako palagi, kahit konting myasthenia gravis as patient will be able to Teach or instruct the patient on how To help relax the patient patient was able to
activity lang ang ginagawa evidenced by irritability, demonstrate active to do deep breathing exercises, and and to allow demonstrate active
ko.” as verbalized by the and verbalization of participation in also provide adequate ventilation in proficient/adequate oxygen participation in necessary
patient. overwhelming tiredness. necessary and desired the room. into the room. and desired activities, and
activities, and also show also has shown an
an increase in activity increase in activity levels.
Objective data: levels. Provide a quiet and peaceful To help give the patient
environment and teach relaxation more comfort and to help
- Change in facial techniques such as visualization, him/her relax more.
expression music therapy, meditation, art
- Droopy eyelids therapy, and Tai Chi.
(ptosis)

DEPENDENT:

Refer the patient to the To help provide more

physiotherapy/occupational therapy
team as required.
specialized care for the
patient in terms of helping
them build confidence and
self-assurance when it
comes to balancing daily
physical activity and rest
periods.
 Assessment
Subjective Data:
“ I am having difficulty
swallowing.” as verbalized by
the patient.
Objective Data:
• Nausea and Vomiting
• Diminished breath
sounds
• Bronchial spasms
Nursing Diagnosis
Risk for aspiration related to
difficulty in swallowing
secondary to myasthenia
gravis
Planning
The patient will be able to
maintain a patent and clear
airway and avoid aspiration.
Intervention
Independent:
Perform a dysphagia screening
to assess for impaired
swallowing.
Assess lung sound before and
after the patient eats, and
effectiveness of patient’s
cough.
Keep head of bed elevated
after meals.
Provide liquids after meals.
Provide oral hygiene after
meals
Turn patient on one side when
nausea or vomiting occurs
Rationale Evaluation
Dysphagia screening will The patient was able to
identify patients at risk for maintain a patent and clear
aspiration. Patients should be airway and was able to avoid
kept NPO until a swallowing aspiration.
evaluation is performed.
New onset of wheezing can
signal aspiration. Patient’s with
weak cough are at risk of
aspiration.
This position facilitates flow of
food and fluids by gravity,
thereby minimizing the
potential for regurgitation.
Give liquids after the patient
has finished eating. Ingesting
both food and liquids together
increase swallowing problems.
Oral hygiene removes food
particles or secretions that
could be aspirated.
This position facilitates
drainage and prevents
aspiration.
 Assessment
Subjective Data:
“ I am having difficulty
swallowing.” as verbalized by
the patient.
Objective Data:
• Nausea and Vomiting
• Diminished breath sounds
• Bronchial spasms
Nursing Diagnosis
Risk for aspiration related to
difficulty in swallowing
secondary to myasthenia
gravis
Planning
The patient will be able to
maintain a patent and clear
airway and avoid aspiration.
Intervention
Assess the mouth frequently,
and suction PRN.
Anticipate need for an
artificial airway if secretions
cannot be cleared.
Dependent:
Administer medications
prescribed by the physician.
Rationale Evaluation
These actions assess for The patient was able to
particles or secretions that maintain a patent and clear
could be aspirated and airway and was able to avoid
removes them. aspiration.
This measure help ensure a
patent airway
Compliance with the
treatment regimen is highly
advisable to improve the
patient’s condition.
 EVALUATION
After conducting this study, Group 4 nursing students were able to obtain a lot of
information regarding the disease –Myasthenia Gravis. Through deeper understanding
of the disease, the students found out the various assessments and clinical
manifestations of Myasthenia Gravis. The students also recognized the affected
systems of the disease through studying the anatomy and physiology, as well as the
pathophysiology of the disease. The group worked together to formulate an accurate
diagnosis to execute proper nursing care plans that have been implemented to address
the needs of their patient and give them the best possible care that they deserve.
Lastly, the students have been able to sharpen their nursing skills and obtain wider
understanding about the management of a patient with Myasthenia Gravis. With these
considered, the goals and objectives of the Student Nurses for this study were
attained.