Myasthenia Gravis

An autoimmune neurologic
disorder

By Lexi Gray & Mary

Kacic

Background
Myasthenia gravis means grave muscle

weakness
It is an autoimmune disease affecting the
myoneural junction
About 60,000 people in the U.S. have this disease
Women affected more frequently than men, at
around 20-40 years of age. Men develop it later,
at around 60-70 years of age.

Symptoms
Causes varying degrees of skeletal muscle

weakness
Hallmark of the disease: muscle weakness increases
during periods of activity and improves during rest.
Areas that MAY be affected: eyes/eyelid movement,
facial expression, chewing, talking, swallowing

Pathophysiology
Normal communication between the nerve and muscle

is interrupted at the neuromuscular junction (where

nerve cells meet with the muscles they control)
Normally, nerve endings release acetylcholine which
travels through the NMJ and binds to receptors,
causing muscle contraction.
In myasthenia gravis, these receptors are blocked or
destroyed

Pathophysiology
Autoimmune disease: the antibodies that attack

or block the acetylcholine receptors are

produced by the bodys own immune system
Thymic hyperplasia or a thymic tumor is present
in 80% of people with myasthenia gravis

Assessment
Onset of the disorder may be sudden
Many times, symptoms are not immediately

recognized as being related to myasthenia gravis

In most cases, weakness of the eye muscles is
noticed first.

Assessment - Severe
Symptoms

Ptosis drooping of one or both eyelids

Diplopia blurred or double vision
Bulbar symptoms weakness of muscles of the face

& throat
Bland facial expression
Difficulty swallowing increased risk of choking &
aspiration
Dysarthia impaired speech
Dysphonia voice impairment
Weakness In arms, hands, legs, neck
Generalized weakness also effects intercostal
muscles, resulting in decreasing vital capacity and
respiratory failure.

Confirming the Diagnosis

Acetylcholinesterase Inhibitor Test
Confirms the diagnosis of myasthenia gravis. During

this test, the breakdown of acetylcholine is stopped.

As a result, acetylcholine is able to accumulate at
the receptor sites.
For this test, edrophoniumchloride is administered
IV. Facial muscle weakness and ptosis will resolve
about 30 second after the drug is administered, if
the patient is positive for a myasthenia gravis
diagnosis. This relief lasts only 5 minutes, so it is
not considered a treatment.
After the drug is administered, the patient's serum
is then tested for acetylcholine receptor antibodies,
which would also be consistent with the diagnosis.
In some cases, patients with myasthenia gravis may
have an enlarged thymus gland.

Nursing Diagnosis #1
Risk for aspiration R/T difficulty swallowing,

weakness of bulbar muscles

Overall goal: No aspiration will occur
Interventions
Give meals with anticholinesterase meds to

inhibit breakdown of acetylcholine and

increase its concentration at the NMJ
Raise the HOB to semi-fowlers position,
which will ensure upper airway patency.
Give food with a pudding-like consistency,
which can be more easily swallowed.

Nursing Diagnosis #2
Deficient knowledge R/T drug therapy, potential for

crisis (myasthenic or cholinergic), and self-care

management
Overall goal: Patient will demonstrate knowledge of
medication management, importance of rest, coping
strategies, and prevention/management of
complications
Interventions
Teach patient about the actions of meds, and importance

of regimen. The patient will verbalize the consequences

delaying med intake, including S&S of myasthenic and
cholinergic crisis.
Teach strategies for patient to conserve their energy. The
patient will develop coping strategies to avoid
overexertion.
If eyes cannot close properly, instruct patient to patch/tape
eyes closed for short intervals to avoid corneal damage.

Treatment of myasthenia
gravis

Pharmacologic Treatment
First-line med is pyridostrigmine bromide

(Mestinon), an anticholinesterase that inhibits the

breakdown, thus improving skeletal muscle
contraction. Side effects can include fasciculations,
abdominal pain, diarrhea.
Immunosuppressive Therapy: Corticosteroids
decrease the amount of antibody production. Cytotoxic
meds (Azathioprine) inhibits production of T-and Bcells, and effects may not be seen for 3-12 months.
Hepatotoxicity is a risk of using cytotoxic meds.
Some common medications exacerbate the symptoms
of myasthenia gravis, including: antibiotics, betablockers, antiseizure meds, Novocain, morphine and
quinine.

Possible Side Effects of

Anticholinesterase Meds
Central
Nervous System

Respiratory/
Cardiovascular

Skeletal Muscles

Irritability

Bronchial relaxation

Fasciculations

Anxiety

Increased bronchial
secretions

Spasms

Insomnia

Tachycardia

Weakness

Headache

Hypotension
Genitourinary

Dysarthia

Frequency
Gastrointestinal

Syncope

Abdominal cramps

Urgency

Seizures

Nausea, vomiting and

diarrhea

Integumentary

Coma

Anorexia

Rash

Diaphoresis

Increased Salivation

Flushing

Treatments
Plasmatheresis
This procedure removes the patients plasma and

plasma components through a centrally placed

catheter. Blood cells are separated from antibodycontaining plasma. The blood cells are then mixed
with plasma substitute and reinfused. Provides
temporary treatment for severe symptoms.

Intravenous immune globulin

Treats exacerbations of myasthenia gravis

temporarily. This procedure does not work as

quickly as plasmatheresis.
These are treatments for myasthenia
gravis, not cures.

Treatments
Surgical Treatments
Thymectomy: Surgical removal of the

thymus gland, which may result in the

production of antigen-specific
immunosuppression, which results in clinical
improvement. Results vary; patient may
have partial or complete remission, or no
remission at all.
Nursing considerations for the patient who

received a thymectomy include monitoring

respiratory function and mechanical
ventilation.

Myasthenia (or cholinergic)

Crisis

Exacerbation of the disease process. Signs &

symptoms include muscle/bulbar weakness.

Causes for myasthenia crisis may include a
respiratory infection, pregnancy, or medications.
Primary management is focused on maintaining
the airway. The nurse assesses respiratory rate,
depth, breath sounds, and pulmonary function.
Endotracheal intubation and mechanical
ventilation may be necessary.
Assess arterial blood gases, I&O, daily weight.
Avoid sedatives and tranquilizers.
Bradycardia and respiratory distress (emergency
situations) are treated with atropine.

References
Doenges, M., Moorhouse, M., Murr, A. (2010).
Nurses Pocket Guide: Diagnoses,
Prioritized Interventions, and Rationales
(12th ed.). Philadelphia: F.A. Davis. ISBN:
0803622341.
Smeltzer, S. C., Bare, B. G., Hinkle, J. L. &
Cheever, K. H. (eds.) (2008). Brunner &
Suddarth's textbook of medical-surgical
nursing (11th ed.). Philadelphia: Lippincott
Williams & Wilkins.