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z_MS1_Neuro Study > GF8: Neuro Myasthenia Gravis, Cholinergic and Myasthenic Crisis > Flashcards

GF8: Neuro Myasthenia Gravis, Cholinergic and Myasthenic Crisis Flashcards

1
Q

What is Myasthenia Gravis?

A

a neurological condition that prevents motor neurons and muscles from communicating with each other. It leads to MUSCLE WEAKNESS.

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2
Q

What is the cause of MG?

A

The exact cause is unknown.

We do know that it’s an autoimmune disorder that triggers the patient’s own immune system to attack the connection between neurons and muscles.

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3
Q

What is the path of MG?

A
  • The immune system creates antibodies to attack the postsynaptic nicotinic acetylcholine receptors
    • These postsynaptic nicotinic receptors are located at the neuromuscular junction (NMJ).
    • Normally, the neuron releases a neurotransmitter called acetylcholine, which then goes and binds to these nicotinic acetylcholine receptors, and this causes your muscles to contract.
  • With MG, Acetylcholine can’t bind to the receptors.
    • The immune system has attacked the nicotinic acetylcholine receptors, so the acetylcholine can’t bind there.
  • Muscles can’t contract
    • Since there are autoantibodies blocking those postsynaptic nicotinic acetylcholine receptors, and the acetylcholine can’t bind, the muscles can’t contract like they should.
    • This leads to muscle weakness
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4
Q

What is important to keep in mind regarding weakness?

A
  • Weakness tends to worsen with repetitive movements and activity as more and more acetylcholine is blocked and then naturally broken down over time.
  • With rest, muscle contractions can improve.
  • Rest will allow more acetylcholine to build up at the neuromuscular junction and allow it to flood more of the receptors
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5
Q

What are the s/s involving the eyes for MG?

A
  • Ptosis
    • due to the constant muscle contractions that occur in order for us to move our eyes and blink
  • Strabismus
    • Strabismus happens when one or both eyes does it’s own thing (looks up, down, in or out). This can lead to…
  • Double vision
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6
Q

Since the muscles can’t contract as they should, what muscles groups may be weaker?

A

Muscles of the face, neck, arms, legs, hands

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7
Q

What are the s/s involving the upper GI system for MG?

A
  • Dysphagia
  • Gagging
  • Difficulty protecting airway
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8
Q

True or False

MG muscle weakness is worst in the morning but gets better as the day progresses.

A

False, it is the opposite

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9
Q

Why is it important to always assess an MG patient’s ability to breathe?

A

They are at an increased risk of airway compromise due to those weaker muscles.

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10
Q

True or False

Speech is not affected by MG.

A

False, Slurred speech, hoarseness: Occurs due to the weakened muscles around the mouth and throat.

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11
Q

The MG patient might be exhausted at the end of the day from doing simple basic ______.

A

activities of daily living

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12
Q

How does MG affect the respiratory system?

A
  • When the respiratory muscles become weakened, it can impair their ability to breathe.
  • This can quickly progress to respiratory distress and failure.
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13
Q

An MG patient’s neck and mouth muscles tend to become affected as the day progresses, what is our teaching regarding timing of meals?

A

Have them eat earlier on in the day before the muscles become tired.

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14
Q

What dx tests are used for MG?

A

Tensilon (edrophonium) test

Blood test for acetylcholine receptor antibodies

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15
Q

What is the purpose of the Tensilon test? Who does it?

A
  • Determine if a patient has myasthenia gravis or not
  • Determine if a patient is in a myasthenic crisis
  • Determine if a patient is in a cholinergic crisis.
  • The test is performed by a neurologist
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16
Q

How is the Tensilon test given?

A

Pt is injected w/ Edrophonium, a cholinesterase inhibitor

Reaction to injection will occur w/in 5-10 mins

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17
Q

What is the Tensilon reaction that gives a POSITIVE result?

A
  • The injection causes the patient to experience IMPROVED muscle strength
  • Ach levels at the neuromuscular junction rise because edrophonium inhibits the breakdown of ACh
  • Signs and symptoms temporarily diminish
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18
Q

What is the treatment for a positive Tensilon Test?

A

Doc needs to boost anticholinesterase dosage to balance the levels with ACH

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19
Q

What is the Tensilon reaction that gives a NEGATIVE result?

A
  • Injection causes the patient to experience even more weakness
  • Ach levels are already ok, the injection causes an increased Ach level to occur causing overstimulation
  • The patient’s signs and symptoms will worsen
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20
Q

What is the treatment for a negative Tensilon Test?

A

HOLD anticholinesterase medication and administer atropine (antidote) per MD order

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21
Q

When does a myasthenic crisis occur?

A
  • When there is so much acetylcholine that has been naturally broken down, that there’s not enough left to bind to the open nicotinic acetylcholine receptors and stimulate muscle contraction
  • Myasthenic crisis can cause respiratory distress and respiratory failure.
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22
Q

When does a cholinergic crisis occur?

A

When the neuromuscular junction was already saturated with acetylcholine and now even more acetylcholine is present due to the tensilon.

This is caused by the patient receiving too much of their treatment medications for myasthenia gravis

23
Q

If a patient is in a cholinergic crisis and is given tensilon, they can _____ quickly, so it’s important to have emergency supplies very readily available before administering it.

A

decline

24
Q

_____ is the antidote to tensilon and will reverse it, so it should be administered if the patient is in a cholinergic crisis.

A

Atropine

25
Q

What is the patho myasthenic crisis?

A
  • It happens due to low to no stimulation at the neuromuscular junction
  • Receptors are not available to do their job because of antibodies attacking them
  • As a result, acetylcholine cannot trigger them which leads to severe muscle weakness
26
Q

What causes a myasthenic crisis to happen?

A

Insufficient amounts of anticholinesterase drug or

An illness, respiratory infection, stress etc has created an exacerbation of MG

27
Q

What is the patho of a cholinergic crisis?

A

It happens due to excessive stimulation at the neuromuscular junction by too much acetylcholine which leads to overdrive in cholinergic response.

28
Q

What causes a cholinergic crisis to occur?

A

Overmedication of anticholinesterase medication given for myasthenia gravis

29
Q

What s/s do both myasthenic and cholinergic crisis share?

A

Muscle weakness

Respiratory failure

30
Q

What are the s/s specific to myasthenic crisis?

A
  • Signs and symptoms will affect all voluntary muscles making them flaccid (from eyes to bowels):
    • pupils dilated
    • tachycardia/HTN
    • no cough or gag
    • aspiration (can’t swallow or cough)
    • incontinence (no muscle strength) of both bowel and bladder
31
Q

What are the s/s specific to cholinergic crisis?

A
  • signs and symptoms that will present are similar to parasympathetic stimulation (the “rest and digest” system), but in OVERDRIVE!!
    • GI issues: vomiting, diarrhea, cramping
    • Pupil constriction
    • Increase salivation and tear production….blurred vision and increase respiratory secretions
    • Muscle fasciculation/twitching…from overstimulation eventually paralysis
    • Low blood pressure and heart rate
32
Q

What emergency should be at bedside at all times for an MG pt?

A
  • O2
  • Ambu bag
  • Suction
33
Q

What nursing interventions can be employed for easing work of breathing and reducing risk of aspiration for the MG pt?

A
  • Elevate HOB
  • Monitor swallowing
  • Eat larger meals earlier in the day when they are stronger
34
Q

What are safety nursing interventions for an MG pt?

A
  • Assist w/ ambulation as they are @risk for falls
  • Move personal belongings where they can see them to promote independence if their vision is impaired
  • Perform ADLs, necessary activities earlier during in the day when they have more energy
  • Always where medic alert bracelet!
35
Q

What is the MG pt education re: triggers?

A
  • Avoid or minimize:
    • Illness/infection
      • Get flu, pneumonia vaccines
      • Avoid crowds
    • Stress and hot temps
    • Hormonal changes (menstrual cycles)
36
Q

What does anticholinesterase do?

A

Blocks the breakdown of acetylcholine making it more available at the neuromuscular junction site

This will increase muscle contraction

37
Q

When giving anticholinesterase medications, watch for signs of cholinergic crisis such as:

A
  • Bradycardia
  • pupil constriction
  • bronchoconstriction
  • respiratory failure
  • increase mucous production and saliva
  • GI upset, and
  • incontinence
38
Q

How does plasmapheresis help with MG?

A

removes the antibodies that attack the neuromuscular junction receptors.

Can be done bedside

39
Q

What is the pharmacological tx for MG?

A
  • IVIG therepy
  • Steroids: reduce inflammation
  • Immunosuppressants: prevent illness/infection
  • Neostigmine: increase secretions
40
Q

Why should a nurse prioritize seeing a patient with myasthenia gravis difficulty swallowing & temperature of 100.7F?

A

Fever indicates illness/infection

Dysphagia is @risk of aspiration, non-patent airway

41
Q

Why would a nurse administer pyridostigmine prior to a meal?

A

To increase secretions to make it easier to swallow

42
Q

True or False

MG can be cured.

A

False, but its symptoms can be managed.

43
Q

Why do we continually monitor for increased secretions of an MG pt?

A

Secretions could indicate pt is in a cholinergic crisis

44
Q

If a patient taking pyridostigmine being managed for myasthenic crisis develops asthma, why would you discontinue pyridostigmine?

A

This will decrease secretions and help open up the airways

45
Q

What are the adverse effects of neostigmine or pyridostigmine? What is the solution?

A
  • Pupil constriction
  • Difficulty with visual accommodation
  • Solution: atropine- given for cholinergic crisis caused by excess amount of neostigmine
46
Q

A client on pyridostigmine having increased salivation, lacrimation and urination. What is the priority nursing action?

A

Notify HCP as this indicates a cholinergic crisis

47
Q

The thymus gland may give incorrect instructions to developing immune cells which results in autoimmunity and production of ACH receptor antibodies. If this is the cause of MG, how is it remedied?

A

Thyroidectomy

48
Q

What is the procedural tx for myasthenia gravis?

A

Plasmapheresis

Thymectomy

49
Q

Why do we tape eyes shut at night for MG pts?

A

To prevent corneal drying/damage

50
Q

What types of meal are provided for MG patient?

A

Provide small, frequent, high-calorie meals.

51
Q

True or False

Obese pts may be able to restore neuromuscular junction by losing weight.

A

True

52
Q

What other autoimmune diseases share similar s/s to MG that need to be ruled out for MG dx?

A
  • Thyroid disease
  • DM1
  • Rheumatoid arthritis
  • Lupus
  • Demyelating CNS disease
53
Q

True or False

If ice is placed on a eye w/ ptosis and the ptosis shows improvement, this is known as a positive ice test that does what?

A

Confirms dx of MG

Ice slowed acetylcholinesterase activity which is allowed ach to attach properly to receptors and improved muscle contraction

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