L21

Question 1

Clinical manifestations of Myasthenia Gravis

Answer 1

1. Muscle weakness
2. Ocular symptoms: diplopia (double vision); ptosis (eyelid droop over the eye)
3. Bulbar symptoms: dysphagia; dysarthia (difficulty speaking)
4. Respiratory weakness:
   - shallow and decreased vital capacity; use of accessory muscles; difficult to cough
   - in severe case, respiratory muscle weakness cause respiratory failure
5. Bladder and bowel sphincter weakness
   *** NO SENSORY LOSS

Question 2

Diagnostic test for myasthenia gavis

Answer 2

1. Blood test for acetylcholine receptor antibodies and thyroxine function
2. EMG: detect the strength and speed of electrical signals sent from the nerve to the muscle
3. CT/MRI

Question 3

Myasthenic crisis

Answer 3

1. Respiratory distress (require incubation and mechanical ventilation)
2. Cyanosis due to hypoxia
3. Absent cough and gag reflex
4. Restlessness
5. Diaphoresis (excessive sweating)
6. Decreased urine output
7. Bladder and Bowel incontinence
8. Dysarthria (difficulty speaking)

Question 4

Cholinergic crisis
(excessive medications given to myasthenia gravis)

Answer 4

1. Muscle twitching (especially around the mouth)
2. Increased secretions
3. Difficulty in chewing, swallowing and speaking
4. Advancing muscle weakness 1 hr after anticholinesterase medication
5. Nausea and vomiting
6. Cramps and diarrhea
7. Syncope and respiratory distress leading to respiratory arrest
8. Headache
9. Confusion
10. Irritability and anxiety

Question 5

Diagnostic test for myasthenia gravis

Answer 5

Tensilon test:
- Use of IVI anticholinesterase agent edrophonium chloride
- Positive result: 30s after injection shows improved muscle strength
- Negative result: no improvement or worsening conditions (cholinergic crisis)
- Prepare resuscitation trolley and atropine if cholinergic crisis

Question 6

Treatment for myasthenia gravis

Answer 6

1. Anticholinesterase
   - inhibit Ach breakdown
   - side effect: excessive salivation, nausea, diarrhea, sweating, abdominal cramps, bradycardia, cholinergic
2. Corticosteroids
   - reduce serum level of Ach antibody
3. Immunosuppressant + cyclosporine
4. Surgical intervention: thymectomy (affect production of antibodies)
5. IV immunoglobin G (decrease antibody production)
6. Plasmapheresis (remove plasma protein containing antibodies)

Question 7

Assessment for myasthenia gravis

Answer 7

1. Assess the respiratory tract:
   - vital signs
   - use of accessory muscles
   - arterial blood gas analysis
   - lung function test
2. Assess muscle strength (especially limbs and face)
3. Assess coughing, choking, gas reflex and speech

Question 8

Nursing interventions of prevent choking and aspiration for myasthenia gravis

Answer 8

1. Assess patient’s gag reflex and ability to chew and swallow
2. Elevated bed head during feeding and for 30-60 mins after feeding
3. Monitor for choking, nasal regurgitation, and aspiration
4. Consider thickening liquids or provided small bites or soft diet
5. Provide oral hygiene
6. Monitor respiratory status and perform suction if needed

Question 9

Nutrition therapy for myasthenia gravis

Answer 9

1. Provide high-calorie snacks
2. Monitor the caloric and food intake
3. Weight the patient weekly
4. Monitor the serum albumin level
5. Administer anticholinesterase drugs 45-60 mins before meal
   (report for side effect: abdominal cramps, diarrhea, fasciculation, increased weakness)

Question 10

Clinical manifestations of systemic lupus erythematosus

Answer 10

1. Fever, fatigue, arthralgia (joint pain), weight change
2. Butterfly rash across the cheeks and the bridge of the nose

Question 11

Laboratory result suggesting Systemic Lupus Erythematous

Answer 11

1. Antinuclear antibody
2. Anti-DNA antibody
3. Erythrocytes Sedimentation Ratio and CRP –> elevated shows inflammation
4. CBC
5. Urinalysis
6. Renal function test
   - elevated serum creatinine
   - elevated BUN
   - elevated eGFR
7. Kidney biopsy

Question 12

Diagnostic criteria for Systemic Lupus Erythematosus

Answer 12

1. Antinuclear antibody
2. Hematologic disorder
3. Immunologic disorder (anti-DNA antibody)
4. Malar rash: butterfly rash
5. Oral ulcer (painless)
6. Nonerosive arthritis
7. Neurologic disorder
8. Photosensitivity: skin rash as unusual reaction to light
9. Renal disorder

Question 13

Warning signs of a flare of Systemic Lupus Erythematosus

Answer 13

1. Increased fatigue
2. Pain, abdominal discomfort
3. Rash
4. Headache
5. Fever
6. Dizziness

Question 14

Treatment for systemic lupus erythematosus

Answer 14

1. NSAID
2. Corticosteroids
3. Immunosuppressive agents
4. Antimalarial agents (treat fatigue, skin and joint problems)

Question 15

Nursing management of Systemic Lupus Erythematosus

Answer 15

1. Monitor fever pattern, vital signs, joint inflammation, limitation of motion, degree and location of discomfort, fatigue
2. Monitor laboratory results (CBC and organ function test)
3. Monitor patient’s weight and I&O (affect the prescription of corticosteroids)
4. Collect 24 hrs urine samples for protein and creatinine clearence
5. Monitor for sign of bleeding, headache, vision problems, adverse effect of medications, etc
6. Educate patient about skin care (avoid direct sunlight, non-perfumed lotion, xxx alcohol-based skin care products)
7. Educate patient about the infertility (renal involvement and corticosteroid, chemotherapy drugs), spontaneous abortion, stillbirth, intrauterine growth retardation